Average — CMS composite of the measures below.
A standard survey is most likely before 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 Sweden Valley Manor during CMS and state inspections, most recent first.
A resident reported receiving stained coffee cups for hot beverages, and observation confirmed that most cups were stained. Documentation review showed that required weekly de-staining was not consistently performed, and Resident Council Meeting minutes indicated ongoing, unresolved concerns about dirty dining ware. The facility failed to address and resolve these grievances in a timely manner.
A resident with Medicaid coverage was charged for new eyeglasses using her personal needs allowance, despite the service being covered by Medicaid. The facility deducted payments for the glasses and an insurance premium from the resident's trust account, leaving her without personal spending money for several months. The NHA confirmed that these charges should not have been taken from the resident's personal funds.
A resident who was discharged after receiving Medicare A services did not receive the required Notice of Medicare Non-Coverage (NOMNC) at least two days before the end of covered services. Documentation and administrator interview confirmed the absence of timely notification, despite clear discharge planning and transition to home health services.
The facility did not follow its own policies requiring background and reference checks for two newly hired employees, as personnel records for a housekeeper and a cook lacked evidence of any attempt to obtain personal or professional references. This deficiency was confirmed by HR staff and identified during a review of policies, records, and staff interviews.
A resident with Alzheimer's disease and a known history of wandering was able to exit the facility despite wearing a secure care device and was later found at a nearby hospital. The facility did not promptly investigate how the resident eloped, failed to document required frequent checks, and did not immediately educate staff or review door alarm procedures following the incident.
A resident with significant weight loss was identified by the RD, who recommended a nutrition supplement twice daily, but there was a 10-day delay before the supplement was ordered and provided. No evidence was found of the supplement being given during this period, nor of further nutrition follow-up or explanation for the delay.
The facility did not establish or maintain an infection prevention and control program as required, resulting in a deficiency identified by surveyors.
The facility's main kitchen and food storage areas were found to be unsanitary, with dried spills, dust, and debris on equipment and surfaces. The coffee station, tray line, and storage areas had significant cleanliness issues, including stained jugs, broken equipment, and improper food storage practices. These conditions were reviewed with the Nursing Home Administrator and DON.
The facility failed to implement restorative nursing programs for maintaining ROM for four residents. A resident with lower extremity ROM limitations did not receive the recommended program, and another resident's plan for active ROM was not documented as completed. Additionally, a resident requiring both active and passive ROM did not receive the prescribed care, and a cognitively impaired resident's upper extremity ROM program was not documented. These deficiencies were confirmed by interviews with facility staff.
A resident experienced inadequate pain management due to the facility's failure to administer pain medication according to the physician's ordered pain scale. Despite having orders for Acetaminophen for mild pain and Tramadol for moderate to severe pain, the resident received Tramadol for lower pain levels, and Acetaminophen was not administered as needed.
A resident was observed self-administering medication without staff supervision, despite a physician's order prohibiting self-administration. The resident's medication administration record indicated that Propranolol, Sinemet, and Seroquel were administered earlier, but the medications were left in the room. The facility's administration confirmed the error.
The facility failed to maintain a clean and homelike environment on the C Nursing Unit, with observations revealing discolored and peeling sealing around a commode, dust accumulation on vents, and debris under heating units in two residents' rooms. These issues were discussed with the Nursing Home Administrator and DON.
A facility failed to ensure accurate MDS assessments for a resident admitted with pneumonia. The MDS dated August 17, 2024, incorrectly indicated an active pneumonia infection, despite no evidence of such since April 27, 2024. The DON confirmed the coding error during an interview.
A facility failed to maintain a resident's ambulation abilities as part of a nursing rehabilitation program. The resident was supposed to be ambulated with staff assistance and a wheeled walker, but there was no documented evidence of the program being completed. The DON and Nursing Home Administrator confirmed these findings, resulting in a deficiency under nursing services regulations.
A resident with macular degeneration and diabetes did not receive necessary vision services from the facility. Despite a physician's order allowing visits to eye specialists, there was no documentation of the facility offering or arranging such services. The resident's cognitive and vision impairments were noted, but the facility failed to address these needs, as confirmed by the Nursing Home Administrator and DON.
A resident with diabetes did not receive necessary foot care, resulting in elongated, thick, and yellow toenails that began to curve. The resident had not seen a podiatrist, and there was no documentation of diabetic foot care in the clinical record until after a surveyor's observation. The DON confirmed these findings.
A facility's medication error rate was found to be 7.69%, exceeding the acceptable limit of 5%. An LPN crushed extended-release tablets of Potassium Chloride and Metoprolol before administering them to a resident, contrary to guidelines that specify these medications should not be crushed. Both the LPN and the DON confirmed the error.
A resident experienced a delay in receiving a top denture due to a lack of follow-up on dental services and a misunderstanding involving her POA. Despite being cognitively intact, the resident was unaware that her denture process was halted by her POA, leading to a deficiency in timely dental care.
Failure to Address Resident Grievances Regarding Stained Coffee Cups
Penalty
Summary
A resident reported that the cups provided for hot water were stained brown. Upon observation of the kitchen's clean racks, most coffee cups were found to be stained. The dietary supervisor confirmed that evening shift dietary staff are responsible for cleaning and de-staining the cups weekly, with staff required to sign off on this task. However, review of cleaning documentation showed that the cups were only de-stained on two occasions over a six-week period, rather than weekly as required. The dietary supervisor confirmed these findings. Review of Resident Council Meeting minutes over several months revealed ongoing resident concerns about dirty utensils, glasses, and coffee cups, with repeated mentions that these issues had not been resolved. The facility did not address or resolve the residents' grievances regarding the stained coffee cups in a timely manner, as evidenced by continued complaints in multiple council meetings and lack of consistent cleaning as documented.
Improper Charges to Resident's Personal Funds for Medicaid-Covered Services
Penalty
Summary
A deficiency occurred when the facility charged a resident's personal funds for eyeglasses, a service that should have been covered by Medicaid. The resident, who is enrolled in a Medicaid plan, required new glasses following an acute vision problem and was sent to a local eye doctor. The resident reported that she had to pay for the glasses using her monthly personal needs allowance, which left her without personal spending money for several months. Clinical record review confirmed the resident's Medicaid coverage and the need for new glasses as documented by the eye doctor. Review of the resident's trust account showed deductions for medical bills related to the glasses and for an insurance premium that covers ancillary services such as vision. The Nursing Home Administrator confirmed that the charges for the glasses were taken from the resident's personal funds instead of being processed as an allowable medical expense under the resident's patient liability. The facility failed to ensure that the resident's personal needs allowance and trust account were managed in accordance with regulations, resulting in improper charges to the resident's personal funds for services covered by Medicaid.
Failure to Provide Timely Notice of Medicare Non-Coverage
Penalty
Summary
The facility failed to provide the required Notice of Medicare Non-Coverage (NOMNC) to a resident whose Medicare-covered services were ending. According to the review, the NOMNC, which informs beneficiaries of the termination of Medicare coverage and their right to appeal, must be delivered at least two calendar days before the end of covered services. For the resident in question, there was no evidence that this notice was given within the required timeframe. Clinical documentation showed that the resident was admitted for Medicare A services and was making progress toward discharge, with plans for home health services upon leaving the facility. Despite clear indications in the record that discharge was anticipated, the facility did not provide documentation that the resident or their representative received the NOMNC two days prior to discharge, as required by regulation. This deficiency was confirmed through both record review and interview with the Nursing Home Administrator.
Failure to Complete Required Reference Checks for New Hires
Penalty
Summary
The facility failed to implement its abuse prohibition policy by not conducting thorough investigations of prospective employees' employment histories for two out of five newly hired staff members. Specifically, the personnel records for a housekeeper and a cook did not contain any evidence that the facility attempted to obtain personal or professional reference information, as required by facility policy. The policies reviewed stated that background and reference checks must be completed and documented prior to employment offers, but these steps were not followed for the two employees in question. These findings were confirmed by the human resources staff member, who acknowledged the lack of reference checks in the personnel files. The deficiency was identified through a review of facility policies, personnel records, and staff interviews, and was discussed with the Nursing Home Administrator. The report cites violations of state code regarding management and personnel policies and procedures.
Failure to Investigate and Prevent Resident Elopement
Penalty
Summary
A resident with a history of elopement and severely impaired cognition due to Alzheimer's disease was identified as an elopement risk upon admission. The resident was ambulatory without a device and had previously wandered from home. Despite being assessed as an elopement risk and fitted with a secure care device, the resident was able to leave the facility and was found at a nearby hospital's helipad. Documentation indicated that the secure care device should have prevented exit, but there was no immediate investigation into how the resident was able to leave undetected. There was a lack of timely and thorough investigation following the elopement incident. Documentation of required 15-minute checks was missing, and there was no evidence of staff education or changes in interventions immediately after the event. Staff statements and investigation into the door alarm and secure care system were not completed until two days after the incident. Additionally, there was no documentation of secure care checks on the exit door or evidence that all staff were educated on responding to door alarms in the immediate aftermath.
Delay in Initiating Nutrition Interventions for Significant Weight Loss
Penalty
Summary
A resident experienced a significant weight loss of 9.6 pounds, or 7.1 percent, over a 30-day period, as documented in the clinical record. The registered dietitian noted the weight loss and recommended adding a nutritional supplement (Boost) twice daily to address the resident's declining meal intake. However, there was a delay of 10 days before the physician order for the supplement was entered, and there was no evidence that the supplement was provided to the resident during this period. Additionally, there was no documentation of further nutritional follow-up or explanation for the delay in implementing the recommended intervention. The resident also refused to be weighed after the initial weight loss was recorded.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. This deficiency was identified during the survey process, indicating that the required measures to prevent and control infections were not established or maintained as per regulatory standards. The report notes the absence of a comprehensive infection prevention and control program but does not provide further details regarding specific actions, inactions, or events, nor does it mention any particular residents or staff involved.
Unsanitary Conditions in Kitchen and Food Storage Areas
Penalty
Summary
The facility failed to maintain a safe and sanitary environment in the main kitchen, leading to potential food contamination. Observations revealed multiple areas of concern, including dried brown liquid spills and food splatter on walls and equipment, dust and debris accumulation, and stained and opaque plastic jugs. The coffee station area was particularly unsanitary, with a soiled cardboard box of coffee filters and a trash can covered in dried debris and spills. Further inspection of the kitchen revealed significant issues with food storage and equipment maintenance. Bag-in-box juices had sticky and dusty tubing connections, and an air compressor was covered in thick dust. The two-door cooler had a broken door gasket, and oven mitts were significantly stained with dried food. The tray line area had cracked, worn, and stained lunch trays, and carts used for food service were soiled with dried food debris and had broken or cracked surfaces. The facility's dry storage and walk-in freezer areas also exhibited unsanitary conditions. The dry storage room had thick dust on shelving units, and the walk-in freezer had significant ice buildup on the floor and shelves. Food products were stored without barriers to prevent contamination from mop water or debris. The walk-in cooler had dried food and debris on the floor, and the shelving was covered in dust and debris. The facility's failure to maintain cleanliness and proper food storage practices was reviewed with the Nursing Home Administrator and Director of Nursing.
Failure to Implement Restorative Nursing Programs for ROM
Penalty
Summary
The facility failed to implement a restorative nursing program as recommended by therapy to maintain range of motion (ROM) for four residents. Resident 22 was assessed with ROM limitations in her lower extremities, and a restorative program was recommended by physical therapy. However, there was no documented evidence that the program was implemented. Similarly, Resident 15's plan of care included a nursing rehab program for active ROM to her lower extremities, but there was no documentation indicating the program was completed. Resident 47 was to receive active ROM for his lower extremities and passive ROM for his upper extremities, as recommended by therapy, but there was no evidence of these programs being carried out. Resident 64, who had severe cognitive impairment, was to participate in an upper extremity active ROM program as tolerated, but there was no documentation of the program being completed or any refusal by the resident. These deficiencies were confirmed through interviews with the Director of Nursing, Nursing Home Administrator, and Director of Therapy.
Inadequate Pain Management for a Resident
Penalty
Summary
The facility failed to provide appropriate pain management for a resident, identified as Resident 48, consistent with professional standards of practice. Resident 48 reported experiencing pain in the tailbone area following a recent fall. The clinical records indicated a physician's order for Acetaminophen 325 mg, two tablets every six hours as needed for a pain level of 1-5, and Tramadol HCL 75 mg every six hours as needed for a pain level of 6-10. However, the medication administration record (MAR) for August and September 2024 showed that Tramadol was administered for pain levels of 4 and 5, which were outside the prescribed pain scale for this medication, and there was no evidence of Acetaminophen being administered on those occasions. The deficiency was confirmed through interviews with Resident 48 and a review of the MAR, which revealed that the facility staff did not adhere to the physician's ordered pain scale. This resulted in the resident receiving Tramadol for pain levels that should have been managed with Acetaminophen, according to the physician's orders. The issue was discussed with the Nursing Home Administrator and Director of Nursing, highlighting the facility's failure to administer pain medication as per the prescribed guidelines.
Medication Administration Deficiency
Penalty
Summary
The facility failed to administer medication per physician's orders for one resident. On September 17, 2024, a surveyor observed a resident lying in bed with a medicine cup containing pills on the bedside table. The resident, upon noticing the surveyor, ingested the pills without any staff present. The clinical record for this resident showed a physician's order from April 9, 2023, indicating that the resident was not permitted to self-administer medication. Despite this, the medication administration record for the same day documented that the resident was administered Propranolol, Sinemet, and Seroquel at 1:25 PM. The Nursing Home Administrator and Director of Nursing confirmed that the resident should not have had medications left in the room for self-administration.
Failure to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to provide a clean, comfortable, and homelike environment on the C Nursing Unit, affecting two residents. Observations on September 18, 2024, revealed that the external sealing around the base of the commode in the C Unit shower room was discolored and peeling, with a significant accumulation of dust on a ceiling vent. Further observations on September 20, 2024, showed extensive dust build-up on the heating unit vents in the rooms of two residents, along with debris accumulation under the units. These findings were confirmed during a meeting with the Nursing Home Administrator and Director of Nursing.
Inaccurate MDS Assessment for a Resident
Penalty
Summary
The facility failed to ensure complete and accurate Minimum Data Set (MDS) assessments for a resident, identified as Resident 60. Resident 60 was admitted with a diagnosis of pneumonia from a hospital setting. A review of the clinical record revealed an MDS assessment dated August 17, 2024, which incorrectly indicated that the resident still had an active pneumonia infection. However, there was no documented evidence in the clinical record to support the continuation of an active pneumonia infection since April 27, 2024. An interview with the Director of Nursing on September 19, 2024, confirmed that the pneumonia diagnosis was coded in error on the MDS.
Failure to Maintain Resident's Ambulation Program
Penalty
Summary
The facility failed to maintain a resident's ability to ambulate as part of a nursing rehabilitation program. Resident 15 was on a program that required ambulation with the assistance of one staff member and a wheeled walker, as ordered on November 7, 2023. A therapy recommendation form dated October 31, 2023, confirmed this program. However, there was no documented evidence that the ambulation program was being completed for Resident 15. The Director of Nursing and the Nursing Home Administrator were informed of these concerns and confirmed the findings on September 19, 2024. This failure to provide the necessary restorative or rehabilitation services resulted in a deficiency under 28 Pa. Code 211.12(d)(1)(5) Nursing services.
Failure to Provide Vision Services to Resident
Penalty
Summary
The facility failed to provide necessary vision services to a resident with a history of macular degeneration and diabetes mellitus. The resident, who was admitted in 2019, expressed concerns about worsening vision and was unsure of her last vision appointment. Despite having a physician's order from February 2020 allowing visits to an optometrist and ophthalmologist, there was no evidence in the clinical records that the facility offered or arranged for vision services for the resident. The resident's Minimum Data Set Assessment indicated cognitive impairment and vision impairment, yet the facility did not document any efforts to address these needs. During a survey, the Nursing Home Administrator and Director of Nursing were unable to provide documentation showing that the resident or her responsible party was offered vision services. The facility's records lacked any indication of an eye exam being offered or conducted since the resident's admission. This deficiency was identified under 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services, highlighting the facility's failure to ensure the resident received appropriate care for her vision concerns.
Failure to Provide Diabetic Foot Care
Penalty
Summary
The facility failed to provide necessary foot care and treatment to a resident, leading to a deficiency. The resident, who was admitted with a diagnosis of diabetes, had not received diabetic foot care to manage his toenails and prevent medical complications. During an interview, the resident reported not having seen a podiatrist for his left foot. Observation revealed that the resident's toenails were elongated, with the nails on the first and second toes being thick, yellow, and beginning to curve. There was no documented evidence in the resident's clinical record indicating that the facility had initiated appropriate foot care until the surveyor's observation and interview prompted action. The Director of Nursing confirmed these findings.
Medication Error Rate Exceeds Acceptable Limit
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as evidenced by a 7.69 percent error rate based on 26 medication opportunities with two errors. During a medication administration pass, an LPN prepared to administer Potassium Chloride 20 MEq ER and Metoprolol 100 mg ER to a resident by crushing the extended-release tablets, which is against the guidelines provided by The Institute for Safe Medication Practices. These guidelines specify that both medications should not be crushed due to their slow-release formulation. The LPN confirmed the error during an interview, and the Director of Nursing also acknowledged that the medications should not have been crushed.
Failure to Provide Timely Dental Services
Penalty
Summary
The facility failed to provide timely dental services for a resident, identified as Resident 29, who had been waiting for her top denture since at least June 2024. The process began with dental impressions made in August 2023, followed by several consults indicating ongoing treatment and adjustments needed for the denture. However, after a dental consult in March 2024, where changes to the denture were noted, there were no further records of dental visits or updates on the denture delivery. The resident expressed concern about not receiving her denture and was unaware of any issues until a recent interview. The situation was further complicated by a misunderstanding involving the resident's power of attorney (POA). An email from the consulting dental clinic indicated that the denture process was halted because the POA declined further services, despite the resident being cognitively intact and capable of making her own decisions. The resident was not informed of this decision, which contradicted her expressed wishes to continue with the denture process. The facility's failure to communicate effectively and ensure the resident's dental needs were met led to the deficiency.
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 14 citations issued within 25 miles in the last 12 months — 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 Coudersport
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Cole Place | 0.1 mi | — | 0 | 0 |
| Guy And Mary Felt Manor, Inc | 22.2 mi | ★★★★★ | 0 | 0 |
| Sena Kean Nursing And Rehabilitation Center | 23.4 mi | ★★★★★ | 11 | 0 |
| Lakeview Healthcare And Rehab | 24 mi | ★★★★★ | 3 | 0 |
| Highland Park Rehabilitation And Nursing Center | 24.4 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.