Cycle 1
Health 2025-06-26 · Fire 2025-06-26
12 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Pittsburgh, PA
Asbury Health Center
2-star overall rating with 2-star inspections with 12 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
700 Bower Hill Road, Pittsburgh, PA
(412) 341-1030
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
139
Certified beds
Average residents
135
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Boncrest Resource Group
Operator or chain grouping
Approved since
1977-08-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
5 facilities
Chain averages 2 overall / 2 health / 4 staffing / 3 quality stars
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
Hours and turnover
RN hours / resident day
1.29
Registered nurse staffing · state 0.78 · national 0.68
LPN hours / resident day
0.51
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
2.27
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
4.07
All reported nurse hours · state 3.89 · national 3.89
Licensed hours
1.80
RN + LPN hours · state 1.69 · national 1.54
Weekend hours
3.64
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.98
Weekend registered nurse coverage · state 0.55 · national 0.47
Physical therapist
0.08
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
1.35
CMS adjusted RN staffing hours
Adjusted total hours
4.25
CMS adjusted total nurse staffing hours
Case-mix index
1.31
Higher values indicate more complex resident acuity
RN turnover
47%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
54%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
478
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
69.14
Composite VBP score used to determine payment impact.
Payment multiplier
1.0219
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
8.81
Baseline 19.67% · Performance 17.35% · Measure score 8.81 · Achievement 8.81 · Improvement 8.29
Healthcare-associated infections
5.02
Baseline 5.05% · Performance 6.33% · Measure score 5.02 · Achievement 5.02 · Improvement 0
Total nurse turnover
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Adjusted total nurse staffing
6.91
Baseline 4.29 hours · Performance 5.04 hours · Measure score 6.91 · Achievement 6.91 · Improvement 4.54
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.95% |
10.72%
0.8 pts better
|
No Different than the National Rate · Eligible stays 121 · Observed rate 8.26% · Lower 95% interval 6.36% |
| Discharge to community | 48.37% |
50.57%
2.2 pts worse
|
No Different than the National Rate · Eligible stays 104 · Observed rate 43.27% · Lower 95% interval 37.94% |
| Medicare spending per beneficiary | 0.8 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 98.11% |
95.27%
2.8 pts better
|
Numerator 52 · Denominator 53 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 53 |
| Discharge self-care score | 59.57% |
53.69%
5.9 pts better
|
Numerator 28 · Denominator 47 |
| Discharge mobility score | 38.3% |
50.94%
12.6 pts worse
|
Numerator 18 · Denominator 47 |
| Pressure ulcers or injuries, new or worsened | 5.66% |
2.29%
3.4 pts worse
|
Numerator 3 · Denominator 53 · Adjusted rate 7.23% |
| Healthcare-associated infections requiring hospitalization | 6.34% |
7.12%
0.8 pts better
|
No Different than the National Rate · Eligible stays 46 · Observed rate 2.17% · Lower 95% interval 3.3% |
| Staff COVID-19 vaccination coverage | 1.21% |
8.2%
7 pts worse
|
Numerator 2 · Denominator 165 |
| Staff flu vaccination coverage | 36.67% |
42%
5.3 pts worse
|
Numerator 77 · Denominator 210 |
| Discharge function score | 40.43% |
56.45%
16 pts worse
|
Numerator 19 · Denominator 47 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 47.06% |
96.28%
49.2 pts worse
|
Numerator 16 · Denominator 34 |
| Resident COVID-19 vaccinations up to date | 20% |
25.2%
5.2 pts worse
|
Numerator 7 · Denominator 35 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 75.7% |
86.9%
11.2 pts worse
|
93.4%
17.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 67.0% · Q2 60.4% · Q3 81.7% · Q4 91.8% · 4Q avg 75.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 77.9% |
93.5%
15.6 pts worse
|
95.5%
17.6 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 77.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.4% |
3.2%
0.2 pts worse
|
3.3%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 2.8% · Q3 2.9% · Q4 4.5% · 4Q avg 3.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.3% |
6.5%
5.2 pts better
|
11.4%
10.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.0% · Q4 3.7% · 4Q avg 1.3% |
| Percentage of long-stay residents who lose too much weight | 6.8% |
6.5%
0.3 pts worse
|
5.4%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.6% · Q2 7.6% · Q3 8.5% · Q4 4.6% · 4Q avg 6.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 11.5% |
19.9%
8.4 pts better
|
19.6%
8.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.1% · Q2 14.3% · Q3 15.9% · Q4 6.9% · 4Q avg 11.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 22.1% |
18.7%
3.4 pts worse
|
16.7%
5.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.2% · Q2 22.7% · Q3 18.5% · Q4 21.3% · 4Q avg 22.1% · 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 | 33.7% |
19.6%
14.1 pts worse
|
16.3%
17.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 41.8% · Q2 35.8% · Q3 39.7% · Q4 19.5% · 4Q avg 33.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 22.2% |
18.3%
3.9 pts worse
|
14.9%
7.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 36.2% · Q2 18.8% · Q3 20.5% · Q4 16.5% · 4Q avg 22.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.9% |
0.9%
About the same
|
1.0%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.8% · Q2 0.7% · Q3 1.1% · Q4 1.1% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.5% |
1.7%
1.2 pts better
|
1.7%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 29.8% |
26.4%
3.4 pts worse
|
19.8%
10 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.3% · Q2 36.6% · Q3 25.8% · Q4 28.9% · 4Q avg 29.8% |
| Percentage of long-stay residents with pressure ulcers | 5.9% |
5.3%
0.6 pts worse
|
5.1%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.0% · Q2 9.5% · Q3 4.5% · Q4 3.1% · 4Q avg 5.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 47.1% |
68.9%
21.8 pts worse
|
81.7%
34.6 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 36.4% · Q2 33.5% · Q3 44.5% · Q4 71.2% · 4Q avg 47.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 14.4% |
9.8%
4.6 pts worse
|
12.0%
2.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 14.4% · Observed 14.1% · Expected 10.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.8% |
1.5%
0.7 pts better
|
1.6%
0.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.5% · Q3 1.5% · Q4 0.0% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 44.9% |
68.7%
23.8 pts worse
|
79.7%
34.8 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 44.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.0% |
23.1%
0.1 pts better
|
23.9%
0.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 23.0% · Observed 22.5% · Expected 23.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-07-17 · Fire 2024-07-17
7 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
6 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Cycle 3
Health 2023-09-15 · Fire 2023-09-15
5 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
5 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-06-26
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-07-08
E · Potential for more than minimal harm
2025-06-26
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2025-07-08
D · Potential for more than minimal harm
2025-06-26
K131 · Construction Deficiencies
Fire Safety
Meet requirements for sections of health care facilities separated by fire resistive construction.
Corrected 2025-07-08
D · Potential for more than minimal harm
2025-06-26
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-07-08
D · Potential for more than minimal harm
2025-06-26
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-07-08
D · Potential for more than minimal harm
2025-06-26
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-07-08
F · Potential for more than minimal harm
2024-07-17
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-08-19
E · Potential for more than minimal harm
2024-07-17
K131 · Construction Deficiencies
Fire Safety
Meet requirements for sections of health care facilities separated by fire resistive construction.
Corrected 2024-08-19
E · Potential for more than minimal harm
2024-07-17
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-08-19
D · Potential for more than minimal harm
2024-07-17
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-08-19
D · Potential for more than minimal harm
2024-07-17
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2024-08-19
D · Potential for more than minimal harm
2024-07-17
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-08-19
F · Potential for more than minimal harm
2023-09-15
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2023-11-06
E · Potential for more than minimal harm
2023-09-15
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-11-06
D · Potential for more than minimal harm
2023-09-15
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-11-06
D · Potential for more than minimal harm
2023-09-15
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-11-06
C · Minimal harm
2023-09-15
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-11-06
Inspection history
Recent health citations
D · Potential for more than minimal harm
2026-01-21
F761 · Pharmacy Service Deficiencies
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 2026-02-17
F · Potential for more than minimal harm
2025-06-26
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-08-03
E · Potential for more than minimal harm
2025-06-26
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-08-03
D · Potential for more than minimal harm
2025-06-26
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-08-03
D · Potential for more than minimal harm
2025-06-26
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-08-03
D · Potential for more than minimal harm
2025-06-26
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-08-03
D · Potential for more than minimal harm
2025-06-26
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-08-03
D · Potential for more than minimal harm
2025-06-26
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2025-08-03
D · Potential for more than minimal harm
2025-06-26
F756 · Pharmacy Service Deficiencies
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 2025-08-03
D · Potential for more than minimal harm
2025-06-26
F836 · Administration Deficiencies
Health
Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards.
Corrected 2025-08-03
D · Potential for more than minimal harm
2025-06-26
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2025-08-03
D · Potential for more than minimal harm
2025-06-03
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-06-18
F · Potential for more than minimal harm
2024-07-17
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-08-27
F · Potential for more than minimal harm
2024-07-17
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2024-08-27
E · Potential for more than minimal harm
2024-07-17
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-08-27
E · Potential for more than minimal harm
2024-07-17
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-08-27
E · Potential for more than minimal harm
2024-07-17
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-08-27
D · Potential for more than minimal harm
2024-07-17
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-08-27
D · Potential for more than minimal harm
2024-07-17
F761 · Pharmacy Service Deficiencies
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 2024-08-27
D · Potential for more than minimal harm
2023-11-13
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2023-11-24
D · Potential for more than minimal harm
2023-09-15
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2023-11-06
D · Potential for more than minimal harm
2023-09-15
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-11-06
D · Potential for more than minimal harm
2023-09-15
F761 · Pharmacy Service Deficiencies
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 2023-11-06
D · Potential for more than minimal harm
2023-03-30
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-05-01
Penalties and ownership
What sits behind the stars
Ownership
Baker, Amelia
Operational/Managerial Control · Individual
Krozel, Michaela
Operational/Managerial Control · Individual
Matheny, Cynthia
Operational/Managerial Control · Individual
Nace, David
Operational/Managerial Control · Individual
Oakdale Seniors Alliance LLC
Operational/Managerial Control · Organization
Rosenbaum, Maurice
Operational/Managerial Control · Individual
Villella, Holly
Operational/Managerial Control · Individual
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1-star overall rating with 1-star inspections with $19,734 in total fines with 23 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#3
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2-star overall rating with 1-star inspections with 26 recent health deficiencies
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