Above average — CMS composite of the measures below.
The next survey window likely opens around June 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Saint Mary's Villa Nursing Hom during CMS and state inspections, most recent first.
Failure to Apply Ordered Skin Protection Devices: A resident with Parkinson’s disease and severe cognitive impairment had a Braden score indicating moderate pressure injury risk and a wound assessment showing incontinence-associated dermatitis and an abrasion. Physician orders required bilateral heel bows, leg protectors, and heel lift boots at all times except during care, but during observation the resident was not wearing any of the ordered protective devices, and an LPN acknowledged they were not in place.
Failure to monitor significant weight loss and follow nutritional interventions. Two residents had documented weight loss that triggered facility policy for weekly weights and reweighing within 24 hours, but one resident was not weighed weekly after a major loss and a dietitian's order to increase Ensure was not implemented. Another resident with Alzheimer's disease and dysphagia had an MNA score indicating malnutrition, then lost 4.5 pounds in one week without a documented reweigh or notification to the MD or responsible party.
Controlled medication count records were not consistently completed for three medication carts. Facility policy required the incoming and off-going nurses to count controlled meds together and sign the record, but an incoming LPN failed to sign on two carts and an off-going LPN failed to sign on one cart; the DON acknowledged the omissions.
A resident's controlled medications, including Tramadol and Diazepam, were stored in the DON's office for an extended period after discharge without proper accounting or timely destruction. Staff had access to the office but not the secured locker, and the facility lacked procedures and documentation for accurate controlled drug records and timely medication disposition.
A resident with intact cognition and a history of lobar pneumonia repeatedly declined participation in several aspects of care, such as BiPap use, OT, nebulizer treatments, and other interventions. Despite these documented choices, the care plan did not reflect or address the resident's preferences, and this omission was confirmed by facility leadership.
The facility did not follow its abuse prohibition policy by failing to verify previous employment for a porter, two LPNs, and a nurse aide during the hiring process, as required for proper staff screening and abuse prevention.
Two residents' MDS assessments were found to be inaccurate, as falls that occurred were not documented in their respective quarterly MDS records. This deficiency was confirmed through clinical record review and staff interviews, including with the DON and Nursing Home Administrator.
A resident returned from acute care with an indwelling catheter and developed MASD and incontinence-associated dermatitis. The facility did not document justification for the catheter, nor did it implement an individualized toileting plan based on the resident's voiding patterns, despite evidence of consistent incontinence episodes and a care plan revision. Facility leadership confirmed the lack of an individualized incontinence management plan.
A resident with osteoarthritis and muscle spasms received PRN Hydrocodone-acetaminophen multiple times without documented attempts at non-pharmacological pain interventions, and the medication was administered outside the prescribed pain scale range, contrary to facility policy and physician orders. The DON confirmed the lack of required documentation.
A facility failed to incorporate PASARR Level II recommendations into the care plan of a resident with Down's syndrome, who required specialized services for intellectual disability. The care plan lacked specific referrals or services, and the Nursing Home Administrator confirmed the absence of coordinated services, potentially affecting the resident's well-being.
A facility failed to accurately account for controlled medications for a resident. Nursing staff signed out doses of Tramadol and Hydrocodone-Acetaminophen, but the administration was not recorded on the MAR. The DON confirmed the inconsistencies in documentation.
The facility failed to adhere to proper food storage practices in two resident pantries, leading to an increased risk of food-borne illness. Observations revealed opened containers of lemon-flavored water stored beyond the manufacturer's recommended period, confirmed by interviews with staff, including the Nursing Home Administrator and DON.
A resident experienced a significant change in condition, including vomiting maroon liquid and low oxygen saturation, but the facility failed to immediately notify the resident's family. The facility's policy allowed for notification during waking hours unless specified otherwise, but the family's preference was not ascertained. The family was informed much later, leading to a grievance.
Failure to Apply Ordered Skin Protection Devices
Penalty
Summary
The facility failed to provide necessary care and services to maintain skin integrity for one resident by not implementing physician-ordered skin protection interventions. Resident 14 was admitted with Parkinson’s disease with dyskinesia and had severe cognitive impairment on the quarterly MDS, with a BIMS score of 99 indicating the assessment could not be completed because the resident was unable to participate. A Braden Scale assessment identified a score of 13, showing moderate risk for pressure injury, with impaired sensory perception, inability to ambulate or bear weight independently, limited ability to reposition without assistance, and very poor nutritional status. The clinical record also showed a wound assessment completed by the wound care NP that identified incontinence-associated dermatitis involving the sacrum and an abrasion to the right knee. Physician orders directed staff to apply bilateral heel bows at all times except during care, and later orders directed staff to apply bilateral leg protectors and bilateral heel lift boots at all times except during care. During an observation, the resident was seated in a Broda chair wearing pants, socks, and sneakers, but was not wearing the ordered bilateral leg protectors, bilateral heel lift boots, or bilateral heel bows. An LPN present during the observation acknowledged the protective devices were not in place, and the NHA and DON later acknowledged nursing staff failed to follow the physician order.
Failure to Monitor Significant Weight Loss and Follow Nutritional Orders
Penalty
Summary
The facility failed to consistently monitor resident weights and implement nutritional interventions after significant weight changes were identified for two residents. Facility policy required residents with a weight gain or loss of three pounds or more to be reweighed within 24 hours, with notification to the physician and dietary manager or registered dietitian if the change was confirmed. Resident 43, who had chronic kidney disease, weighed 103.8 pounds on May 15, 2026, then returned from hospitalization on June 1, 2026 at 96 pounds, a 7.5% loss over 16 days, and later weighed 92.4 pounds on June 16, 2026. The record did not show a weekly weight during the week of June 8, 2026 as required after the significant loss. A dietary progress note for Resident 43 documented unplanned significant weight loss and recommended increasing Ensure from twice daily to three times daily, but the record did not show that this recommendation was implemented. Resident 87, who had Alzheimer's disease and dysphagia, had a Mini Nutritional Assessment score of 5, indicating malnutrition. After a DON discussed declining appetite and weight loss with the resident's spouse and responsible party, the spouse requested weekly weights. The resident then weighed 142.3 pounds and 137.8 pounds one week later, a 4.5-pound loss, but the record did not show a reweigh within 24 hours or documentation that the physician or responsible party was notified of the significant weight loss.
Incomplete Controlled Medication Count Documentation
Penalty
Summary
The facility failed to consistently implement its controlled medication count procedures for three of four medication carts reviewed. The facility policy titled Narcotic Control required the nurse coming on duty and the nurse going off duty to perform the controlled medication count together, document the count, and immediately report any discrepancies to the Director of Nursing Services. On Unit 33 Long Hall Medication Cart, the July 28, 2026 Shift-to-Shift Count Record showed the incoming day shift LPN did not sign to verify the controlled medication count, and an LPN confirmed this omission during interview. On Unit 33 Short Hall Medication Cart, the same record showed the incoming day shift LPN did not sign to verify the count, and an LPN confirmed the omission. On Unit 30 Long Hall Medication Cart, the July 28, 2026 Shift-to-Shift Count Record showed the off-going day shift LPN did not sign to verify the controlled medication count, and an LPN confirmed the omission. The DON acknowledged the omissions and confirmed the facility policy required both the incoming and off-going nurses to complete and sign the controlled medication count record.
Failure to Secure and Timely Dispose of Controlled Substances
Penalty
Summary
The facility failed to implement procedures to ensure accurate controlled drug records and timely disposition of resident medications, specifically for one resident who was discharged to the hospital with no anticipation of return. Upon discharge, two controlled substances, Tramadol and Diazepam, were secured in the DON's office, with 39 Tramadol tablets and 38 Diazepam tablets documented as placed there. The controlled substance log showed that these medications were not destroyed until 20 days later, indicating they were stored in the DON's office for an extended period before proper disposition. Observation revealed that the locker designated for controlled substance storage in the DON's office had only one key, which was kept by the DON, but staff had access to the office itself, creating an opportunity for unauthorized access to the medications. The DON confirmed that when she was unavailable, staff placed controlled medications in her office, but did not have access to the locker. During the DON's absence, the medications remained unsecured. The facility was unable to provide a narcotic log for the medications stored in the locker and had no plan in place for proper accounting of narcotics awaiting disposition. Interviews with the DON and NHA confirmed the lack of documentation and procedures to ensure accurate controlled drug records and timely medication disposition.
Failure to Incorporate Resident Choices into Care Plan
Penalty
Summary
The facility failed to honor and incorporate a resident's expressed preferences and choices into the care planning process. Clinical record review showed that the resident, who was cognitively intact and had a history of lobar pneumonia, repeatedly chose not to participate in various aspects of care, including use of a BiPap machine, occupational therapy, nebulizer treatments, blood pressure readings, meals, weights, skin treatments, and bathing. Despite these documented choices, the resident's care plan did not address or reflect these specific preferences or provide tailored interventions to meet the resident's needs related to their decisions to refrain from certain care activities. Facility policy required the development of a comprehensive, person-centered care plan focused on resident choices and abilities, with the goal of maintaining or improving functional abilities and quality of life. However, the care plan in effect at the time of the survey did not accurately represent the resident's expressed choices. This was confirmed in interviews with the Nursing Home Administrator and Director of Nursing, who acknowledged that the resident's preferences were not incorporated into the care plan.
Failure to Verify Previous Employment During Staff Screening
Penalty
Summary
The facility failed to fully develop and implement procedures to screen new employees in accordance with its abuse prohibition policy. Specifically, a review of the facility's policy required obtaining references from the most recent or previous employer as part of the screening process for potential employees. However, personnel files for four out of five recently hired employees showed no documentation that the facility had contacted their most recent former employers to verify eligibility for employment in a long-term care setting. During interviews, the Nursing Home Administrator confirmed that there was no evidence the facility attempted to obtain information from previous or current employers regarding the employees' past work history. This lack of verification was found for a porter, two LPNs, and a nurse aide, all of whom had listed previous employers on their applications. The facility did not follow its own policy, resulting in a deficiency related to employee screening and abuse prevention.
Inaccurate MDS Assessments for Fall History
Penalty
Summary
The facility failed to complete accurate Minimum Data Set (MDS) assessments for two residents, as required by the Resident Assessment Instrument (RAI) Manual. For one resident admitted with pneumonia and acute kidney failure, the quarterly MDS did not reflect a fall that occurred on February 2, 2025, despite documentation of the incident in the clinical record. Similarly, another resident with monoplegia of the upper limb experienced a fall on May 4, 2025, which was not recorded in the MDS completed on June 24, 2025. These inaccuracies were confirmed through a review of clinical records, resident observation, and staff interviews, including confirmation by the Director of Nursing and Nursing Home Administrator. The failure to accurately document fall history in the MDS assessments resulted in noncompliance with both federal and state regulations regarding resident assessment and medical records.
Failure to Individualize Incontinence and Catheter Care
Penalty
Summary
The facility failed to develop and implement an individualized plan to meet the toileting needs of a resident who returned from an acute care stay with an indwelling catheter. Upon readmission, there was no documentation justifying the continued use of the catheter, despite facility policy requiring evaluation of catheter necessity. The resident, who was cognitively intact and required staff assistance for toileting and transfers, had previously been incontinent without a catheter prior to hospitalization. After the catheter was removed, the resident experienced consistent episodes of incontinence, particularly at 9:00 PM over several days, as documented in the voiding pattern record. The resident developed Moisture Associated Skin Damage (MASD) and Incontinence Associated Dermatitis upon return from the hospital. Although the care plan was revised to address frequent incontinence and included general interventions such as two-hourly incontinence checks, cleansing, and barrier cream, it did not specify the type of incontinence, include a structured toileting schedule, or incorporate individualized interventions based on the resident's documented voiding patterns. There was no evidence that the facility evaluated or implemented a plan tailored to the resident's specific toileting needs, and this was confirmed by facility leadership during an interview.
Failure to Follow Individualized Pain Management Protocols and Physician Orders
Penalty
Summary
The facility failed to develop and implement an individualized pain management program consistent with professional standards of practice for a resident with osteoarthritis and muscle spasms. Despite a facility policy and physician orders requiring the use of non-pharmacological interventions prior to administering as-needed narcotic pain medication, staff repeatedly administered Hydrocodone-acetaminophen without documenting any attempt at non-pharmacological pain relief methods. The facility policy also required the use of a verbal numeric pain scale to guide medication administration, but staff did not consistently follow the pain scale parameters outlined in the physician's orders. Review of the resident's medication administration records over several months showed multiple instances where narcotic pain medication was given without prior non-pharmacological interventions and outside the prescribed pain scale range. Specifically, the medication was administered for both mild and severe pain, contrary to the order specifying use only for moderate pain. The Director of Nursing confirmed that there was no documentation to support the use of non-pharmacological interventions or justification for administering the narcotic outside the physician's parameters.
Failure to Incorporate PASARR Recommendations in Care Plan
Penalty
Summary
The facility failed to incorporate the recommendations from the Pre-Admission Screening and Resident Review (PASARR) Level II determination into the assessment, care planning, and transitions of care for a resident diagnosed with Down's syndrome. The resident's clinical record indicated a positive screen for Serious Mental Illness, Intellectual Disability, and/or Other Related Condition, necessitating further evaluation. The PASARR Level II determination confirmed the need for specialized services for the resident's intellectual disability, which were not reflected in the resident's care plan. During the survey, it was found that the care plan did not identify specific referrals or services recommended and/or provided to the resident as a result of the PASARR II evaluation. An interview with the Nursing Home Administrator confirmed the lack of evidence for coordination of services, including care planning, for the resident. This deficiency potentially affected the resident's ability to achieve and maintain their highest practicable physical, mental, and psychosocial well-being.
Inaccurate Accounting of Controlled Medications
Penalty
Summary
The facility failed to implement procedures to ensure accurate accounting of controlled medications for a resident. The clinical record review revealed that the resident had a physician's order for Tramadol HCl, an opioid pain medication, to be administered as needed for moderate pain. However, on two occasions, the nursing staff signed out doses of Tramadol, but the administration of the medication was not recorded on the resident's Medication Administration Record (MAR). Additionally, the resident had a physician's order for Hydrocodone-Acetaminophen, another opioid pain medication, to be administered as needed for moderate pain. On four separate occasions, the nursing staff signed out doses of this medication, but again, the administration was not recorded on the MAR. The Director of Nursing confirmed these inconsistencies during an interview, acknowledging the need for clear and accurate documentation of controlled substances.
Improper Food Storage Practices in Resident Pantries
Penalty
Summary
The facility failed to maintain acceptable practices for the storage and service of food, which increased the risk of food-borne illness in two of four resident pantries. During an observation of the resident food pantry on the second floor, Extension 31, it was found that several opened containers of lemon-flavored water were stored in the refrigerator beyond the manufacturer's recommended seven-day period after opening. Specifically, there were containers dated October 21 and October 23, 2024, which were well past the safe consumption period. An interview with a registered nurse confirmed these observations. Similarly, in the resident food pantry on the second floor, Extension 33, an opened container of lemon-flavored water dated October 16, 2024, and another container without an open date were found. These findings were confirmed by another registered nurse. Further interviews with the Nursing Home Administrator and the Director of Nursing confirmed that the food and beverages in the resident pantry were supposed to be dated when opened and discarded according to the manufacturer's instructions, which was not adhered to in these instances.
Failure to Notify Family of Significant Change in Resident's Condition
Penalty
Summary
The facility failed to immediately notify a resident's designated representative of a significant change in the resident's medical condition. The resident, who had a history of chronic obstructive pulmonary disease, dementia, and hypertension, experienced a significant change in condition on May 22, 2024, at approximately 4:32 AM. The resident vomited a large amount of maroon liquid, had a distended abdomen, an elevated temperature, low blood pressure, and low oxygen saturation. Despite these changes, the facility did not notify the resident's son, who was the designated representative, at the time of the incident. The facility's policy allowed for notification during waking hours unless specified otherwise by the family, but there was no indication that the facility had ascertained the family's preference in this case. The resident's condition was reviewed by a physician later that morning, and further medical evaluations were ordered. However, the resident's family was not informed of the significant change until much later in the day, which led to a grievance being filed. The grievance expressed concern that the family was not notified of the resident's condition change and that the resident was not sent to the emergency room for evaluation and treatment until approximately 6:20 PM. An interview with the Nursing Home Administrator confirmed that the facility had not previously determined the family's notification preferences and did not immediately notify the resident's representative of the change in condition.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Moscow
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Dunmore Health Care Center | 4.1 mi | ★★★★★ | 13 | 0 |
| Elan Skilled Nursing And Rehab, A Jewish Senior Li | 5.2 mi | ★★★★★ | 15 | 1 |
| Embassy Of Scranton | 5.5 mi | ★★★★★ | 41 | 1 |
| Linwood Nursing And Rehabilitation Center | 5.5 mi | ★★★★★ | 18 | 0 |
| Marywood Heights | 5.6 mi | ★★★★★ | 7 | 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 October 2026) and official state health department websites.