3 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Wilkes Barre, PA
4-star overall rating with 4-star inspections with 3 recent health deficiencies
200 S. Meade Street, Wilkes Barre, PA
(570) 823-6131
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Beds
133
Certified beds
Average residents
109
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1975-03-01
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
0.70
Registered nurse staffing · state 0.78 · national 0.68
LPN hours / resident day
0.97
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
2.82
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
4.48
All reported nurse hours · state 3.89 · national 3.89
Licensed hours
1.67
RN + LPN hours · state 1.69 · national 1.54
Weekend hours
3.76
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.40
Weekend registered nurse coverage · state 0.55 · national 0.47
Physical therapist
0.09
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.72
CMS adjusted RN staffing hours
Adjusted total hours
4.62
CMS adjusted total nurse staffing hours
Case-mix index
1.33
Higher values indicate more complex resident acuity
RN turnover
38%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
47%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Program rank
868
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
62.76
Composite VBP score used to determine payment impact.
Payment multiplier
1.0176
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
6.58
Baseline 15.53% · Performance 18.38% · Measure score 6.58 · Achievement 6.58 · Improvement 0
Healthcare-associated infections
9.27
Baseline 5.60% · Performance 5.07% · Measure score 9.27 · Achievement 9.27 · Improvement 8.36
Total nurse turnover
6.17
Baseline 29.70% · Performance 38.46% · Measure score 6.17 · Achievement 6.17 · Improvement 0
Adjusted total nurse staffing
3.08
Baseline 3.81 hours · Performance 3.95 hours · Measure score 3.08 · Achievement 3.08 · Improvement 0.21
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.22% |
10.72%
1.5 pts better
|
No Different than the National Rate · Eligible stays 267 · Observed rate 8.24% · Lower 95% interval 6.9% |
| Discharge to community | 55.09% |
50.57%
4.5 pts better
|
No Different than the National Rate · Eligible stays 265 · Observed rate 46.79% · Lower 95% interval 49.17% |
| Medicare spending per beneficiary | 0.85 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 99.44% |
95.27%
4.2 pts better
|
Numerator 176 · Denominator 177 |
| Falls with major injury | 1.13% |
0.77%
0.4 pts worse
|
Numerator 2 · Denominator 177 |
| Discharge self-care score | 45.39% |
53.69%
8.3 pts worse
|
Numerator 64 · Denominator 141 |
| Discharge mobility score | 38.3% |
50.94%
12.6 pts worse
|
Numerator 54 · Denominator 141 |
| Pressure ulcers or injuries, new or worsened | 1.69% |
2.29%
0.6 pts better
|
Numerator 3 · Denominator 177 · Adjusted rate 1.27% |
| Healthcare-associated infections requiring hospitalization | 5.06% |
7.12%
2.1 pts better
|
No Different than the National Rate · Eligible stays 191 · Observed rate 3.14% · Lower 95% interval 3.31% |
| Staff COVID-19 vaccination coverage | 6.01% |
8.2%
2.2 pts worse
|
Numerator 11 · Denominator 183 |
| Staff flu vaccination coverage | 33.83% |
42%
8.2 pts worse
|
Numerator 68 · Denominator 201 |
| Discharge function score | 37.59% |
56.45%
18.9 pts worse
|
Numerator 53 · Denominator 141 |
| Transfer of health information to provider | 99.1% |
95.95%
3.1 pts better
|
Numerator 110 · Denominator 111 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 22.67% |
25.2%
2.5 pts worse
|
Numerator 17 · Denominator 75 |
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 · Adjusted 2.0 · Observed 2.0 · Expected 1.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.2 |
1.2
About the same
|
1.8
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.1 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.7% |
86.9%
12.8 pts better
|
93.4%
6.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.9% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.7% |
| 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 | 4.6% |
3.2%
1.4 pts worse
|
3.3%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 6.5% · Q3 5.6% · Q4 4.2% · 4Q avg 4.6% · 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 | 7.8% |
6.5%
1.3 pts worse
|
5.4%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.1% · Q2 8.3% · Q3 7.4% · Q4 8.2% · 4Q avg 7.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 14.6% |
19.9%
5.3 pts better
|
19.6%
5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.7% · Q2 17.0% · Q3 11.0% · Q4 13.3% · 4Q avg 14.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 3.3% |
18.7%
15.4 pts better
|
16.7%
13.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 4.4% · Q3 3.2% · Q4 2.9% · 4Q avg 3.3% · 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 | 20.3% |
19.6%
0.7 pts worse
|
16.3%
4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.5% · Q2 17.8% · Q3 19.5% · Q4 25.8% · 4Q avg 20.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 8.7% |
18.3%
9.6 pts better
|
14.9%
6.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 17.5% · Q3 3.9% · Q4 9.4% · 4Q avg 8.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.1% |
0.9%
1.2 pts worse
|
1.0%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.7% · Q3 4.6% · Q4 3.1% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.2% |
1.7%
0.5 pts worse
|
1.7%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.1% · Q3 3.4% · Q4 4.3% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 21.2% |
26.4%
5.2 pts better
|
19.8%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.9% · Q2 20.2% · Q3 23.0% · Q4 22.7% · 4Q avg 21.2% |
| Percentage of long-stay residents with pressure ulcers | 10.3% |
5.3%
5 pts worse
|
5.1%
5.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 11.5% · Q2 11.2% · Q3 9.9% · Q4 8.7% · 4Q avg 10.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 93.8% |
68.9%
24.9 pts better
|
81.7%
12.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 93.3% · Q2 91.4% · Q3 91.9% · Q4 98.5% · 4Q avg 93.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 3.9% |
9.8%
5.9 pts better
|
12.0%
8.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 3.9% · Observed 3.8% · Expected 10.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.6% |
1.5%
0.9 pts better
|
1.6%
1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 0.0% · Q3 0.0% · Q4 1.3% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 96.6% |
68.7%
27.9 pts better
|
79.7%
16.9 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 96.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 28.4% |
23.1%
5.3 pts worse
|
23.9%
4.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 28.4% · Observed 30.1% · Expected 25.2% · Used in QM five-star |
Survey summary
Top issue: Pharmacy Service (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Top issue: Quality of Life and Care (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Top issue: Nutrition and Dietary (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Inspection history
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2026-02-17
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 2026-02-17
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-05-29
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-05-06
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-05-06
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-05-29
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-05-06
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2025-05-06
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 2025-05-06
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-06-11
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-06-11
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2024-06-11
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 2024-06-11
Health
Implement a program that monitors antibiotic use.
Corrected 2024-06-11
Health
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Corrected 2024-06-11
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2024-06-11
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2024-06-11
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-06-11
Health
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Corrected 2024-06-11
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2024-06-11
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
W-2 Managing Employee · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
Nearby options
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