10 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Waymart, PA
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
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
Staffing
RN hours / resident day
0.49
Registered nurse staffing
LPN hours / resident day
0.94
Licensed practical nurse staffing
Aide hours / resident day
2.37
Nurse aide staffing
Weekend hours
3.45
Weekend nurse staffing
RN turnover
75%
Annual RN turnover
Total nurse turnover
61%
Annual nurse turnover
Quality measures
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
Survey summary
Top issue: Pharmacy Service (3 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Top issue: Freedom from Abuse and Neglect and Exploitation (8 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Top issue: Quality of Life and Care (4 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire Safety
Use approved construction type or materials.
Corrected 2026-01-31
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2026-01-31
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2026-01-31
Fire Safety
Provide properly protected cooking facilities.
Corrected 2026-01-31
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2026-01-31
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2026-01-31
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2026-01-31
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-03-17
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-03-17
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2025-03-17
Fire Safety
Establish an Emergency Preparedness Program (EP).
Corrected 2024-06-11
Fire Safety
Use approved construction type or materials.
Corrected 2024-06-11
Fire Safety
Have an alternate power supply for its alarm system.
Corrected 2024-06-11
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-06-11
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-06-11
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-06-11
Inspection history
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2026-01-13
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2026-01-13
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
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
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
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2026-01-13
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2026-01-13
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2026-01-13
Health
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Corrected 2026-01-13
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-07-31
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
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2025-04-10
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2025-04-10
Health
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected 2025-04-10
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2025-04-10
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
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2025-04-10
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
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
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
Health
Respond appropriately to all alleged violations.
Corrected 2024-09-17
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
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
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-06-21
Health
Respond appropriately to all alleged violations.
Corrected 2024-06-21
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
Health
Provide and implement an infection prevention and control program.
Corrected 2024-05-23
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
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
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-05-23
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-05-23
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-01-04
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2024-01-04
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
Fine · fine $11,911
Fine
5% Or Greater Direct Ownership Interest · Organization
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Organization
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