Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Delaware Valley Skilled Nursing & Rehabilitation C during CMS and state inspections, most recent first.
A resident with sepsis and a UTI did not receive all prescribed IV antibiotic doses due to medication unavailability, and the facility failed to notify the physician or representative as required. Additionally, staff did not consistently complete required shift count documentation for controlled substances, with missing signatures on the medication cart log.
A resident with dementia expressed suicidal ideation to staff, leading to an evaluation by social services and implementation of frequent safety checks. However, the facility did not update the resident's care plan to include interventions or measurable objectives addressing the risk of self-harm or psychosocial needs, as confirmed by the Nursing Home Administrator.
A resident with dementia and nutritional risk experienced significant weight loss over a 30-day period. Despite assessment by an RD and ongoing recommendations, the care plan was not reviewed or revised to address the change in nutritional status or weight trends, and no new interventions were documented.
The facility failed to follow physician orders for bowel protocols, therapeutic devices, and preventative measures for residents, leading to extended periods without bowel movements and improper application of devices. Additionally, inaccurate documentation of food and fluid intake for a resident with heart disease resulted in delayed identification of condition changes, leading to hospitalization.
A resident experienced significant weight loss and dehydration due to the facility's failure to consistently monitor weights and implement effective nutrition management interventions. Despite being cognitively intact and having a history of weight fluctuations, the resident's declining oral intake was not timely addressed, leading to hospitalization and the need for a feeding tube.
The facility failed to provide evening snacks to residents, as required by policy, when the interval between dinner and breakfast exceeded 14 hours. Residents reported not being offered snacks, and observations confirmed insufficient snack options. The Registered Dietitian could not explain the inconsistency in offering snacks.
A resident with multiple health conditions and at risk for pressure sores was not adequately monitored or cared for, leading to the development of a new wound. The facility failed to follow its Skin Impairment Protocol, and the wound was not properly evaluated. Despite the care plan including an air mattress and regular repositioning, these measures were not effectively implemented.
A facility failed to provide necessary emergency supplies for a resident receiving hemodialysis. Despite a physician's order for an emergency kit at bedside, the resident's care plan lacked interventions for emergency care, and no kit was observed at the bedside. Interviews with the resident and DON confirmed the absence of the emergency kit.
The facility failed to provide timely dental services for two residents, one with a broken dental bridge and another with poor dentition and a high-risk heart condition. Despite scheduled appointments and identified needs, there was no follow-up or evidence of dental care provided, leading to unresolved dental issues.
A resident with cognitive impairments and mobility assistance needs suffered a dislocated shoulder, but the facility failed to fully investigate the incident or identify the root cause. Despite signs of pain and an odd sound reported by a nurse aide, the facility's investigation was incomplete, and no specific concerns or corrective actions were identified. The facility's QAPI program did not effectively address the incident or ensure quality care.
Failure to Ensure Timely Medication Administration and Accurate Controlled Drug Documentation
Penalty
Summary
The facility failed to ensure the timely acquisition and administration of a prescribed intravenous antibiotic for one resident who was readmitted from the hospital with sepsis and a urinary tract infection, and who required IV medication via a PICC line. Despite a physician's order for Meropenem to be administered every 12 hours for five days, the medication was not available for administration on two separate occasions, resulting in missed doses. Facility policy required staff to check the automated medication dispensing system, contact the pharmacy for STAT delivery, notify the physician and resident representative if the medication was unavailable, and document these actions. However, the clinical record lacked documentation that the physician or resident representative was notified of the missed doses, and the resident did not receive the full course of prescribed antibiotic therapy. The Nursing Home Administrator confirmed that backup pharmacy resources were available but not utilized to prevent the missed doses. Additionally, the facility failed to maintain accurate controlled drug shift count documentation on one of two medication carts reviewed. Facility policy required Schedule II medications to be counted and verified at each shift change by both oncoming and outgoing nurses, with signatures required to verify accuracy. Review of the controlled medication shift change log revealed missing signatures on multiple occasions, and staff interviews confirmed that the required sign-offs were not completed. The Nursing Home Administrator acknowledged the facility's failure to consistently adhere to procedures for verifying and documenting controlled substance counts.
Failure to Update Care Plan for Resident Expressing Suicidal Ideation
Penalty
Summary
The facility failed to develop a comprehensive, person-centered care plan with measurable objectives and timetables to address the needs of a resident who expressed suicidal ideation. Clinical record review showed that the resident, who had dementia, was admitted with multiple diagnoses and, on one occasion, communicated to staff a desire to harm herself. Although the social services department evaluated the resident and initiated every 15-minute checks, the resident's care plan was not updated to reflect her expressed suicidal ideation or to include interventions addressing her mental health risk. The care plan lacked documentation of strategies to monitor, support, and ensure the resident's safety regarding her psychosocial needs. The Nursing Home Administrator confirmed that the care plan had not been updated to address these concerns.
Failure to Update Care Plan After Significant Weight Loss
Penalty
Summary
The facility failed to review and revise the comprehensive care plan for a resident who experienced a significant change in condition related to weight loss. The resident, who had dementia and was at nutritional risk with a mechanically altered diet, lost 6.8% of body weight over a 30-day period. Although a registered dietitian assessed the resident and continued to recommend interventions following the weight loss, the care plan, originally developed months earlier, was not updated to reflect the resident's new nutritional status or to address ongoing weight trends. During the survey, it was found that there was no documented evidence that the care plan had been reviewed or revised after the significant weight loss was identified. No new interventions were added, nor were existing interventions updated to address the change in the resident's condition. The Nursing Home Administrator confirmed that the care plan should have been updated to reflect the resident's current needs following the weight loss.
Failure to Follow Physician Orders and Document Resident Care
Penalty
Summary
The facility failed to provide nursing services consistent with professional standards of practice by not following physician orders for a bowel protocol for a resident with Alzheimer's Disease and chronic kidney disease. The resident had physician orders for a bowel regimen that included Milk of Magnesia, Bisacodyl, and Fleet Enema to be administered sequentially if no bowel movement occurred. However, the Medication Administration Record showed no evidence that the prescribed bowel protocol was followed during periods of constipation, leading to extended periods without bowel movements. Additionally, the facility did not consistently apply prescribed therapeutic devices and preventative measures for three residents. One resident was observed without Geri-sleeves and TED stockings, which were ordered to protect skin integrity and manage edema. Another resident was not wearing TED stockings as ordered, and a third resident's heels were not offloaded, and hip precautions were not maintained as prescribed. These observations were confirmed by staff interviews, indicating a failure to adhere to physician orders and care plans. The facility also failed to accurately document food and fluid intake for a resident with a history of heart disease and chronic heart failure. The resident experienced significant weight loss and had poor oral intake, but meal intake records were incomplete, with nearly half of the entries missing. This lack of documentation contributed to a delay in identifying changes in the resident's condition, resulting in critical lab values and hospitalization. The Director of Nursing confirmed the inconsistencies in documentation and the failure to act on the resident's condition changes.
Failure to Monitor Resident Weight and Nutrition
Penalty
Summary
The facility failed to consistently and accurately monitor the weights of a resident, leading to significant weight loss and dehydration. The facility's policy required re-weighing residents whose weight fluctuated by a certain amount, but this was not adhered to for a resident who experienced a significant weight loss over a period of time. The resident, who was cognitively intact, had a history of weight fluctuations and was on a therapeutic diet due to conditions such as hypertension and diabetes. Despite these conditions, the facility did not timely obtain, assess, and monitor the resident's weights to develop effective nutrition management interventions. The resident's weight records showed a progressive decline from 127 lbs to 97.6 lbs over several months, indicating a 20.9% weight loss. The Registered Dietitian (RD) noted the need for re-weighing and identified significant weight loss, but the interventions, such as the use of appetite stimulants and nutritional supplements, were not effectively evaluated or adjusted. The resident's oral intake was inconsistent, and the discontinuation of an appetite stimulant was linked to decreased intake, yet alternative methods for nutrition and hydration were not adequately explored or discussed with the resident and the interdisciplinary team. Ultimately, the resident was admitted to the hospital with dehydration, acute kidney injury, and other complications, necessitating the insertion of a feeding tube. The facility's Director of Nursing confirmed that the facility did not timely address the resident's declining oral intake, which led to the significant weight loss and hospitalization. The report highlights the facility's failure to adhere to its own policies and procedures regarding weight monitoring and nutrition management, resulting in adverse health outcomes for the resident.
Failure to Provide Evening Snacks to Residents
Penalty
Summary
The facility failed to routinely offer evening snacks to residents, as required by their policy, which states that all residents should be provided a nourishing snack at bedtime unless medically contraindicated. During a group meeting with residents, four residents reported that they were not offered snacks in the evening as desired. One resident mentioned that they had not been offered snacks for several months, while another recalled that staff used to offer snacks after supper, but this practice had ceased. All residents in attendance agreed that they were not offered evening snacks. The review of meal delivery times showed that the interval between dinner and breakfast exceeded 14 hours, necessitating the provision of a nourishing snack. However, the available snacks in the nursing unit were insufficient to meet this requirement. Observations revealed limited snack options, including a single rice crispy treat and 15 peanut butter crackers, with minimal items in the refrigerator/freezer. The Registered Dietitian was unable to explain why residents were not consistently offered a nourishing snack at bedtime, despite the extended interval between meals.
Failure to Implement Pressure Ulcer Prevention and Care
Penalty
Summary
The facility failed to consistently implement measures to promote healing and prevent the development of pressure sores for a resident identified as Resident 43. The resident, who was admitted with diagnoses including Parkinson's disease, heart disease, and diabetes, was moderately cognitively impaired and required substantial assistance for daily activities. Despite being at risk for pressure sore development, the facility did not adequately monitor or address the resident's significant weight loss, which was a risk factor for pressure ulcers. The care plan included interventions such as the use of an air mattress, regular repositioning, and skin assessments, but these measures were not effectively implemented. A new wound was discovered on the resident's sacrum, which was not identified by staff prior to its development. The facility's investigation revealed that the wound was not evaluated for size, drainage, or the condition of surrounding tissue, and the Skin Impairment Protocol was not followed. The resident was later sent to the emergency room due to a change in condition, and hospital documentation recommended consideration for an air mattress, which was supposedly already in place. The interim Director of Nursing confirmed the facility's failure to evaluate the pressure area and implement the necessary protocol.
Failure to Provide Emergency Dialysis Supplies
Penalty
Summary
The facility failed to ensure the availability of necessary emergency supplies for a resident receiving hemodialysis. Resident 218, who was admitted with end-stage renal disease and dependent on renal dialysis, had a physician order dated July 29, 2024, for an emergency kit at bedside for the dialysis access site. However, the resident's care plan did not include interventions for emergency care of the Ash Cath, and an observation on August 6, 2024, revealed no emergency kit or supplies at the resident's bedside. Interviews conducted with Resident 218 and the Director of Nursing (DON) confirmed the absence of the emergency kit. Resident 218 stated that he had never seen or been informed of an emergency kit since his admission. The DON acknowledged that each resident receiving dialysis should have emergency supplies at bedside and confirmed the facility's failure to provide the necessary emergency kit for Resident 218.
Failure to Provide Timely Dental Services
Penalty
Summary
The facility failed to promptly refer a resident with a broken dental bridge for necessary dental services and did not provide dental care for another resident with poor dentition and a high-risk heart condition. Resident 4, who was moderately cognitively impaired, had a broken upper bridge noted on July 1, 2024. Although a dental appointment was scheduled for July 17, 2024, there was no documentation of the appointment's outcome or any follow-up by the speech therapist. By the time of the survey ending on August 8, 2024, there was no evidence that the dental appliance had been repaired or replaced. Resident 24, who was cognitively intact and had a history of atherosclerotic heart disease with a xenogeneic heart valve, was identified with broken teeth and dentures upon admission. Despite these findings and a subsequent hospitalization for endocarditis, which highlighted poor dentition as a contributing factor, the facility did not arrange for dental services to address the resident's dental issues. The Director of Nursing confirmed that dental services were not provided to prevent the infection related to the resident's poor dental condition.
Failure to Implement Effective QAPI Program
Penalty
Summary
The facility failed to demonstrate the implementation of ongoing Quality Assurance and Performance Improvement (QAPI) programs, specifically in investigating and analyzing the root cause of adverse events. This deficiency was evidenced by the case of a resident who was admitted with diagnoses including hemiplegia, hemiparesis, aphasia, and dementia. The resident was moderately cognitively impaired and required extensive assistance for daily activities. An incident occurred where the resident was found to have a dislocated left proximal humerus, but the facility did not fully investigate the circumstances surrounding the injury. The resident's care plan indicated the need for assistance with mobility and toileting, and there were multiple instances where the resident showed signs of pain. On one occasion, a nurse aide reported hearing an odd sound while providing care, but there was no evidence that this was communicated to the nursing staff. The resident was later found to be guarding her left arm and shoulder, leading to an x-ray that confirmed the dislocation. Despite these events, the facility's investigation did not identify any specific concerns with the care provided or determine the root cause of the injury. The facility's QAPI plan outlined goals for infection control, creating a QAPI team, and staff training, but there was no evidence of corrective actions developed from the QAPI review of this incident. The investigation was incomplete, and the facility did not demonstrate an effective QAPI program to ensure quality of care and life by thoroughly investigating resident incidents and maintaining documentation to support their analysis and corrective actions.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Matamoras
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| St Josephs Place | 1.7 mi | — | 3 | 0 |
| Milford Rehabilitation And Healthcare Center | 5.2 mi | — | 1 | 0 |
| Homestead Rehabilitation & Health Care Center | 16.2 mi | — | 0 | 0 |
| Highland Rehabilitation And Nursing Center | 16.5 mi | — | 3 | 0 |
| The Valley View Center For Nursing Care And Rehab | 17.8 mi | — | 2 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.