7 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Wilkes Barre, PA
5-star overall rating with 3-star inspections with 7 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
80 E. Northampton Street, Wilkes Barre, PA
(570) 826-1031
Overall
5 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Beds
92
Certified beds
Average residents
66
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1983-07-01
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
RN hours / resident day
0.82
Registered nurse staffing · state 0.78 · national 0.68
LPN hours / resident day
1.06
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
2.69
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
4.57
All reported nurse hours · state 3.89 · national 3.89
Licensed hours
1.88
RN + LPN hours · state 1.69 · national 1.54
Weekend hours
4.06
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.56
Weekend registered nurse coverage · state 0.55 · national 0.47
Physical therapist
0.13
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.81
CMS adjusted RN staffing hours
Adjusted total hours
4.47
CMS adjusted total nurse staffing hours
Case-mix index
1.40
Higher values indicate more complex resident acuity
RN turnover
28%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
38%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Program rank
3,289
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
45.03
Composite VBP score used to determine payment impact.
Payment multiplier
0.9982
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
3.40
Baseline 18.09% · Performance 19.86% · Measure score 3.40 · Achievement 3.40 · Improvement 0
Healthcare-associated infections
5.16
Baseline 5.59% · Performance 6.29% · Measure score 5.16 · Achievement 5.16 · Improvement 0
Total nurse turnover
5.15
Baseline 19.36% · Performance 42.65% · Measure score 5.15 · Achievement 5.15 · Improvement 0
Adjusted total nurse staffing
4.31
Baseline 3.11 hours · Performance 4.31 hours · Measure score 4.31 · Achievement 4.31 · Improvement 3.97
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.3% |
10.72%
0.6 pts worse
|
No Different than the National Rate · Eligible stays 128 · Observed rate 12.5% · Lower 95% interval 7.83% |
| Discharge to community | 47.25% |
50.57%
3.3 pts worse
|
No Different than the National Rate · Eligible stays 132 · Observed rate 40.91% · Lower 95% interval 37.83% |
| Medicare spending per beneficiary | 1 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 96.77% |
95.27%
1.5 pts better
|
Numerator 120 · Denominator 124 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 124 |
| Discharge self-care score | 52.43% |
53.69%
1.3 pts worse
|
Numerator 54 · Denominator 103 |
| Discharge mobility score | 37.86% |
50.94%
13.1 pts worse
|
Numerator 39 · Denominator 103 |
| Pressure ulcers or injuries, new or worsened | 2.42% |
2.29%
0.1 pts worse
|
Numerator 3 · Denominator 124 · Adjusted rate 1.82% |
| Healthcare-associated infections requiring hospitalization | 6.29% |
7.12%
0.8 pts better
|
No Different than the National Rate · Eligible stays 105 · Observed rate 4.76% · Lower 95% interval 4.1% |
| Staff COVID-19 vaccination coverage | 30.38% |
8.2%
22.2 pts better
|
Numerator 24 · Denominator 79 |
| Staff flu vaccination coverage | 49.11% |
42%
7.1 pts better
|
Numerator 83 · Denominator 169 |
| Discharge function score | 40.78% |
56.45%
15.7 pts worse
|
Numerator 42 · Denominator 103 |
| Transfer of health information to provider | 70.27% |
95.95%
25.7 pts worse
|
Numerator 26 · Denominator 37 |
| Transfer of health information to patient | 96.15% |
96.28%
0.1 pts worse
|
Numerator 50 · Denominator 52 |
| Resident COVID-19 vaccinations up to date | 31.03% |
25.2%
5.8 pts better
|
Numerator 18 · Denominator 58 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.6 |
1.7
0.1 pts better
|
1.9
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 1.4 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.7 |
1.2
0.5 pts better
|
1.8
1.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.7 · Observed 0.6 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
86.9%
13.1 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
93.5%
6.5 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.0% |
3.2%
2.2 pts better
|
3.3%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.0% · Q4 2.0% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
6.5%
6.5 pts better
|
11.4%
11.4 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 who lose too much weight | 9.2% |
6.5%
2.7 pts worse
|
5.4%
3.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 5.3% · Q3 14.3% · Q4 13.3% · 4Q avg 9.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 18.0% |
19.9%
1.9 pts better
|
19.6%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.9% · Q2 22.0% · Q3 15.6% · Q4 17.0% · 4Q avg 18.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 11.0% |
18.7%
7.7 pts better
|
16.7%
5.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.1% · Q2 13.9% · Q3 11.1% · Q4 8.1% · 4Q avg 11.0% · 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 | 19.9% |
19.6%
0.3 pts worse
|
16.3%
3.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 19.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 15.7% |
18.3%
2.6 pts better
|
14.9%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 11.1% · Q2 10.3% · Q3 13.3% · Q4 26.1% · 4Q avg 15.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.0% |
0.9%
1.1 pts worse
|
1.0%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 1.6% · Q3 3.1% · Q4 1.8% · 4Q avg 2.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.7% |
1.7%
2 pts worse
|
1.7%
2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 4.2% · Q3 4.3% · Q4 6.4% · 4Q avg 3.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 36.9% |
26.4%
10.5 pts worse
|
19.8%
17.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.6% · Q2 46.9% · Q3 27.3% · Q4 46.0% · 4Q avg 36.9% |
| Percentage of long-stay residents with pressure ulcers | 6.8% |
5.3%
1.5 pts worse
|
5.1%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.9% · Q2 10.9% · Q3 5.7% · Q4 3.4% · 4Q avg 6.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 92.7% |
68.9%
23.8 pts better
|
81.7%
11 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 94.6% · Q2 95.6% · Q3 92.5% · Q4 88.3% · 4Q avg 92.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 6.4% |
9.8%
3.4 pts better
|
12.0%
5.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 6.4% · Observed 6.3% · Expected 11.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.4% |
1.5%
1.1 pts better
|
1.6%
1.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.3% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 95.7% |
68.7%
27 pts better
|
79.7%
16 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 95.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 14.7% |
23.1%
8.4 pts better
|
23.9%
9.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 14.7% · Observed 15.8% · Expected 25.5% · Used in QM five-star |
Survey summary
Top issue: Quality of Life and Care (5 deficiencies)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Top issue: Infection Control (1 deficiency)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Top issue: Resident Rights (4 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2026-01-09
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2026-01-09
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-02-27
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-04-12
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-04-12
Inspection history
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2026-01-06
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2026-01-06
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2026-01-06
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 2026-01-06
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2026-01-06
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 2026-01-06
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2026-01-06
Health
Provide and implement an infection prevention and control program.
Corrected 2025-02-25
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-02-25
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-02-25
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2025-02-25
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-04-16
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2024-04-16
Health
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Corrected 2024-04-16
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-04-16
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-04-16
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 2024-04-16
Health
Provide bedrooms that don't allow residents to see each other when privacy is needed.
Corrected 2024-04-16
Health
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Corrected 2024-04-16
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Not marked corrected
Penalties and ownership
5% Or Greater Direct Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
Operational/Managerial Control · Organization
Corporate Director · Individual
Corporate Officer · Individual
Corporate Director · Individual
Corporate Director · Individual
Operational/Managerial Control · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
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