Cycle 1
Health 2025-11-21 · Fire 2025-11-21
10 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Waymart, PA
Wayne Woodlands Manor
1-star overall rating with 2-star inspections with $11,911 in total fines with 10 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
37 Woodlands Drive, Waymart, PA
(570) 488-7130
Overall
1 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
117
Certified beds
Average residents
91
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1994-09-22
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.49
Registered nurse staffing · state 0.78 · national 0.68
LPN hours / resident day
0.94
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
2.37
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.81
All reported nurse hours · state 3.89 · national 3.89
Licensed hours
1.44
RN + LPN hours · state 1.69 · national 1.54
Weekend hours
3.45
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.32
Weekend registered nurse coverage · state 0.55 · national 0.47
Physical therapist
0.10
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.55
CMS adjusted RN staffing hours
Adjusted total hours
4.23
CMS adjusted total nurse staffing hours
Case-mix index
1.23
Higher values indicate more complex resident acuity
RN turnover
75%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
61%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
8,323
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
27.12
Composite VBP score used to determine payment impact.
Payment multiplier
0.9844
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.32
Baseline 18.38% · Performance 19.89% · Measure score 3.32 · Achievement 3.32 · Improvement 0
Healthcare-associated infections
1.65
Baseline 7.79% · Performance 7.34% · Measure score 1.65 · Achievement 1.65 · Improvement 1.12
Total nurse turnover
2.39
Baseline 26.56% · Performance 53.91% · Measure score 2.39 · Achievement 2.39 · Improvement 0
Adjusted total nurse staffing
3.49
Baseline 3.63 hours · Performance 4.07 hours · Measure score 3.49 · Achievement 3.49 · Improvement 1.54
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.6% |
10.72%
0.1 pts better
|
No Different than the National Rate · Eligible stays 165 · Observed rate 9.09% · Lower 95% interval 8.14% |
| Discharge to community | 48.94% |
50.57%
1.6 pts worse
|
No Different than the National Rate · Eligible stays 147 · Observed rate 45.58% · Lower 95% interval 42% |
| Medicare spending per beneficiary | 1.04 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 94.94% |
95.27%
0.3 pts worse
|
Numerator 75 · Denominator 79 |
| Falls with major injury | 2.53% |
0.77%
1.8 pts worse
|
Numerator 2 · Denominator 79 |
| Discharge self-care score | 40% |
53.69%
13.7 pts worse
|
Numerator 24 · Denominator 60 |
| Discharge mobility score | 50% |
50.94%
0.9 pts worse
|
Numerator 30 · Denominator 60 |
| Pressure ulcers or injuries, new or worsened | 1.27% |
2.29%
1 pts better
|
Numerator 1 · Denominator 79 · Adjusted rate 1.11% |
| Healthcare-associated infections requiring hospitalization | 7.34% |
7.12%
0.2 pts worse
|
No Different than the National Rate · Eligible stays 110 · Observed rate 6.36% · Lower 95% interval 4.55% |
| Staff COVID-19 vaccination coverage | 4.13% |
8.2%
4.1 pts worse
|
Numerator 5 · Denominator 121 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 45% |
56.45%
11.5 pts worse
|
Numerator 27 · Denominator 60 |
| Transfer of health information to provider | 95.83% |
95.95%
0.1 pts worse
|
Numerator 23 · Denominator 24 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 28 · Denominator 28 |
| Resident COVID-19 vaccinations up to date | 59.46% |
25.2%
34.3 pts better
|
Numerator 22 · Denominator 37 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.0 |
1.7
0.3 pts worse
|
1.9
0.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.0 · Observed 1.7 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.4 |
1.2
1.2 pts worse
|
1.8
0.6 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.4 · Observed 2.1 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 91.6% |
86.9%
4.7 pts better
|
93.4%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 98.8% · Q2 94.8% · Q3 88.3% · Q4 84.4% · 4Q avg 91.6% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.8% |
93.5%
5.3 pts better
|
95.5%
3.3 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.8% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.9% |
3.2%
0.7 pts worse
|
3.3%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 5.2% · Q3 3.9% · Q4 5.2% · 4Q avg 3.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.0% |
6.5%
4.5 pts better
|
11.4%
9.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.4% · Q3 4.1% · Q4 2.7% · 4Q avg 2.0% |
| Percentage of long-stay residents who lose too much weight | 4.3% |
6.5%
2.2 pts better
|
5.4%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.7% · Q2 1.6% · Q3 3.3% · Q4 3.2% · 4Q avg 4.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 26.6% |
19.9%
6.7 pts worse
|
19.6%
7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.8% · Q2 18.9% · Q3 30.6% · Q4 34.2% · 4Q avg 26.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 13.3% |
18.7%
5.4 pts better
|
16.7%
3.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.8% · Q2 12.9% · Q3 13.1% · Q4 15.6% · 4Q avg 13.3% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.2%
0.2 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 31.2% |
19.6%
11.6 pts worse
|
16.3%
14.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.8% · Q2 20.3% · Q3 40.4% · Q4 31.3% · 4Q avg 31.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 28.9% |
18.3%
10.6 pts worse
|
14.9%
14 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 32.9% · Q2 20.0% · Q3 35.7% · Q4 26.5% · 4Q avg 28.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 5.5% |
0.9%
4.6 pts worse
|
1.0%
4.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.8% · Q2 5.4% · Q3 5.9% · Q4 5.0% · 4Q avg 5.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.3% |
1.7%
0.6 pts worse
|
1.7%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 2.8% · Q3 1.4% · Q4 3.9% · 4Q avg 2.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 32.2% |
26.4%
5.8 pts worse
|
19.8%
12.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.0% · Q2 31.7% · Q3 34.3% · Q4 38.2% · 4Q avg 32.2% |
| Percentage of long-stay residents with pressure ulcers | 2.7% |
5.3%
2.6 pts better
|
5.1%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.9% · Q2 1.2% · Q3 3.7% · Q4 5.0% · 4Q avg 2.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 93.9% |
68.9%
25 pts better
|
81.7%
12.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 98.5% · Q2 97.1% · Q3 92.7% · Q4 89.2% · 4Q avg 93.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 16.0% |
9.8%
6.2 pts worse
|
12.0%
4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 16.0% · Observed 15.0% · Expected 10.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.0% |
1.5%
0.5 pts better
|
1.6%
0.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.3% · Q3 1.7% · Q4 0.0% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 87.5% |
68.7%
18.8 pts better
|
79.7%
7.8 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 87.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 27.2% |
23.1%
4.1 pts worse
|
23.9%
3.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 27.2% · Observed 26.2% · Expected 23.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2025-02-14 · Fire 2025-02-14
15 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (8 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2024-04-05 · Fire 2024-04-05
9 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-11-21
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2026-01-31
E · Potential for more than minimal harm
2025-11-21
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2026-01-31
E · Potential for more than minimal harm
2025-11-21
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2026-01-31
C · Minimal harm
2025-11-21
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2026-01-31
C · Minimal harm
2025-11-21
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2026-01-31
C · Minimal harm
2025-11-21
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2026-01-31
C · Minimal harm
2025-11-21
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2026-01-31
E · Potential for more than minimal harm
2025-02-14
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-03-17
E · Potential for more than minimal harm
2025-02-14
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-03-17
E · Potential for more than minimal harm
2025-02-14
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2025-03-17
F · Potential for more than minimal harm
2024-04-05
E1 · Emergency Preparedness Deficiencies
Fire Safety
Establish an Emergency Preparedness Program (EP).
Corrected 2024-06-11
E · Potential for more than minimal harm
2024-04-05
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2024-06-11
E · Potential for more than minimal harm
2024-04-05
K344 · Smoke Deficiencies
Fire Safety
Have an alternate power supply for its alarm system.
Corrected 2024-06-11
E · Potential for more than minimal harm
2024-04-05
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-06-11
C · Minimal harm
2024-04-05
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-06-11
C · Minimal harm
2024-04-05
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-06-11
Inspection history
Recent health citations
G · Actual harm
2025-11-21
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2026-01-13
F · Potential for more than minimal harm
2025-11-21
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2026-01-13
E · Potential for more than minimal harm
2025-11-21
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2026-01-13
E · Potential for more than minimal harm
2025-11-21
F761 · Pharmacy Service Deficiencies
Health
Ensure 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.
Corrected 2026-01-13
E · Potential for more than minimal harm
2025-11-21
F809 · Nutrition and Dietary Deficiencies
Health
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
Corrected 2026-01-13
D · Potential for more than minimal harm
2025-11-21
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2026-01-13
D · Potential for more than minimal harm
2025-11-21
F744 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2026-01-13
D · Potential for more than minimal harm
2025-11-21
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2026-01-13
D · Potential for more than minimal harm
2025-11-21
F773 · Administration Deficiencies
Health
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Corrected 2026-01-13
D · Potential for more than minimal harm
2025-07-08
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-07-31
G · Actual harm
2025-02-14
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-04-10
E · Potential for more than minimal harm
2025-02-14
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2025-04-10
E · Potential for more than minimal harm
2025-02-14
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2025-04-10
E · Potential for more than minimal harm
2025-02-14
F740 · Quality of Life and Care Deficiencies
Health
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected 2025-04-10
D · Potential for more than minimal harm
2025-02-14
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2025-04-10
D · Potential for more than minimal harm
2025-02-14
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2025-04-10
D · Potential for more than minimal harm
2025-02-14
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2025-04-10
B · Minimal harm
2025-02-14
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2025-04-10
G · Actual harm
2024-08-05
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-09-17
E · Potential for more than minimal harm
2024-08-05
F943 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
Corrected 2024-09-17
D · Potential for more than minimal harm
2024-08-05
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-09-17
D · Potential for more than minimal harm
2024-08-05
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-09-17
D · Potential for more than minimal harm
2024-08-05
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-09-17
D · Potential for more than minimal harm
2024-05-23
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-06-21
D · Potential for more than minimal harm
2024-05-23
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-06-21
E · Potential for more than minimal harm
2024-04-05
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2024-05-23
E · Potential for more than minimal harm
2024-04-05
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-05-23
D · Potential for more than minimal harm
2024-04-05
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-05-23
D · Potential for more than minimal harm
2024-04-05
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-05-23
D · Potential for more than minimal harm
2024-04-05
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-05-23
D · Potential for more than minimal harm
2024-04-05
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-05-23
D · Potential for more than minimal harm
2023-11-16
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-01-04
D · Potential for more than minimal harm
2023-11-16
F744 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2024-01-04
D · Potential for more than minimal harm
2023-08-30
F563 · Resident Rights Deficiencies
Health
Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing.
Corrected 2023-09-20
Penalties and ownership
What sits behind the stars
$11,911
2023-05-19
Fine
Fine · fine $11,911
Fine
Ownership
Wayne Woodlands Manor
5% Or Greater Direct Ownership Interest · Organization
Branning, Phillip
Operational/Managerial Control · Individual
Eisenhauer, Judy
Operational/Managerial Control · Individual
Wayne Memorial Health System Inc.
Operational/Managerial Control · Organization
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#3
Forest City Nursing And Rehab Center
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