Marywood Heights
2500 Adams Avenue, Scranton, PA 18509 · For profit - Limited Liability company · 72 certified beds · (570) 343-4065 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a high payroll-based staffing rating (4/5)
- CMS has flagged it for abuse
- it has abuse, neglect, or exploitation citations (F0600, F0602) — most recent Mar 2026
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0605) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has a citation for mishandling residents’ money or property (F0565)
- it has 3 actual-harm citations
- a high number of inspection citations overall (33) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $32,646 in federal fines (most recent 2024-07-25)
- its payroll-based staffing score sits well above its independent inspection score
- its independent health-inspection rating is low (2/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 3 of 5 |
Worth a closer look. This home's staffing rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the staffing score rests on the facility's own payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 3 of 5 |
| Long-stay residentspeople who live here | 3 of 5 |
| Short-stay residentsrehab / post-hospital | 3 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 2 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 19.8% | 16.8% | 15.4% | worse |
| Long-stay residents who lose too much weight | 1.7% | 6.2% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 2.1% | 0.7% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 0.8% | 1.5% | 2.0% | better |
| Long-stay residents with depressive symptoms | 12.5% | 10.8% | 6.5% | worse |
| Long-stay residents who were physically restrained | 0.0% | 0.2% | 0.1% | better |
| Long-stay residents with falls causing major injury | 5.6% | 3.1% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 18.5% | 17.0% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 22.5% | 20.0% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 97.2% | 93.5% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 5.4% | 4.8% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 20.7% | 25.5% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 11.8% | 17.7% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.4% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 71.9% | 68.7% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 14.1% | 22.5% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 10.6% | 9.5% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.41 | 1.62 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 1.01 | 1.18 | 1.80 | better |
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
30.9% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that worse than the national rate. This is CMS’s risk-adjusted rate over 82 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 50.0% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 42 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 0.27 therapist hours per resident per day in 2026Q1 — more than 40% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 3% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 30.9%CMS range 23.8–39.4 | 51.5% | Oct 2022–Sep 2024 | worse than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 9.4%CMS range 6.4–12.3 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 50.0% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 42.9% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 26.2% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 26.4% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 90.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 1.9% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 5.7% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 6.6%CMS range 3.8–11.5 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.74 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 72 beds and averages 70.2 residents a day — about 98% occupied, or roughly 2 beds typically open. It runs essentially full — expect a waiting list. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.03 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.59 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.29 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.78 hrs/resident/day on weekends vs 4.14 on weekdays — 9% thinner on weekends. RN hours go from 0.67 to 0.39 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 46% is about the same as the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
33 citations, most serious first. The 13 most serious are shown; the remaining 20 are one tap away and print in full.
- Actual harm · Gcited before2026-03-26 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records, the facility's abuse prohibition policy, facility investigative documentation, and staff interviews, it was determined the facility failed to ensure that a resident was free from neglect by not providing care with the required assistance of two staff members and the use of a mechanical lift as planned to ensure safety and prevent major injuries. As a result, the resident sustained a fracture of the clavicle and a fracture of the first rib, representing actual harm for one resident (Resident 65) out of 20 residents sampled.Findings include: A review of a facility policy titled Investigation of Allegations of any Abuse Type last reviewed by the facility on January 3, 2026, revealed it is the facility's policy to provide protection for the health, welfare, and rights of each resident by developing and implementing written policies that prohibit and prevent abuse and neglect. The policy defined neglect as the failure of the facility, its employees, or service providers to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Actual harm · G2024-07-25 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records and select investigation reports and staff interviews, it was determined that the facility failed to provide necessary supervision, and implement effective individualized safety measures for a resident with known unsafe behaviors to prevent multiple falls for one resident (Resident 13) and a serious burn, to one resident (Resident 27) out of 19 residents sampled. Findings include: A review of Resident 27's clinical record revealed that the resident was admitted to the facility April 14, 2023, with diagnoses to include hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage affecting left dominant side. (Hemiparesis, also called unilateral paresis, is the weakness of one entire side of the body. Hemiplegia, in its most severe form, is the complete paralysis of one entire side of the body). A quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted at specific intervals to plan resident care) dated May 15,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Actual harm · Gcited before2024-01-31 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of the facility's abuse prohibition policy, select investigative reports and clinical records, and interview with staff it was determined that the facility neglected to provide the care and services necessary to avoid physical harm and maintain physical health for one resident out of five residents sampled (Resident 2). Findings include: A review of the facility's Resident Abuse policy, last revised January 2023, revealed that the facility will provide each resident with the highest practicable physical, mental, and psychological services to meet their individual needs and to promote or maintain the resident at their highest level of well-being. This includes the protection of Resident's Rights. Each resident has the right to privacy, dignity and confidentiality for all aspects of care and services. A review of the clinical record revealed that Resident 2 was admitted to the facility on [DATE], 2022, with diagnoses, which included dementia, muscle weakness and the need for assistance with…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2026-03-26 · tag F0757 — failed to avoid unnecessary drugs — patternEnsure each resident’s drug regimen must be free from unnecessary drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records, facility policy, and staff interview, it was determined the facility failed to ensure residents were free from unnecessary antibiotic medications for two of 20 residents reviewed (Residents 2 and 50). Findings include: A review of the facility policy titled Antibiotic Stewardship, last reviewed January 3, 2026, revealed appropriate indications for antibiotic use include meeting minimum clinical criteria for active infection utilizing McGeer Criteria (standardized clinical criteria used in long-term care to determine whether sufficient signs and symptoms are present to support diagnosis of infection and initiation of antibiotic therapy). A review of Resident 2's clinical record revealed Resident 2 was admitted to the facility on [DATE], with diagnoses including dementia (decline in memory and thinking ability affecting daily functioning), urinary retention (inability to completely empty the bladder), history of cystitis (inflammation of the bladder), and presence of a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-03-26 · tag F0565 — failed to support the resident council — isolatedHonor the resident's right to organize and participate in resident/family groups in the facility.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on a review of facility policy, Resident Council meeting minutes, grievance documentation provided by the facility, and resident and staff interviews, it was determined the facility failed to make reasonable efforts to address concerns raised by the Resident Council and failed to keep residents informed regarding the status and outcome of identified concerns. The facility did not ensure ongoing communication or timely follow-up regarding issues presented by five of five residents attending a Resident Council group meeting (Residents 31, 48, 30, 38, and 35).Findings include: A review of the facility's Grievance Policy last reviewed on January 5, 2026, indicated the residents', families, and their representatives have the right to voice grievances concerning care and treatment, behavior of staff or other residents or any concerns regarding their stay. Further stating the grievance official will follow up on all concerns and grievances registered by any resident or resident representative. A review of the Minutes from a Resident Council meeting dated December 29, 2025, revealed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-03-26 · tag F0605 — failed to not use drugs as a restraint — isolatedPrevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of clinical records, facility policy, pharmacy recommendations, behavior monitoring documentation, observations, and staff interview, it was determined the facility failed to ensure one of 20 residents reviewed (Resident 36) was free from the use of a chemical restraint Findings include: A review of a facility policy titled Use of Psychotropic Medication(s) last reviewed by the facility on January 3, 2026, revealed it is the policy of the facility to ensure that residents only receive psychotropic medications when other nonpharmacological interventions (approaches that do not involve medication, such as environmental modification, reassurance, or behavioral techniques) are clinically contraindicated. The policy defined a psychotropic medication as a drug that affects brain activity associated with mental processes and behavior. The policy indicated that use of psychotropic medications without documentation demonstrating that other treatments were clinically contraindicated is considered inadequate justification for use. The policy revealed the indications for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-03-26 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records, observation, and staff interviews, it was determined the facility failed to develop and implement an individualized, person-centered comprehensive care plan that addressed ongoing behavioral concerns and identified interventions to manage accusatory behaviors for one of 20 residents reviewed (Resident 57).Findings include: A review of the clinical record revealed Resident 57 was admitted to the facility on [DATE], with diagnoses to include generalized anxiety (a common, mental health condition characterized by excessive, persistent worry and fear that disrupts daily life) and depression (common mental illness characterized by persistent sadness, loss of interest in activities, and reduced energy, affecting how a person feels, thinks, and acts). A review of Resident 57's quarterly Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated February 9, 2026 revealed that Resident 57 was moderately…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-03-26 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of clinical records, and staff interviews, it was determined the facility failed to provide services consistent with professional standards of practice by failing to follow physician orders for a bowel protocol for one of 20 residents reviewed (Resident 8). Findings include: According to the American Academy of Family Physicians one of the largest medical organizations in the US founded to promote the science and art of family medicine), the primary goal of constipation management (treatment of difficulty passing stool or infrequent bowel movements) is improvement of symptoms, with the passage of soft, formed stool without straining generally occurring at least three times per week. A review of the clinical record revealed Resident 8 had physician orders dated July 19, 2024, for a bowel regimen (a step-by-step treatment plan used to prevent or relieve constipation) which included: Milk of Magnesia (magnesium hydroxide, a medication used to relieve constipation by drawing water into the bowel) suspension 400 mg/5 ml; administer 30 milliliters by mouth as needed for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-03-26 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records, select facility policy, and staff interview, it was determined the facility failed to implement procedures to maintain accurate records of controlled drugs and ensure accurate documentation of drug administration for one of 20 residents reviewed (Resident 34).Findings include:A review of the facility policy titled Controlled Substances, (medications regulated by federal law due to their potential for misuse or dependence and require accurate tracking from receipt through administration and disposition) last reviewed March 13, 2025, revealed the facility maintains a Master Controlled Substance Log, which includes individual medication sign-off sheets for each controlled medication and a shift-to-shift count reconciliation sheet located on each medication cart. The policy indicated staff are responsible for accurately documenting each dose removed and administered to ensure accountability and safe medication practices. A review of the clinical record revealed Resident 34 was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-05-08 · tag F0684 — failed to provide proper treatment and quality of care — patternProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on select facility policy, a review of clinical records and staff interviews it was determined the facility failed to provide nursing services consistent with professional standards of quality by failing to ensure that licensed nurses timely administered residents' medications for 2 of 18 residents reviewed. (Resident 9 and 41). Findings included: According to the Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicates the registered nurse (RN) was to carry out nursing care actions that promote, maintain, and restore the well-being of individuals. The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.145 Functions of the Licensed Practical Nurse (LPN) (a) The LPN is prepared to function as a member of the health-care team by exercising sound judgement based on preparation, knowledge, skills, understandings and past experiences in nursing situations. The LPN participates in the planning, implementation, and evaluation of nursing care in settings where nursing takes…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-05-08 · tag F0755 — failed to provide safe pharmacy services — patternProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on a review of controlled drug shift count records, and staff interview, it was determined the facility failed to implement procedures to promote accurate controlled medication records on two of two medication carts observed. Findings include: A review of facility policy entitled Marywood Heights Count Records last reviewed January 2, 2025, revealed controlled drugs are inventoried and documented under proper conditions in regard to security and state/federal regulations. Further the policy indicated Scheduled II medications are counted by the oncoming nurse and outgoing nurse at the change of each shift and documented on the individual shift count sheet for narcotics. A review of the facility Master Control Substance Log from the 215 to 271 nursing unit medication cart revealed the following: April 13, 2025, the day shift on coming nurse failed to sign that the narcotic count was completed and correct. April 13, 2025, the evening shift off going nurse failed to sign that the narcotic count was completed and correct. April 15, 2025, the night shift off going nurse failed to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-05-08 · tag F0761 — failed to label and store drugs safely — patternEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, select facility policy review and staff interview, it was determined the facility failed to implement procedures to ensure acceptable storage for medications on one of two nursing units observed. Findings include: A review of facility policy titled Disposal of Medications and Medication Related Supplies, last reviewed by the facility in January 2, 2025, revealed that discontinued medications and mediations left in the facility after a resident's discharge, which do not qualify for return to the pharmacy for credit, are destroyed. Observation of the medication storage room on May 6,2025, at 8:44 AM revealed an unsecured, opened white paper bag located on the counter of the medication room. The bag contained the following: Two separate rolls of medication packets, one roll containing 46 packets of medications, the second roll contained 29 packets of medications. One box containing two tabletss of Cefdinir (antibiotic). A clear plastic envelope containing two capsules of tizanidine (a muscle relaxant). One clear plastic envelope containing two tablets of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-05-08 · tag F0565 — failed to support the resident council — isolatedHonor the resident's right to organize and participate in resident/family groups in the facility.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on a review of facility policy, the minutes from facility Resident Council meetings, and grievances lodged with the facility, and resident and staff interviews, it was determined the facility failed to put forth sufficient efforts to promptly resolve continued resident complaints and grievances expressed during Resident Council meetings and verbal grievances, including those voiced by six of six residents attending a resident group meeting (Residents 16, 43, 62, 129, 32, and 71) and failed to keep the residents apprised of the status of the facility's decisions and efforts toward grievance resolution. Findings include: A review of the facility's Grievance Policy last revised in December 2019 indicated the residents', families, and their representatives have the right to voice grievances concerning care and treatment, behavior of staff or other residents or any concerns regarding their stay. Further stating the grievance official or designee will meet with the resident to formally review the resolution to the grievance. A review of the Minutes from Resident Council meetings…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 20 citations
- Potential for harm · D2025-05-08 · tag F0697 — failed to manage pain — isolatedProvide safe, appropriate pain management for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record and select facility policy review and staff interview, it was determined the facility failed to provide effective pain management and administer pain medication as prescribed by the physician and failed to attempt non-pharmacological interventions to alleviate pain prior to the administration of a narcotic pain medication prescribed on an as needed basis for one resident out of 18 sampled residents (Resident 69). Findings include: A review of the facility's policy entitled Pain Management with a policy review date of January 2, 2025, indicated that all residents are assessed for pain every shift by a nurse utilizing a 0 (zero) to 10 pain intensity scale (0 = no pain, 1,2, and 3 are classified as mild pain, 4, 5, 6, and 7 are classified as moderate pain, 8, 9, and 10 are classified severe pain). Non-pharmacological interventions may be effective for pain relief and might include ice packs, heat, (these require a physician's order) toileting, position changes, therapeutic touch, music,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-05-08 · tag F0757 — failed to avoid unnecessary drugs — isolatedEnsure each resident’s drug regimen must be free from unnecessary drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records, and staff interviews, it was determined the facility failed to ensure that a resident's drug regimen was free of unnecessary antibiotics for one out of 18 residents sampled (Resident 56). Findings included: A review of Resident 56's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses to include senile degeneration of the brain (a decline in cognitive function associated with aging) and chronic lymphocytic leukemia (a slow growing cancer of the white blood cells). A nursing progress note dated April 23, 2025, indicated the resident was noted to have yellow discharge from his penis. The physician was notified, and an order was obtained for a Urinalysis with Culture and Sensitivity (UA C&S a laboratory test used to detect and identify bacteria or fungi in urine, A urine culture is a method to grow and identify bacteria that may be in the urine. The sensitivity test helps select the best medicine to treat the infection) to assess for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-07-25 · tag F0756 — failed to review each resident's drug regimen — patternEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review clinical records and medication administration record, and staff interview, it was determined that the facility failed to ensure that the attending physician acted upon on the pharmacist's reports of irregularities in the drug regimen of one resident of 19 residents reviewed (Resident 41). Findings include: Review of Resident 41's clinical record revealed admission to the facility on October 29, 2018, with diagnoses that included major depressive disorder (major loss of interest in pleasurable activities), anxiety disorder, obsessive-compulsive disorder and dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning). Review of the consultant pharmacist's Note to Attending Physician/Prescriber dated January 24, 2024, addressed the physician's order for Ativan (an antianxiety medication) 0.5 mg three times a day for anxiety. The pharmacist recommended a Gradual Dose Reduction (GDR), noting that per CMS guidelines for psychotropic drugs, a GDR must me…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-07-25 · tag F0842 — failed to keep accurate, complete medical records — patternSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records and resident and staff interview, it was determined that the facility failed to maintain accurate and complete clinical records, according to professional standards of practice, reflecting the medial care for three residents out of 19 sampled (Residents 13, 37 and 60). Findings included: The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.145 Functions of the Licensed Practical Nurse (LPN) (a) The LPN is prepared to function as a member of the health-care team by exercising sound judgement based on preparation, knowledge, skills, understandings, and past experiences in nursing situations. The LPN participates in the planning, implementation, and evaluation of nursing care in settings where nursing takes place. 21.148 Standards of nursing conduct (a) A licensed practical nurse shall: (5) Document and maintain accurate records. According to the American Nurses Association Principles for Nursing Documentation, nurses document their…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-07-25 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records and the Resident Assessment Instrument and staff interview, it was determined that the facility failed to ensure that the Minimum Data Set Assessments (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) accurately reflected the status of one resident out of 19 sampled (Resident 13). Findings included: Clinical record review revealed that Resident 13 was admitted to the facility on [DATE], with diagnoses which included hemiplegia and hemiparesis following a stroke affecting left non-dominant side, bipolar disorder, and anxiety. Review of Resident 13's transfer paperwork revealed that the resident was at high risk for falls and had last experienced a fall on May 24, 2024. A review of Resident 13's admission MDS assessment dated [DATE], Section J - Health Conditions, question J1700 Fall History on Admission/Entry or Reentry, did the resident have a fall any time in the last month prior to admission/entry or reentry,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-07-25 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records and staff interview it was determined that the facility failed to provide care and services according to accepted standards of clinical practice in the identification of a resident's diagnosis of bipolar disorder for one resident (Resident 41) out of 19 residents sampled. Findings include: A review of the Resident 41's clinical record revealed that the resident was admitted to the facility on [DATE], with three psychiatric/mood disorders: major depressive disorder, anxiety disorder, and obsessive-compulsive disorder. A review of Resident 41's resident's medical diagnosis list revealed a diagnosis of bipolar disorder, was added on April 4, 2023. A review of a physician progress note dated April 30, 2023, at 4:32 PM revealed that the physician examined the resident who presented with severe anxiety. Since the previous dose reduction and reintroduction (of medications), the resident has not responded to medical management. The physician indicated that her impression was the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-07-25 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, review of clinical records, and resident and staff interviews it was determined that the facility failed to provide services consistent with professional standards of practice by failing to follow physician orders for bowel protocol for one resident (Resident 24) to promote normal bowel activity to the extent practicable and failed to follow physician orders for the consistent application of a prescribed therapeutic measure, Darco shoes, for one resident of 19 sampled (Resident 55). Findings include: According to the American Academy of Family Physicians {The American Academy of Family Physicians is one of the largest medical organizations in the US founded to promote the science and art of family medicine} the primary goal of constipation management should be symptom improvement, and the secondary goal should be the passage of soft, formed stool without straining at least three times per week). A review of the clinical record revealed that Resident 24 had physician orders, dated February 27, 2024, for the following bowel regimen: - Milk of Magnesia (MOM)…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-07-25 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records and staff interview, it was determined that the facility failed provided necessary care to prevent urinary tract infections to the extent possible for one resident with an indwelling urinary catheter out of 19 sampled residents (Resident 1). Findings included: Clinical record review revealed Resident 1 was admitted on [DATE], with diagnoses, which included retention of urine, acute cystitis without hematuria, urinary tract infection, and required the use of an indwelling catheter for urination. Review of physician orders revealed an order dated March 15, 2024, to change catheter monthly/every 30 days and as needed for blockage, leakage, or dislodgement with 16 French and a 10 cc balloon (size of catheter) on the night shift. Review of Treatment Administration Record dated April 2024, failed to provide evidence that the resident's catheter was changed as ordered by the physician during the month of April 2024. Review of clinical record revealed that on May 17, 2024, the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-07-25 · tag F0740 — failed to provide behavioral / mental-health care — isolatedEnsure each resident must receive and the facility must provide necessary behavioral health care and services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records and staff interview it was determined that the facility failed to consistently provide necessary services to meet the behavioral health needs of one of 19 sampled residents (Resident 27). Findings include: Review of the clinical record revealed that Resident 27 was admitted to the facility on [DATE], and had diagnoses, which included major depressive disorder. Resident 27's clinical record revealed documentation dated from the time of the resident's admission through the survey ending July 25, 2024, that the resident had consistent behavioral symptoms of yelling out repeatedly. These episodes occurred almost daily and not easily redirectable. Review of Resident 27's care plan in effect at time of survey ending July 25, 2024, revealed a focus area related to the resident's history of depression with an intervention for psyche follow ups as ordered/scheduled. A review of Resident 27's clinical record revealed the resident had an appointment with a psychiatrist scheduled for May…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-07-25 · tag F0757 — failed to avoid unnecessary drugs — isolatedEnsure each resident’s drug regimen must be free from unnecessary drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records and staff interviews it was determined that the facility failed to ensure that the resident's drug regimen was free of unnecessary antibiotic drugs for one out of 19 residents sampled (Resident 13). Findings included: Clinical record review revealed that Resident 13 was admitted to the facility on [DATE], with diagnoses which included hemiplegia and hemiparesis following a stroke affecting left non-dominant side, bipolar disorder, and anxiety and was cognitively intact. A review of documentation dated June 25, 2024, at 2:27 PM, revealed that the resident was sent to the emergency room for an evaluation due to complaints of dizziness and nausea after sustaining a fall in the bathroom and hitting her head earlier that day. Documentation dated June 25, 2024, at 11:35 PM, indicated that the resident returned to the facility with no acute injuries and an order for Keflex 500mg twice a day for 10 days for diagnosis of possible urinary tract infection and will follow-up with…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-07-25 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review clinical records and staff interviews, it was determined that the facility failed to ensure that a resident was free from unnecessary psychoactive drugs by failing to assure the presence of the documented prescriber clinical rationale for the use of a psychotropic medication one of five residents reviewed (Resident 45). Findings include: Review of Resident 45's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses including dementia. The resident had a physician order initially dated December 10, 2023 for Xanax Oral Tablet 0.25 MG (Alprazolam) anti anxiety for anxiety. A review of a pharmacist consult to the physician dated June 26, 2024 reveled a request for a gradual dose reduction (GDR) for the Xanax. There was no physician response to this request. Further review of Resident 45's clinical record revealed that the pharmacy consult was sent to the wrong physician and at time of survey ending July 25, 2024 had not been reviewed by Resident 45's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-07-25 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation and staff interview, it was determined that the facility failed to ensure adherence to medication and pharmaceuticals expiration dates in one of 4 medication carts. Findings include: An observation of the second-floor Cart A medication cart on July 25, 2024, at 8:05 AM revealed two multidose insulin vials opened. One multidose vial of Lantus 100units/ mL and one multidose vial of Admelog 100units/ mL were labeled with an expiration date of July 17, 2024. Employee 4, licensed practical nurse, confirmed the observations of the expired medications at the time of observation. Interview with the Director of Nursing on July 25, 2024, at 1:33 PM confirmed that the expired medications should have been removed from the medication cart and discarded. 28 Pa. Code 211.9 (a)(1)(k) Pharmacy Services 28 Pa. Code 211.12 (c)(d)(3)(5) Nursing services
- Potential for harm · D2024-07-25 · tag F0791 — failed to provide routine dental services — isolatedProvide or obtain dental services for each resident.
What the surveyor found here — the official record, unedited, may be distressing
Based on review of clinical records and staff interview, it was determined that the facility failed to offer routine annual dental services for one Medicaid payor source out of four residents sampled (Resident 23) for dental services. Findings include: Review of the clinical record of Resident 23 revealed admission to the facility on July 15, 2014, and the resident's payor source was Medicaid. There was no documented evidence at the time of the survey ending July 25, 2024, that the resident had been offered dental services in the past year. Review of Resident 23's care plan initially dated April 13, 2020, and revised December 9, 2023, indicated that the resident declined dental visits. However, the facility was unable to provide documented evidence that the resident was offered and declined dental services for the past year. Interview with the Director of Nursing on July 25, 2024, at 1:27 PM confirmed that the facility had not offered Resident 23 routine dental services in the past year. 28 Pa. Code 211.12 (c)(d)(3)(5) Nursing services
- Potential for harm · D2024-07-25 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observations, and staff interview, it was determined that the facility failed to maintain infection control practices to prevent potential spread of infection on one resident care unit out of two. (Second Floor). Findings include: Clinical record review revealed Resident 1 was admitted on [DATE], with diagnoses which included retention of urine, acute cystitis (sudden bacterial infection of the bladder or lower urinary tract) without hematuria (blood in urine), urinary tract infection ([UTI] an infection of the urinary system which includes the kidney, bladder, or urethra), and required the use of an indwelling catheter( a thin hollow tube inserted through the urethra into the urinary bladder to collect and drain urine) for urination. Review of clinical record revealed that on May 17, 2024, the resident had an appointment with Urology. Orders received from urology included to irrigate foley daily to prevent sediment buildup, irrigate as needed for decreased urinary output,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-01-31 · tag F0602 — failed to protect residents from theft of their belongings — patternProtect each resident from the wrongful use of the resident's belongings or money.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records, select facility policy and investigative reports it was determined that the facility failed to ensure that one of five residents sampled were free from misappropriation of property, medications (Resident 3). Findings include: A review of the facility's Resident Abuse policy, last revised January 2023, revealed that misappropriation of Resident Property is the deliberate misplacement, exploitation or wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent. Examples of misappropriation include, but are not limited to taking resident's monies, using their phone to make personal calls, administering a resident's medication to another resident, or eating food items off a resident's tray. Clinical record review revealed Resident 3 was admitted to the facility on [DATE], with diagnoses of peripheral vascular disease and chronic pain and readmitted to the facility after a hospital stay on December 22, 2023. A physician order was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-01-31 · tag F0684 — failed to provide proper treatment and quality of care — patternProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records and facility provided documentation and staff interviews it was determined that the facility failed to provide nursing services consistent with professional standards of practice for one resident (Resident 1) out of 5 residents reviewed by failing to show ongoing monitoring, identification and documentation of changes in resident condition to assure prompt and necessary treatment of fracture. Findings included: According to the Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicates that the registered nurse was to collect complete ongoing data to determine nursing care needs, analyze the health status of individuals and compare the data with the norm when determining nursing care needs, and carry out nursing care actions that promote, maintain, and restore the well-being of individuals. The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.145 Functions of the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-01-31 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of clinical records and grievances lodged with the facility and staff interview, it was determined that the facility failed to notify a resident's representative of an unwitnessed fall incurred by one resident out of five sampled (Resident 4). Findings include: A review of the clinical record revealed that Resident 4 was admitted into the facility on October 18, 2023, with diagnoses including chronic kidney disease and dementia. A nurse's note dated December 23, 2023, at 4:30 PM, but entered into the record on December 24, 2023, at 7:33 PM revealed that the resident had an unwitnessed fall and staff found the resident on the floor. The entry noted that the resident's physician and responsible party were notified of the fall. A review of a facility concern/grievance form dated January 15, 2024, revealed that Resident 4's responsible part stated that she was not notified of Resident 4's fall on December 23, 2023. An interview with the Director of Nursing on January 31, 2024, at approximately 2 PM confirmed the facility failed to timely notify the resident's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-01-31 · tag F0726 — failed to have competent, trained nursing staff — isolatedEnsure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records and facility investigative reports and staff and family interviews it was determined the facility failed to provide nursing staff with the appropriate competencies and skills sets necessary to provide physician ordered care and services, the use of a wound vacuum, for one resident admitted to the facility with a surgical wound, (Resident 4), out of eight sampled residents. Findings include: A review of Resident 4's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses to include, status post fracture of the humerus (the upper arm) with an open wound. Post hospitalization treatment at the facility was to include wound treatments. The resident was cognitively intact with a BIMS score of 15 (brief interview for mental status - a tool to assess cognitive function, a score of 13 to 15 indicates the resident is cognitively intact) according to a quarterly Minimum Data Set Assessment (MDS - a federally mandated standardized assessment…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-01-31 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of controlled drug records and select facility policy and staff interview, it was determined that the facility failed to implement pharmacy procedures for reconciling controlled drugs and records accounting for their administration for one of five residents sampled (Resident 3). Finding include: Clinical record review revealed Resident 3 was admitted to the facility on [DATE], with diagnoses of peripheral vascular disease and chronic pain. The resident was readmitted to the facility after a hospital stay on December 22, 2023. A physician order was noted November 20, 2023, for Percocet (Oxycodone-APAP, an opioid narcotic combination pain medication) 5/325 mg, one tab every 4 hours as needed for pain. A review of a pharmacy invoice dated November 20, 2023, revealed that 90 Oxycodone-APAP 5-325 mg were delivered to the facility for administration to Resident 3 A review of Medication Administration Records revealed that from November 22, 2023 through November 30 2023, revealed documented evidence…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-01-31 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation and and staff interview, it was determined that the facility failed to implement procedures to store medications under proper temperature controls in one of two medication storage rooms. Findings include: An observation on March 26, 2024, at approximately 1 PM, in the presence of Employee 6, Agency LPN, revealed two multi-dose containers of Ativan Oral Concentrate 2 MG/ML (Lorazepam, an antianxiety medication) were in the locked compartment of the second floor medication cart. Observation revealed that the 2 mg per ml oral concentrate was supplied as a clear colorless to light yellow solution, with labeling instructions for the drug to be stored at Cold Temperature-Refrigerate 2°-8°C (36°-46°F). Interview with the Nursing Home Administrator (NHA) on January 11, 2023, at approximately 12:40 PM, confirmed that Ativan concentrate was to be stored in the refrigerator and not the med cart. 28 Pa. Code 211.9 (a)(1)(k) Pharmacy services 28 Pa. Code 211.12 (d)(3)(5) Nursing services
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$32,646 in federal fines across 1 penalty.
- $32,646 — penalty dated 2024-07-25
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| KLINGERMAN, DANIEL | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 50% | since 12/01/2019 |
| KLINGERMAN, DAVID | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 20% | since 12/01/2019 |
| LACKAWANNA HEALTHCARE ASSOCIATES LLC | Organization | DIRECT OWNERSHIP INTEREST | — | since 12/01/2019 |
| WELKOM, KAREN | Individual | CORPORATE OFFICER | — | since 10/01/2024 |
| LIBERTY HEALTHCARE MGT LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 04/14/2025 |
| SWEETZ, MELISSA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 11/25/2024 |
CMS files one row per role, so the 8 rows in the source record cover these 6 parties — each is shown once here with every role it holds. Nothing is omitted.
2 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $318K paid to related parties (affiliated landlords or management companies) in its most recent cost report.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in PA
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Pennsylvania Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 395625. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-03-26, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.