Sweden Valley Manor
1028 East Second Street, Coudersport, PA 16915 · Potter County · 121 certified beds · avg 100 residents/day · certified since May 16, 1985
Part of chain: HCF MANAGEMENT (22 facilities, chain avg rating 3.1★)
3/5
Health inspection rating (on-site)
0
Serious findings on record
$0
Fines, last 3 years
3.53
Nurse hours/resident/day (adjusted)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★★☆☆3/5 · CMS overall rating: 3/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
All citations in the current public record (29)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Aug 8, 2025 | E · Potential for harm, repeated | The facility did not honor residents' right to voice complaints without discrimination or retaliation, or did not have a working complaint process that resolves issues promptly. |
| Aug 8, 2025 | D · Potential for harm, one-off | The facility charged residents' personal funds for items or services that Medicare or Medicaid already pays for. Facilities may not bill residents for covered items. |
| Aug 8, 2025 | D · Potential for harm, one-off | The facility did not give residents proper notice about what Medicare or Medicaid covers, or about charges the resident might owe for services that aren't covered. |
| Aug 8, 2025 | D · Potential for harm, one-off | The facility did not develop and follow policies and procedures to prevent abuse, neglect, and theft. These written safeguards are the foundation of resident protection. |
| Aug 8, 2025 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Aug 8, 2025 | D · Potential for harm, one-off | The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration. |
| Aug 8, 2025 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Sep 20, 2024 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Sep 20, 2024 | E · Potential for harm, repeated | The facility did not provide the care needed to maintain or improve residents' movement and flexibility — such as range-of-motion exercises — leading to avoidable decline. |
| Sep 20, 2024 | E · Potential for harm, repeated | The facility did not provide safe and appropriate pain management for a resident who needed it. |
| Sep 20, 2024 | D · Potential for harm, one-off | The facility did not allow residents to take their own medications when a clinical review showed they could do so safely. Residents have this right if their care team determines it's appropriate. |
| Sep 20, 2024 | D · Potential for harm, one-off | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. |
| Sep 20, 2024 | D · Potential for harm, one-off | The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. |
| Sep 20, 2024 | D · Potential for harm, one-off | The facility allowed residents to lose the ability to do daily activities — like bathing, dressing, and eating — when there was no medical reason for the decline. Good care helps residents keep the abilities they have. |
| Sep 20, 2024 | D · Potential for harm, one-off | The facility did not help a resident get vision and hearing services — such as eye exams, glasses, hearing tests, or hearing aids. |
| Sep 20, 2024 | D · Potential for harm, one-off | The facility did not provide proper foot care for residents. Foot care includes routine care like nail trimming and attention to foot problems, which matter greatly for older adults. |
| Sep 20, 2024 | D · Potential for harm, one-off | The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time. |
| Sep 20, 2024 | D · Potential for harm, one-off | The facility did not provide or arrange dental services for its residents. Nursing homes are responsible for making sure residents can get dental care. |
| Oct 20, 2023 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Oct 20, 2023 | E · Potential for harm, repeated | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. |
| Oct 20, 2023 | E · Potential for harm, repeated | The facility did not provide the care needed to maintain or improve residents' movement and flexibility — such as range-of-motion exercises — leading to avoidable decline. |
| Oct 20, 2023 | E · Potential for harm, repeated | The facility used bed rails without first trying safer alternatives, or without assessing the resident's safety risk, discussing the risks and benefits with the resident or family, getting consent, and installing the rails correctly. |
| Oct 20, 2023 | D · Potential for harm, one-off | The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. |
| Oct 20, 2023 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Oct 20, 2023 | D · Potential for harm, one-off | The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration. |
| Oct 20, 2023 | D · Potential for harm, one-off | The facility did not provide safe, appropriate care for residents who need dialysis — the treatment that filters the blood when kidneys fail. |
| Oct 20, 2023 | D · Potential for harm, one-off | The facility did not make sure residents actually saw their doctor face-to-face at all required visits. Doctors must examine nursing home residents in person on a regular schedule. |
| Oct 20, 2023 | D · Potential for harm, one-off | The facility did not employ enough qualified food and nutrition staff, including a qualified dietician, to properly run its food service. |
| Oct 20, 2023 | D · Potential for harm, one-off | The facility did not bring in qualified outside professionals to provide a required service when it didn't have a qualified professional on staff. |
Inspection trend by year
Citations from standard inspections decreased between the last two inspection cycles (11 → 7).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 11 | 0 | F |
| 2024 | 11 | 0 | F |
| 2025 | 7 | 0 | E |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
No fines or payment denials in the published 3-year window.
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Pennsylvania avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 3.53 | 3.94 | 3.95 | bottom 45% in Pennsylvania; bottom 38% in the U.S. |
| Registered Nurse hours | 0.55 | 0.80 | 0.69 | bottom 36% in Pennsylvania; bottom 45% in the U.S. |
| Weekend total nurse staffing | 3.15 | 3.58 | 3.50 | bottom 39% in Pennsylvania; bottom 39% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.27 | 0.56 | 0.48 | bottom 15% in Pennsylvania; bottom 27% in the U.S. |
| Total nursing staff turnover (%) | 35.9 | 44.5 | 45.8 | top 26% in Pennsylvania; top 26% in the U.S. |
| RN turnover (%) | 50.0 | 39.9 | 42.9 | bottom 31% in Pennsylvania; bottom 39% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.13, RN 0.49, weekend 2.79. Staffing rating: 3/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 3/5 · long-stay residents: 5/5 · short-stay residents: 1/5
Who owns this facility
For profit - Corporation
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Chad M. Unverferth 12-14-11 Irrv Grantor Tr | Organization | 5% or Greater Indirect Ownership Interest | 6% | 12/13/2021 |
| David V. Unverferth 12-14-11 Irrv Grantor Tr | Organization | 5% or Greater Indirect Ownership Interest | 6% | 12/13/2021 |
| Jeffrey L. Unverferth 12-14-11 Irrv Grantor Tr | Organization | 5% or Greater Indirect Ownership Interest | 6% | 12/13/2021 |
| Joann C. Unverferth 12-29-04 Revocable Trust | Organization | 5% or Greater Indirect Ownership Interest | 5% | 12/13/2021 |
| Joann C. Unverferth 12-31-12 Irrevocable Grantor Trust Fbo Kendra M. U | Organization | 5% or Greater Indirect Ownership Interest | 7% | 12/13/2021 |
| Joann C. Unverferth 12-31-12 Irrevocable Grantor Trust Fbo Kerri A. Ro | Organization | 5% or Greater Indirect Ownership Interest | 7% | 12/13/2021 |
| Joann C. Unverferth 12-31-12 Irrevocable Grantor Trust Fbo Kevan R. Un | Organization | 5% or Greater Indirect Ownership Interest | 7% | 12/13/2021 |
| Joann C. Unverferth 12-31-12 Irrevocable Grantor Trust Fbo Kristen S. | Organization | 5% or Greater Indirect Ownership Interest | 7% | 12/13/2021 |
| Joann C. Unverferth 12-31-12 Irrevocable Grantor Trust Fbo Kyle J. Unv | Organization | 5% or Greater Indirect Ownership Interest | 7% | 12/13/2021 |
| Joseph L. Unverferth 12-15-11 Irrv Grantor Tr | Organization | 5% or Greater Indirect Ownership Interest | 6% | 12/13/2021 |
| Lawrence G. Unverferth 12-13-11 Irrv Grantor Tr | Organization | 5% or Greater Indirect Ownership Interest | 6% | 12/13/2021 |
| R. Steven Unverferth 12-14-11 Irrv Grantor Tr | Organization | 5% or Greater Indirect Ownership Interest | 6% | 12/13/2021 |
| HCF Management, INC. | Organization | Operational/Managerial Control | NOT APPLICABLE | 01/01/2004 |
| Klay, Celeste | Individual | W-2 Managing Employee | NOT APPLICABLE | 08/01/2011 |
| Klay, Celeste | Individual | Corporate Officer | NOT APPLICABLE | 01/01/2016 |
| Redmond, Angela | Individual | W-2 Managing Employee | NOT APPLICABLE | 05/22/2023 |
| Redmond, Angela | Individual | Corporate Director | NOT APPLICABLE | 05/22/2023 |
| Romes, Kerri | Individual | W-2 Managing Employee | NOT APPLICABLE | 04/01/2013 |
| Romes, Kerri | Individual | Corporate Director | NOT APPLICABLE | 03/29/2019 |
| Romes, Kerri | Individual | Corporate Officer | NOT APPLICABLE | 11/01/2019 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "Walk me through what happens when a resident or family files a grievance — who responds and how fast?"
- "Can you give me a written list of exactly what residents are charged for beyond what Medicare or Medicaid covers?"
- "Before any service that isn't covered by Medicare or Medicaid, how will you notify us and get our agreement?"
- "What specific steps do you take to prevent abuse and neglect, and how are staff trained on them?"
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "How do you monitor residents' weight and eating, and what happens when someone starts losing weight?"
- "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
- "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
No other Medicare-certified nursing homes within 20 miles in the current records.
All facilities in Coudersport →
Facility data as of CMS processing date 2026-08-01. CCN 395699.