Above average — CMS composite of the measures below.
A standard survey is most likely before around December 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 Saint Mary's Villa Nursing Hom during CMS and state inspections, most recent first.
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 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.
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 483 citations issued within 25 miles in the last 12 months — including the 5 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 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 | ★★★★★ | 6 | 0 |
| Elan Skilled Nursing And Rehab, A Jewish Senior Li | 5.2 mi | ★★★★★ | 14 | 1 |
| Embassy Of Scranton | 5.5 mi | ★★★★★ | 24 | 1 |
| Linwood Nursing And Rehabilitation Center | 5.5 mi | ★★★★★ | 18 | 0 |
| Marywood Heights | 5.6 mi | ★★★★★ | 7 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Saint Mary's Villa Nursing Hom.
100% money-back within 48 hours.
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.