Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around November 2026
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 Mahoning Operating Llc during CMS and state inspections, most recent first.
A resident with chronic respiratory failure and muscle weakness had multiple scheduled medications, including diuretics, pulmonary hypertension treatments, psychotropic medication, and vitamin/mineral supplements, that were not administered within the facility’s required 90‑minute window. Audit reports showed several morning and afternoon doses given significantly late, ranging from just over an hour to several hours past the scheduled time, despite policy and professional standards requiring timely administration and accurate MAR documentation. The NHA acknowledged that medications are expected to be administered in a timely manner consistent with facility policy and nursing standards.
A resident with dementia, decreased mobility, and incontinence developed multiple pressure ulcers on the buttocks and sacrum despite having a care plan that included skin assessments and preventive interventions. Staff documented the resident's resistance to repositioning and the progression of wounds from open areas to deep tissue injuries and unstageable pressure injuries. The facility did not implement timely and adequate preventive measures, and detailed wound information was not provided to the resident's family prior to discharge.
The facility failed to provide proper oxygen administration and infection control for three residents. A resident had an empty humidifier bottle and undated oxygen tubing, while another had outdated nebulizer equipment. A third resident was not receiving prescribed oxygen therapy, with no physician order for discontinuation. These issues were confirmed by staff and management.
The facility failed to ensure medications were administered according to physician's parameters for two residents. One resident received Humalog injections despite low blood glucose levels, and another received Midodrine despite high blood pressure. These incidents were confirmed by the DON and Nursing Home Administrator.
The facility did not ensure the Medical Director or designee attended the quarterly QAPI meetings for two quarters. This was confirmed through sign-in sheets and an interview with the DON, revealing non-compliance with the requirement for quarterly attendance.
The facility did not send copies of written notices of facility-initiated hospital transfers to the Ombudsman for a resident transferred twice in September 2024. The social services director confirmed the lack of documentation for these and other transfers in previous months.
The facility failed to provide person-centered pain management for two residents by not consistently attempting non-pharmacological interventions before administering opioid medication and not documenting pain levels prior to administration.
The facility failed to timely report an incident of physical abuse involving two residents to the State Survey Agency. A nurse aide observed one resident hitting another in the mouth, and although the incident was reported to supervisory staff and documented, it was not reported to the State Survey Agency within the required time frames.
The facility failed to develop a comprehensive care plan for a resident with heart failure and an AICD. The care plan lacked necessary checks, monitoring for complications, and emergency procedures for the AICD device. This deficiency was confirmed through a clinical record review and staff interview.
The facility failed to develop and implement individualized plans to manage a resident's dementia-related behavioral symptoms, compromising the resident's safety and well-being. Despite documented behavioral issues such as incessantly calling out, yelling, and physical aggression, the resident's care plan did not address these behaviors or include individualized non-pharmacological approaches, purposeful activities, or environmental modifications.
The facility failed to provide written notice of facility-initiated transfers to the hospital for four residents. Clinical record reviews and staff interviews revealed that the required written notices, including the reason for the transfer and contact information for the Ombudsman, were not provided. The Nursing Home Administrator confirmed the absence of these notifications.
Failure to Administer Medications Within Required Timeframes
Penalty
Summary
The deficiency involves the facility’s failure to ensure that licensed nurses administered medications within the facility’s required timeframes and in accordance with professional standards of practice and state nursing regulations. Facility policy titled “Medication Administration,” last reviewed on September 1, 2025, required that medications be administered within 90 minutes of the scheduled time. Pennsylvania Code provisions for RNs and LPNs require that nurses carry out nursing care actions that promote, maintain, and restore well-being, exercise sound judgment, and document and maintain accurate records. The American Nurses Association principles for nursing documentation further emphasize timely documentation of medication records in the EHR to support informed decisions and continuity of care. The clinical record for one resident (CR1) showed the resident was admitted with chronic respiratory failure and muscle weakness and had multiple prescribed medications, including several scheduled for administration at 9:00 AM. These medications included Vitamin D3, Oyster Shell Calcium, Vitamin C, a multivitamin, aspirin, bumetanide, biotin, ropinirole, potassium, sildenafil, Lexapro (escitalopram), and Tyvaso (treprostinil) inhalation solution. The resident’s medication regimen included drugs for pulmonary hypertension, edema, anxiety, restless leg syndrome, and various vitamin and mineral supplements, all of which were to be administered according to the times and frequencies ordered and documented on the MAR. A review of the February 2026 medication administration audit report revealed multiple instances where this resident’s medications were administered outside the facility’s 90‑minute window. On one date, a 9:00 AM biotin dose was given at 2:18 PM, 318 minutes late. On another date, multiple 9:00 AM medications, including Tyvaso, Lexapro, Vitamin D3, potassium, Oyster Shell Calcium, bumetanide, aspirin, and ropinirole, were administered between 10:41 AM and 10:56 AM, 101 to 116 minutes after the scheduled time. Additionally, a 1:00 PM Tyvaso dose was given at 2:35 PM (95 minutes late), and a 1:00 PM sildenafil dose was given at 4:22 PM (202 minutes late). In an interview, the Nursing Home Administrator confirmed review of these late medication administrations and acknowledged that medications are expected to be administered timely in accordance with professional standards of practice and facility policy.
Failure to Prevent and Manage Pressure Ulcers in High-Risk Resident
Penalty
Summary
The facility failed to consistently provide care and services in accordance with professional standards to prevent the development of pressure ulcers for one resident. The resident, who had multiple risk factors including dementia, decreased mobility, incontinence, and a history of falls, was identified as being at risk for impaired skin integrity. The care plan included interventions such as regular skin assessments, keeping the skin clean and dry, applying protective creams, and using a mechanical lift for transfers. Despite these interventions, the resident developed multiple open and discolored areas on the buttocks and sacrum, which were identified by staff during routine care. Clinical documentation and staff witness statements revealed that the resident was resistive to repositioning and required significant assistance with activities of daily living. Initial assessment found a new open area on the left inner gluteal fold, followed by the discovery of additional open and non-blanchable areas on the buttocks and sacrum. The wounds progressed to deep tissue injuries and unstageable pressure injuries, with the presence of slough and eschar. The facility's investigative reports and nursing notes documented the progression of these wounds and the resident's combative behavior during care, which further complicated wound management. Although the care plan addressed the resident's risk factors, the facility did not implement timely and adequate preventive measures to prevent the development of pressure ulcers. The documentation also indicated that detailed wound descriptions and measurements were not provided to the resident's wife prior to discharge. Interviews with the DON and NHA confirmed the failure to prevent the development of pressure ulcers in this resident, as required by professional standards and regulatory requirements.
Deficiency in Oxygen Administration and Infection Control
Penalty
Summary
The facility failed to provide supplemental oxygen administration care consistent with professional standards of practice for three residents. For Resident 2, the humidifier bottle was found empty, and the oxygen tubing was not dated as per facility policy. Resident 16 had nebulizer tubing and a mask that had not been replaced for over 25 days, exceeding the recommended timeframe. These observations were confirmed by a licensed practical nurse. Resident 82 was observed with the oxygen concentrator on, but the nasal cannula was not applied to the resident and was instead placed in a clear bag. The oxygen tubing was also not dated. An interview with a licensed practical nurse revealed that the resident was being evaluated for discontinuation of oxygen therapy, but there was no physician order to withhold oxygen therapy. The nursing home administrator and the Director of Nursing confirmed that the nursing staff failed to adhere to facility policies concerning oxygen administration and infection control practices, and that Resident 82 was not receiving oxygen as prescribed.
Failure to Administer Medications According to Physician's Parameters
Penalty
Summary
The facility failed to provide nursing services consistent with professional standards by not ensuring that licensed nurses accurately administered prescribed medication according to physician's parameters for two residents. Resident 75, who had diagnoses including diabetes and chronic kidney disease, received Humalog injections outside the prescribed parameters on two occasions. The medication was administered despite blood glucose levels being below the threshold specified by the physician's order. This was confirmed by the Director of Nursing during an interview. Resident 11, diagnosed with Parkinson's disease, benign prostatic hyperplasia, and a history of COVID-19, was also affected by improper medication administration. The resident received Midodrine for hypotension despite having a systolic blood pressure exceeding the physician-ordered threshold. This incident was confirmed by both the Nursing Home Administrator and the Director of Nursing. The facility's failure to adhere to professional standards of nursing care resulted in medications being administered contrary to specific physician-ordered parameters.
Medical Director's Absence at QAPI Meetings
Penalty
Summary
The facility failed to ensure the Medical Director or their designee attended the quarterly Quality Assurance Process Improvement (QAPI) Committee meetings for two out of four quarters, specifically in April 2024 and January 2025. This deficiency was identified through a review of the QAPI Committee meeting sign-in sheets, which showed the absence of the Medical Director or designee at the meetings held on April 25, 2024, and January 30, 2025. An interview with the Director of Nursing on February 21, 2025, confirmed the absence of the Medical Director or designee at these meetings, indicating a failure to meet the regulatory requirement for quarterly attendance.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to provide copies of written notices of facility-initiated hospital transfers to a representative of the Office of the State Long-Term Care Ombudsman for one resident. Specifically, Resident 56 was transferred to the hospital on two occasions in September 2024, and although written notices were provided to the resident and their representative, there was no documented evidence that these notices were sent to the Ombudsman. An interview with the social services director confirmed the absence of documentation for these transfers and additional facility-initiated transfers in previous months, including April, June, July, and September 2024.
Failure to Provide Person-Centered Pain Management
Penalty
Summary
The facility failed to provide person-centered pain management consistent with professional standards of practice for two residents. Resident 43, who was admitted with cervical and intervertebral disc disorders, experienced almost constant pain as indicated in the MDS assessment. Despite having a care plan that included non-pharmacological interventions, the facility did not consistently attempt these methods before administering oxycodone. The MAR for March 2024 showed that Resident 43 received oxycodone 18 times without documentation of pain levels prior to administration, and the resident confirmed that non-pharmacological interventions were not offered consistently. Similarly, Resident 8, admitted with pyogenic arthritis and spondylosis, had a physician's order for oxycodone for severe pain. The MAR for February and March 2024 revealed that the resident received the medication 48 times in February and 12 times in March, with non-pharmacological interventions not attempted prior to administration in almost all instances. Interviews with the DON and NHA confirmed the lack of consistent non-pharmacological interventions and pain level assessments before administering pain medication.
Failure to Timely Report Resident Abuse
Penalty
Summary
The facility failed to timely report an incident of physical abuse involving two residents to the State Survey Agency. According to the facility's abuse prohibition policy, staff are required to report any allegations of abuse immediately to their supervisor, and the facility administrator or designee is responsible for follow-up investigation and reporting to the required agencies within five days. However, the facility did not adhere to this policy when a nurse aide observed one resident hitting another resident in the mouth with the back of her hand. The incident was reported to supervisory staff, but the facility did not report the abuse to the State Survey Agency within the required time frames. The incident involved Resident 4 hitting Resident 5 in the mouth after holding her wrist and telling her to shut up. Resident 5 was assessed and found to have no skin impairments, open areas, bruising, swelling, or dental issues. Despite the immediate reporting to supervisory staff and documentation in progress notes, the Nursing Home Administrator and Director of Nursing confirmed that the physical abuse was not reported to the State Survey Agency as required by the facility's policy and state regulations.
Failure to Develop Comprehensive Care Plan for Resident with AICD
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan to meet the individualized needs of a resident with heart failure and an automatic implantable cardiac defibrillator (AICD). The resident's care plan did not include necessary checks or monitoring for signs and symptoms of AICD complications, nor did it outline emergency care procedures for the AICD device. This deficiency was identified during a survey ending on March 22, 2024, and confirmed through a review of the resident's clinical record and an interview with the MDS Coordinator. The resident, who was admitted to the facility with diagnoses including heart failure and the presence of an AICD, had a cardiology progress note indicating the need to ensure the move to the skilled nursing facility did not affect the AICD device. Despite this, the care plan lacked specific actions to be taken if the AICD was activated, such as consulting the physician, obtaining vital signs, and ensuring the safety of the resident and staff. The deficiency was confirmed by Employee 1, the RN and MDS Coordinator, who acknowledged the failure to fully address the care and management of the resident's AICD in the care plan.
Failure to Address Dementia-Related Behaviors
Penalty
Summary
The facility failed to develop and implement individualized plans to manage a resident's dementia-related behavioral symptoms, compromising the resident's safety and well-being. Resident 4, diagnosed with Alzheimer's disease and exhibiting severe cognitive impairment, displayed numerous behavioral issues such as incessantly calling out, yelling, entering other residents' rooms, and physical aggression. Despite these behaviors being documented in nursing progress notes over several months, the resident's care plan did not address these specific behaviors, nor did it include individualized interdisciplinary non-pharmacological approaches to care, purposeful activities, or environmental modifications tailored to the resident's needs. The facility did not provide evidence of specialized services and supports for Resident 4, such as specialized activities, nutrition, and environmental modifications, based on the resident's abilities and dementia-related behaviors. During an interview, the Nursing Home Administrator and Director of Nursing confirmed the lack of an individualized, person-centered care plan for Resident 4's dementia care and behaviors. This failure to provide necessary care and services was a significant deficiency identified during the survey.
Failure to Provide Written Notice of Transfer
Penalty
Summary
The facility failed to ensure that a written notice of facility-initiated transfer to the hospital was provided to the resident and resident's representative for four residents. Specifically, Residents 47, 8, 18, and 39 were transferred to the hospital on various dates, but there was no evidence that written notices containing all required contents were provided. These contents include the reason for the transfer, the effective date of the transfer, the location to which the resident was transferred, contact and address information for the Office of the State Long-Term Care Ombudsman, and, if applicable, information for the agency responsible for the protection and advocacy of individuals with developmental disabilities. An interview with the Nursing Home Administrator confirmed that there was no evidence of written notifications being provided to the residents and their representatives for these facility-initiated transfers. This deficiency was identified through clinical record reviews and staff interviews, which revealed the absence of the required written notices for the transfers of Residents 47, 8, 18, and 39.
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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 Lehighton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Summit At Blue Mountain Nursing & Rehab Ctr, The | 2.1 mi | — | 0 | 0 |
| St Luke's Rehabilitation And Nursing Center | 7.8 mi | — | 0 | 0 |
| Forest Hills Rehabilitation & Healthcare Center | 8.2 mi | — | 10 | 0 |
| Greenwood Center For Nursing And Rehab | 10.5 mi | — | 17 | 0 |
| Manor At St Luke Village,the | 12.6 mi | — | 16 | 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.