Below 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 Sweden Valley Manor during CMS and state inspections, most recent first.
Food items in the kitchen, storage areas, and resident pantry were repeatedly found unlabeled, undated, expired, or improperly stored, including prepared foods, dairy items, condiments, and staff drinks. Observations also noted dirty equipment, debris, dust, cobwebs, flies in the dish room, missing dishwasher temp log entries, and a cook handling ready-to-eat turkey sandwiches without gloves before serving them to residents.
Failure to Conduct and Document Facility Assessment: The facility did not have evidence of a required Facility Assessment to determine the resources, staffing, and skill sets needed to care for residents during routine operations and emergencies. The NHA and an RN confirmed that no such assessment was available until after the surveyor requested it.
A facility failed to provide written notice to the resident and the resident's representative or legal representative explaining the reason for discharge for three residents who were transferred to the hospital after a change in condition. Clinical records contained no evidence that written notification was given, and the NHA and an RN confirmed the lack of documentation.
Insufficient nursing staff resulted in delayed morning med passes on two hallways. An LPN reported being assigned two hallways and said late meds were happening more and more, while another LPN stated that when the facility did not have four nurses, meds were always late. Several residents on both hallways had 8:00 AM meds that were not given within the required 60-minute window, and staffing records showed only 2.5 to 3 LPNs scheduled on the day shift.
The facility failed to show that nurses and nurse aides had the competencies needed to care for residents with specific needs. The DON and NHA could not provide evidence of competency evaluations for staff assisting a resident with peritoneal dialysis, and the TAR showed LPNs were administering those treatments. The facility also lacked competency records for nurse aides on feeding, bathing, and transfers, as well as for LPNs and an RN on medication administration, changes in resident condition, and peritoneal dialysis. The facility also had no evidence that LPNs were educated on the second-shift RN coverage plan.
Failure to respond to consultant pharmacist medication review recommendations: two residents had unresolved MRR findings, including requests related to Amiodarone use, discontinuation of Voltaren gel, and review of multiple psychotropic meds. The DON and NHA confirmed missing responses in the chart, and one resident’s monthly pharmacist reviews were not documented in the physical chart for several months.
The facility failed to implement EBP for a resident with an indwelling abdominal device for peritoneal dialysis. There was no physician order, no EBP signage, and no gown, glove, or used-gown disposal setup outside the room, and staff said they did not know the resident was on EBP. The facility also failed to maintain proper laundry processing practices, as a laundry aide reported overfilling washers and not weighing loads, while the machine brochure listed a 60-lb capacity.
Failure to Offer Pneumococcal and Influenza Immunizations: The facility did not ensure that immunizations were offered or documented for three residents reviewed. One resident had received PPSV23 but had no evidence of follow-up pneumococcal vaccination or consent/declination documentation, another had no record of being offered or receiving any pneumococcal vaccine, and a third had no documentation of receiving or refusing the current influenza vaccine despite prior annual flu vaccination history. The NHA and an RN confirmed the findings.
COVID-19 Vaccination Education and Documentation Deficiency: The facility failed to document staff COVID-19 immunization education and failed to show that two residents were educated and offered the COVID-19 vaccine. One resident had no chart evidence of immunization status, education, or vaccination, while another had a prior COVID-19 vaccine history and a booster refusal, but no further evidence of vaccine offers or education after that refusal.
A resident with schizoaffective disorder, bipolar type, depression, anxiety, and other mental health diagnoses was prescribed multiple psychotropic meds, including an antipsychotic, antidepressants, an anxiolytic, and a mood stabilizer. The record showed limited behavior tracking only for the antipsychotic, with no ongoing target behavior or side effect monitoring documented for the antidepressant and anxiolytic meds. Consultant pharmacist requests for semi-annual psychotropic review were deferred to psychiatry, but the psychiatry provider did not document a response to those recommendations, and a later pharmacist review was also not addressed in the psychiatry note.
A facility failed to ensure MDS assessments accurately reflected resident status for three residents. One resident with Parkinson's disease and contractures was incorrectly coded as having no ROM impairment on one MDS, another resident was incorrectly coded as receiving insulin despite no insulin use in the MAR, and a third resident's vision was assessed without her customary glasses even though she wore corrective lenses and this was not reflected in her care plan.
A facility failed to maintain a comprehensive person-centered care plan for a resident with a pacemaker, with no existing plan addressing the device, related assessments, or precautions until one was created after surveyor inquiry. The facility also failed to follow a resident’s care plan for hearing aids; the cognitively intact resident reported needing to ask for them and often being told they were not charged, and staff observed the resident without the hearing aids in place despite the plan requiring their availability and function.
Failure to Implement Recommended Restorative Nursing Program: A resident with a displaced intertrochanteric fx of the R femur and cognitive impairment had PT discharge documentation recommending restorative treatment and noting an RNP was developed, but the clinical record contained no documentation that the restorative nursing program was completed or attempted. The NHA later reported that PT recommended a restorative program and it was not put into place.
The facility failed to follow physician-ordered weight monitoring for two residents with nutritional concerns. One resident had weekly weights ordered after admission, but the record showed only three documented weights and missed several weekly measurements. Another resident had an admission weight order followed by weekly weights for four weeks, but only one weight was documented. Both residents’ care plans identified nutritional problems or potential nutritional problems, and one plan also included monitoring for signs of malnutrition.
A resident who wore glasses on admission lost them while in the facility, but the care plan did not address her need for corrective lenses and staff did not take timely steps to locate or replace them. The NHA and DON reported no knowledge of or investigation into the missing glasses, and repeated observations showed the resident without glasses.
A resident with cognitive impairment and two unstageable pressure ulcers had multiple ordered wound treatments for the sacrum, coccyx, and mid-spine that were not documented as completed on several shifts. The TAR lacked entries for several ordered dressing changes and wound care treatments, and the facility had no documentation explaining why the treatments were missed.
Unanswered exit door alarms at the smoker’s patio were repeatedly observed sounding at the nurses’ station while staff did not respond to check the door or residents in the area. A resident with elopement risk, wandering, and poor safety awareness had orders for a Secure care device and was observed near the exit door, and another resident with wandering behaviors was also observed self-propelling near the same door while the alarm continued.
A resident receiving PD was involved in a procedure where an RN did not perform hand hygiene before donning gloves, entered the room without closing the door, and then put on a mask from the resident’s bedside table while continuing the same procedure. The facility’s PD disconnecting procedure required the door to be closed, a mask to be applied, and hand hygiene to be performed before gloves were applied, and the RN had not received facility training related to the resident’s PD.
Failure to assess entrapment risk and obtain informed consent for bed enabler bars. Two residents had bilateral enabler bars on their beds and were observed using them for positioning and bed mobility. One resident had dx including difficulty walking and muscle weakness; the other had repeated falls and generalized weakness. Surveyors requested documentation, but the facility could not provide entrapment zone measurements, and for one resident there was no informed consent documentation.
An LPN’s med cart on Nursing Unit B contained several unsecured and unidentified pills in the bottom of the drawer where blister cards were stored, including multiple tablets of different shapes and colors. The findings were reviewed with the NHA and an RN.
Incomplete PD documentation was found for a resident receiving PD. A surveyor observed an RN complete the disconnection procedure, but the chart showed an LPN had initialed the task. The record also lacked documentation for several other PD disconnections and did not identify who initiated PD on multiple treatment dates.
Improper Disposal and Containment of Garbage and Refuse: Surveyors observed an open recyclable dumpster and multiple dumpsters surrounded by broken wheelchairs, equipment parts, wooden pallets, a broken lawn chair, and other debris. A paper with a resident name and room number was also found in the grass near the dumpster area, and the debris remained on later observation.
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.
Food Storage, Labeling, and Sanitation Deficiencies
Penalty
Summary
The facility failed to store food in accordance with professional standards in the main kitchen, dishwashing area, dry storage area, walk-in freezer, walk-in cooler, and resident pantry area. During observation, multiple food items were found without labels, dates, or use-by information, including prepared tuna salad, jelly packets, saltine crackers, flour, yellow zucchini, cheese, iced coffee, lemonade, and pudding-like product. Staff-owned drink packets were also observed with an expired use-by date, and resident pantry items such as opened jelly and yogurt lacked required dating or identifying information. The kitchen and storage areas also contained numerous sanitation and storage issues. Observations included spills and buildup on the refrigerator vents, juice machine filter buildup, debris around the oven and steamer, burnt debris in the toaster, dirty utility carts, dust on vents, cobwebs near doorframes, stained containers, and food contact items stored uncovered. Bottled water was stored directly on the floor, a broken plastic container with jagged edges was holding ice cream cups in the freezer, and ice buildup was observed on boxes of food. In the walk-in cooler, items were found on the floor, including butter packets, a lid, lettuce, yogurt, and a towel, while other items such as chocolate syrup and iced coffee were past their use-by dates or lacked proper dating. Additional observations showed sanitizer strip containers in the three-compartment sink area, one with an expiration date of June 1, 2021 and another with no identifying information or expiration date. Small flies were observed in the dish machine room, and the dishwasher wash and rinse temperature log had multiple missing entries across breakfast, lunch, and dinner cycles in July 2026. On follow-up, unlabeled black dishes were found in the freezer, and a cook was observed cutting ready-to-eat turkey sandwiches without gloves before placing them on resident plates.
Failure to Conduct and Document Facility Assessment
Penalty
Summary
The facility failed to conduct and document a facility-wide assessment to determine what resources were necessary to care for residents competently during day-to-day operations, including nights and weekends, and during emergencies. During interviews with the Nursing Home Administrator on July 21, 2026, July 22, 2026, and July 23, 2026, the surveyor requested the Facility Assessment document, described as an assessment of the resident population that includes evaluation of diseases, conditions, physical or cognitive limitations, acuity, and other pertinent information affecting services the facility must provide. On July 24, 2026, the Nursing Home Administrator and an RN confirmed that the facility had no evidence of a Facility Assessment identifying the education and skill sets necessary for nursing staff providing resident care until after the surveyor requested the document.
Failure to Provide Written Discharge Notification
Penalty
Summary
The facility failed to notify the resident and the resident's representative(s) or legal representative in writing of the reason for discharge for three sampled residents who were transferred out of the facility. Resident 4 was transferred to the hospital on July 13, 2026 after a change in condition, Resident 9 was transferred to the hospital on July 13, 2026 after a change in condition, and Resident 117 was transferred to the hospital on July 18, 2026 after a change in condition. For each of these residents, the clinical record contained no documented evidence that written notification of the transfer had been provided to the resident and the resident's responsible party or legal representative. During an interview on July 23, 2026 at 2:00 PM, the Nursing Home Administrator and an RN confirmed that the facility had no evidence of such written notification.
Insufficient Nursing Staff for Timely Medication Administration
Penalty
Summary
Sufficient nursing staff were not provided each day to meet resident needs related to medication administration on two hallways. The facility policy titled Medication Administration - General Guidelines stated that medications were to be administered within 60 minutes of the scheduled time. On July 23, 2026, an LPN reported that she had only begun the morning medication pass on D Hallway because she was assigned two halls for morning medications, and said this was happening more and more. At the time of the interview and observation, morning medications scheduled for 8:00 AM had not yet been administered to residents on D Hallway, including Residents 7, 14, 15, 20, 26, 29, 41, 42, 43, 44, 46, 55, 56, 61, 70, 72, 88, 93, 94, 95, 96, 97, and 118. On July 24, 2026, another LPN stated that she was still passing medications on B Hallway for the 8:00 AM morning medication pass and that when the facility did not have four nurses, one assigned to each hallway, medications were always late. Clinical record review showed that Residents 37, 62, and 117 on B Hallway had not received their morning medications within 60 minutes of the scheduled 8:00 AM time. Facility staffing records showed only 2.5 LPNs scheduled for the day shift on July 23, 2026, and three LPNs scheduled on July 24, 2026. The administrator and an RN were informed of the findings on July 24, 2026, at 12:00 PM.
Missing Staff Competency Evidence for Resident Care Tasks
Penalty
Summary
The facility failed to ensure that nurses and nurse aides had the competencies needed to care for residents with specific needs, affecting nine of 10 employees reviewed and one resident receiving peritoneal dialysis. During the survey, the Nursing Home Administrator and DON were asked for the Facility Assessment and for a list of qualified staff providing assistance with peritoneal dialysis, but the facility could not provide the Facility Assessment during multiple interviews. The facility also confirmed that it permits LPNs to take verbal orders from physicians and that Resident 117 was receiving peritoneal dialysis treatments, with the TAR showing treatments started at 10:00 PM and stopped at 7:00 AM daily. The TAR initials showed that LPNs Employees 4, 14, 19, and 20 administered the treatments, but the facility did not have evidence that all staff assisting with the dialysis had completed competency evaluations. The facility was unable to provide competency evidence for Employees 4, 14, 19, and 20 related to peritoneal dialysis. It also could not provide competency assessments for nurse aides Employees 11, 12, and 13 related to feeding, bathing, and resident transfer, including use of mechanical lifts. In addition, the facility could not provide evidence of LPN competencies for Employees 9 and 14 related to medication administration and responding to changes in resident condition, or RN competency for Employee 6 related to medication administration, peritoneal dialysis, and responding to changes in resident condition. The interview further confirmed that the facility did not staff an RN on second shift every day, used an LPN as charge nurse on many days, and had no evidence that LPN staff were educated on the on-call RN staffing plan and protocol.
Failure to Respond to Consultant Pharmacist Medication Review Recommendations
Penalty
Summary
The facility failed to ensure timely physician response to consultant pharmacist medication regimen review recommendations for two residents. The facility policy stated that non-emergent recommendations were to be addressed within 30 days, with follow-up if no response was received. During interview, the Nursing Home Administrator and DON stated that monthly consultant pharmacist reviews were documented in residents’ physical charts on the nursing unit rather than in the electronic medical record. Review of one resident’s physical chart showed no evidence of consultant pharmacist review after April 14, 2026, with no documentation for May, June, or July 2026. For that resident, a Note to Attending Physician/Prescriber requested a diagnosis to support the use of Amiodarone and asked for comment on benefits versus risks, and another note requested discontinuation of Voltaren gel due to non-use; the facility confirmed there was no evidence of physician response to either request. For the second resident, consultant pharmacist reports requested semi-annual evaluation of psychotropic medications and later evaluation of multiple psychotropic and related medications, including Sertraline, Trazodone, Topamax, Clonazepam, Wellbutrin, and Haldol. The physician responses directed staff to psychiatry, but the record contained no evidence that the contracted psychiatry provider responded to the earlier recommendations, and a later psychiatry progress note did not reference the March 19, 2026 consultant pharmacist report.
Failure to Implement EBP and Laundry Processing Deficiencies
Penalty
Summary
The facility failed to implement enhanced barrier precautions for Resident 117, who had an indwelling medical device inserted into the abdomen for peritoneal dialysis treatments. The facility’s EBP policy stated that residents with indwelling medical devices were to have signage outside the doorway and require gloves and gowns for high-contact resident care activities, with gowns stored in a hanging bag and used gowns placed in a closed receptacle. However, clinical record review found no physician order for EBP, and observations of the resident’s room on July 21, 2026, and July 22, 2026, showed no EBP signage, no gown or glove storage, and no receptacle for used supplies inside or outside the room. The facility also failed to ensure an environment free from the potential spread of infection related to resident laundry processing. A laundry aide stated that washing machines were filled to the top until a hand just fit inside and that laundry loads were not weighed for the new machines. The aide also stated there was no operating manual in the laundry room. Maintenance provided the model number for the washing machines, and a review of the manufacturer brochure for that model indicated a 60-pound capacity. The Nursing Home Administrator was made aware of the laundry findings on July 24, 2026.
Failure to Offer Pneumococcal and Influenza Immunizations
Penalty
Summary
The facility failed to ensure that residents were offered pneumococcal and influenza immunizations unless contraindicated for three of five residents reviewed for immunizations. Clinical record review showed that Resident 16 was admitted on June 28, 2021, and received PPSV23 on July 2, 2021, but there was no evidence of any additional pneumococcal vaccination in the five years since that dose and no Pneumococcal Immunization Consent/Declination form in the record. When interviewed on July 23, 2026, Resident 16 stated that they had never been offered a pneumococcal vaccine. Resident 3’s record contained no historical data showing that the resident had been offered or received any pneumococcal vaccinations, and no Pneumococcal Immunization Consent/Declination information was collected. Resident 59’s record showed no indication that the resident received or refused the 2025 influenza vaccination, despite having received influenza vaccine in each of the previous four years, and the facility could not provide a signed influenza consent/declination form or explain why the vaccine was not given. The Nursing Home Administrator and an RN confirmed these findings during interview on July 23, 2026.
COVID-19 Vaccination Education and Documentation Deficiencies
Penalty
Summary
The facility failed to ensure residents were educated and offered the COVID-19 immunization unless contraindicated for two residents reviewed for immunizations, and failed to maintain documentation related to staff COVID-19 vaccination education. Review of Resident 3’s clinical record showed the resident was admitted on July 4, 2026, but there was no information in the chart indicating COVID-19 immunization status or whether the resident had been offered COVID-19 immunization education, and there was no evidence the resident received a COVID-19 vaccine. Review of Resident 59’s record showed admission on March 21, 2024, historical documentation of a COVID-19 immunization in 2021, and a COVID-19 booster refusal dated February 2, 2024, but no further evidence that the resident or resident representative had been offered any COVID-19 vaccinations or education since that time. In interview, the Nursing Home Administrator and an RN stated the facility had no evidence of documentation regarding staff COVID-19 immunization education and no practice documenting that education.
Psychotropic Medication Monitoring and Review Deficiency
Penalty
Summary
The facility failed to ensure that one resident’s medication regimen was free from potentially unnecessary psychotropic medication. Resident 12 had active physician orders for multiple psychotropic medications, including haloperidol, Wellbutrin, sertraline, trazodone, Topamax, and clonazepam, for diagnoses including schizoaffective disorder, bipolar type, personality disorder, bipolar disorder, major depressive disorder, anxiety disorder, and related mental health conditions. The resident’s care plans included interventions for psychotropic medication use, mood problems, anxiety, depression, personality disorder, schizoaffective disorder, fixed delusions, and other behavioral health concerns, with directions to monitor behaviors, side effects, and medication effectiveness. However, the resident’s Psychoactive Drug Monthly Flow Records only documented three target behaviors for haloperidol use: hallucinations, delusions, and agitation. The record did not show ongoing target behavior monitoring or potential side effect monitoring for the antidepressant and antianxiety medications used by the resident. A consultant pharmacist requested semi-annual evaluations for continued use of sertraline, haloperidol, trazodone, clonazepam, Wellbutrin, and Topamax, but the physician responses stated the psychotropic medications were managed by psychiatry. The resident’s chart contained psychiatry progress notes, but there was no evidence that the contracted psychiatry provider responded to the pharmacist’s recommendations. A later pharmacist review again requested evaluation of the resident’s psychotropic drug therapy, and the physician directed the issue to psychiatry more than a month later; the subsequent psychiatry note did not reference that pharmacist report. Surveyor interviews with the Nursing Home Administrator and an RN confirmed the concerns regarding the lack of ongoing behavior monitoring, side effect monitoring, and routine review for gradual dose reduction.
Inaccurate MDS Assessments and Missing Vision Care Planning
Penalty
Summary
The facility failed to ensure that assessments accurately reflected resident status for three residents. For one resident with Parkinson's disease and documented contractures of the left hand and muscle, an active physician order directed staff to place a carrot splint to the left hand every shift with gentle passive ROM, and nursing documentation later noted Botox injections for left arm and hand contractures. Despite this history, one quarterly MDS dated April 8, 2026, was coded as showing no ROM impairments, even though other quarterly MDS assessments identified ROM impairments of both upper and lower extremities. The Nursing Home Administrator and an RN confirmed that the April 8, 2026 MDS had been coded in error. For another resident, a quarterly MDS indicated that she received one insulin injection during the seven-day lookback period, but review of her May 2026 medication regimen showed no evidence that she received insulin, and the Nursing Home Administrator and RN confirmed the MDS was coded incorrectly. For a third resident admitted on April 10, 2026, the admission assessment documented that she had glasses and was wearing a corrective vision appliance on admission, and her electronic record profile picture also showed her wearing glasses. However, the admission MDS assessed her vision while she was not wearing corrective lenses, and available care plans did not show that her use of glasses was incorporated into her plan of care. Her husband reported that she wears glasses but lost them at the facility and staff could not find them.
Incomplete care planning and failure to provide hearing aids
Penalty
Summary
The facility failed to implement a comprehensive, person-centered care plan for a resident with a cardiac pacemaker. Clinical record review showed the resident had a diagnosis of a pacemaker, and a quarterly MDS dated May 17, 2026 also listed the presence of a cardiac pacemaker. A chest x-ray documented on March 31, 2026 noted a pacemaker. However, review of the resident’s care plan showed no current comprehensive care plan addressing the pacemaker, related assessments, clinical care, or precautions. When the pacemaker care plan was requested during a meeting with the Nursing Home Administrator and DON on July 22, 2026, the facility later provided a pacemaker care plan created that same day, and the facility confirmed the resident had not previously had a pacemaker care plan. The facility also failed to provide a resident with hearing aids as reflected in the resident’s plan of care. The resident, who had a BIMS score of 14 indicating cognitive intactness, told the surveyor she was having difficulty hearing and was waiting for staff to provide her hearing aids. She stated she had to specifically ask for them and was often told they were not charged, so she did not receive them for the day. The hearing aids were not kept in the resident’s room. Review of the care plan showed the resident used hearing aids and that staff were to ensure their availability and function, but observations on two separate occasions showed the resident did not have her hearing aids in place, and an LPN confirmed this during one observation.
Failure to Implement Recommended Restorative Nursing Program
Penalty
Summary
Facility staff failed to provide care and services to maintain or improve the ability to perform ADLs for Resident 104, who had a diagnosis of a displaced intertrochanteric fracture of the right femur. A Medicare 5-Day MDS dated June 8, 2026, identified the resident as having a BIMS score of 3, indicating cognitive impairment. Clinical documentation showed that PT completed a discharge report and that an RNP was developed after therapy services ended. The PT Discharge Summary for June 30, 2026, through July 2, 2026, listed restorative treatment as follow-up care recommended. A daily note dated July 2, 2026, also stated that an RNP was developed. However, the clinical record contained no documentation that the restorative nursing program for Resident 104 was completed or attempted as recommended by PT. During meetings with the NHA and DON, and later with the NHA and an RN, the NHA reported that PT recommended a restorative program and it was not put into place.
Missing Ordered Weights for Two Residents
Penalty
Summary
The facility failed to provide the highest practical care regarding ordered weights for two residents with nutritional concerns. Resident 11 had a physician order dated May 22, 2026, directing staff to obtain weight every week for four weeks, then monthly and as needed. The resident’s care plan identified a nutritional problem or potential nutritional problem related to medical history, and an intervention directed staff to weigh per orders, monthly, and as needed. However, the documented weights showed measurements only on May 22, 2026, June 30, 2026, and July 4, 2026, with no documented weights for the weeks of May 25, June 1, June 8, June 15, or June 22, 2026. Resident 104 had a physician order dated June 4, 2026, directing staff to obtain an admission weight, then weekly for four weeks, then monthly and as needed. The resident’s care plan also identified a nutritional problem or potential nutritional problem related to medical history, with interventions to weigh per orders, monthly, and as needed, and to monitor, record, and report signs and symptoms of malnutrition, including significant weight loss. Despite this, the record showed only one documented weight on June 4, 2026, with no additional weekly weights documented.
Failure to Assist Resident With Replacement Glasses
Penalty
Summary
The facility failed to assist a resident in gaining access to vision services by not including her use of glasses in the plan of care and not implementing timely measures to obtain replacement glasses after they were lost. The resident was admitted with glasses and her electronic medical record profile picture showed her wearing them, and a nursing admission progress note documented that she had a corrective vision appliance on admission. Her husband later reported that she wore glasses but had lost them while living at the facility and staff could not find them. Review of the available care plans showed no evidence that the resident’s need for glasses was incorporated into her plan of care. The Nursing Home Administrator and DON stated they had no knowledge of or investigation into the missing glasses, and observations on multiple dates showed the resident without glasses.
Missed Documentation of Ordered Pressure Ulcer Treatments
Penalty
Summary
The facility failed to provide the highest practical care to promote pressure ulcer healing for one resident who was admitted with a displaced intertrochanteric fracture of the right femur and had a BIMS score of 3, indicating cognitive impairment. On admission, the resident had two unstageable pressure ulcers present on the left sacrum and coccyx. Medical provider orders directed staff to cleanse the wounds, apply Santyl or other ordered wound products, and cover with specified dressings on a daily or twice-daily basis depending on the wound order. Review of the June and July 2026 TARs showed multiple dates when the ordered wound treatments were not documented as completed, including missed documentation for the sacral and coccyx dressings and later for the coccyx wound care with Vashe and Dakin's-soaked gauze. The facility provided no documentation explaining why the treatments were not recorded as completed, such as resident refusal, unavailability of treatment, or the resident not being available. The Nursing Home Administrator confirmed there was no further documentation or reason for the missing treatments.
Unanswered Exit Door Alarms and Elopement Risk
Penalty
Summary
The facility failed to ensure an environment free from accident hazards and adequate supervision when multiple unsecured exit door alarms at the smoker’s patio were observed sounding for extended periods without staff response. On July 22, 2026, the nurses’ station alarm showed a red flashing light and audible high-pitched alarm for the Common Smokers Patio door, with the alarm already active for 27 minutes; staff at the nurses’ station did not respond to the area. The alarm was again observed sounding later that morning, and a male resident was seen sitting on his walker seat outside the glass door while several staff walked through the area without responding to the alarm or checking the safety of the residents outside. Employee 3, the activities director, was observed on the patio with three residents and stated she had no way to turn off the door alarm once she exited the building, explaining that staff were to respond when the alarm activated and turn it off at the door. The alarm continued for additional minutes until the residents returned inside and the alarm was discontinued. Later that day, the smoker’s patio door alarmed again while three staff were present at the nurses’ station, but no staff went to determine the cause, and the alarm continued until it stopped at noon. Resident 5 had physician orders for a Secure care device at all times, with staff to check placement and function every shift, and her care plan addressed elopement risk and history of attempts to leave unattended. Records noted cognitive impairment, poor safety awareness, wandering, exit-seeking, and an unwitnessed fall outside the dining room near the smoker’s patio exit area. Resident 14’s MDS identified wandering behaviors placing her at significant risk of getting to a potentially dangerous place, and her care plan addressed elopement risk and required staff to always be aware of her location. Observations showed Resident 14 independently self-propelling her wheelchair near the smoker’s patio exit door while the door alarm continued to alert without staff response.
Failure to Follow PD Disconnect Procedure
Penalty
Summary
The facility failed to implement care consistent with professional standards of practice to prevent potential complications from a dialysis access site for one resident receiving peritoneal dialysis. The facility’s procedure for disconnecting PD directed staff to close the resident’s door, apply a mask, and then wash hands and apply gloves before accessing the PD port. During observation of the resident’s PD disconnecting procedure, a registered nurse placed gloves on without performing hand hygiene, entered the resident’s room without closing the door, and then applied a mask from the resident’s bedside table while continuing the procedure with the same gloves. The record also showed that the nurse had not received any facility training related to the resident’s PD.
Failure to Assess Entrapment Risk and Obtain Informed Consent for Bed Enabler Bars
Penalty
Summary
The facility failed to assess all potential risk areas for entrapment for two residents with enabler bars used as bed accident hazard devices, and failed to obtain informed consent for one resident's enabler bars. Resident 99 had diagnoses including difficulty walking and muscle weakness, a BIMS score of 15 indicating no cognitive impairment, and care plan interventions that included assist rails and bilateral grab bars to help with turning, repositioning, and bed mobility. During observation, bilateral enabler bars were attached to the resident's bed, and the resident stated he used them to help position himself. When surveyors requested documentation of informed consent, entrapment zone measurements, and risk assessments, the facility provided a nursing acknowledgement form dated January 17, 2025, but it did not include entrapment zone measurements, and the facility later stated it could provide no further documentation showing the potential entrapment zones were assessed. Resident 86 had diagnoses including repeated falls, a BIMS score of 14 indicating no cognitive impairment, and a care plan intervention that included grab bars on the bed to assist with bed mobility related to generalized weakness. During observation, bilateral enabler bars were present on the resident's bed, and the resident stated she used them to get in and out of bed. When surveyors requested documentation related to the enabler bars, the facility provided a nursing physical device review form dated March 23, 2026, but it did not contain entrapment zone measurements or documentation of informed consent. The facility later stated it could provide no further documentation showing the potential entrapment zones were assessed or that informed consent was obtained for the enabler bars.
Improper Storage of Unsecured and Unidentified Medications
Penalty
Summary
The facility failed to properly store resident medications on Nursing Unit B. During observation of the medication pass, a medication cart used by an LPN was found with several unsecured and unidentified medications in the bottom of the drawers where medication blister cards were stored. The items observed included two oblong yellow tablets, a round beige pill, half of an oblong shaped tablet, an oblong green colored tablet, a white round pill, and a smaller white round pill. The findings were reviewed with the Nursing Home Administrator and an RN during a meeting later that day.
Incomplete PD Documentation
Penalty
Summary
The facility failed to ensure complete and accurate clinical documentation for Resident 117’s peritoneal dialysis (PD) care. During an observation on July 23, 2026, at 8:10 AM, a surveyor observed Employee 6, an RN, complete the disconnection procedure after the resident’s PD treatment. However, review of the clinical record showed that the nurse who initialed completion of this procedure was Employee 4, an LPN. The record also lacked documented completion of the disconnection task on three additional July 2026 dates, including July 15, 16, and 18. In addition, the resident’s treatment record did not identify who initiated the PD on July 19, 20, and 21, 2026. This information was reviewed with the Nursing Home Administrator and Employee 5, an RN, on July 23, 2026, at 2:30 PM.
Improper Disposal and Containment of Garbage and Refuse
Penalty
Summary
The facility failed to properly contain and dispose of garbage and refuse at the outside dumpster area. On July 21, 2026, surveyors observed the main dumpsters on facility property with a recyclable dumpster lid open, and next to two additional dumpsters were several broken wheelchairs, miscellaneous equipment parts, five wooden pallets, and one broken lawn chair. On July 22, 2026, the same area contained added metal framing for a pop-up tent along with the previously observed broken wheelchairs and parts, and a piece of paper with a resident identifying name and room number was found in the grass near the dumpsters and pile of broken items. Surveyors also observed debris on the ground around a single dumpster, including plastic lids, leaves, an empty crushed nutritional container, cigarette butts, three medical gloves, plastic silverware, and a plastic paint tray. On July 24, 2026, the debris around the single dumpster and the paper with the resident name and room number remained in place.
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 19 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 | ★★★★★ | 7 | 0 |
| Sena Kean Nursing And Rehabilitation | 23.4 mi | ★★★★★ | 9 | 0 |
| Amaryllis Nursing And Rehab | 24 mi | ★★★★★ | 3 | 0 |
| Highland Park Rehabilitation And Nursing Center | 24.4 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.