Cycle 1
Health 2025-05-22 · Fire 2025-05-22
8 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
6 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Indiana, PA
Beacon Ridge
3-star overall rating with 3-star inspections with 8 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
1515 Wayne Avenue, Indiana, PA
(724) 349-5300
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
118
Certified beds
Average residents
80
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1985-05-31
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
Hours and turnover
RN hours / resident day
0.44
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
2.31
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.81
All reported nurse hours · state 3.89 · national 3.89
Licensed hours
1.50
RN + LPN hours · state 1.69 · national 1.54
Weekend hours
3.46
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.31
Weekend registered nurse coverage · state 0.55 · national 0.47
Physical therapist
0.07
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.50
CMS adjusted RN staffing hours
Adjusted total hours
4.30
CMS adjusted total nurse staffing hours
Case-mix index
1.21
Higher values indicate more complex resident acuity
RN turnover
58%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
48%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
8,589
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
26.27
Composite VBP score used to determine payment impact.
Payment multiplier
0.9841
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1.63
Performance 20.67% · Measure score 1.63 · Achievement 1.63 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
2.40
Performance 7.12% · Measure score 2.40 · Achievement 2.40 · This facility did not have sufficient data to calculate a baseline period measure result.
Total nurse turnover
3.84
Baseline 40.32% · Performance 48.00% · Measure score 3.84 · Achievement 3.84 · Improvement 0
Adjusted total nurse staffing
2.64
Baseline 3.53 hours · Performance 3.83 hours · Measure score 2.64 · Achievement 2.64 · Improvement 0.83
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.39% |
10.72%
0.7 pts worse
|
No Different than the National Rate · Eligible stays 68 · Observed rate 13.24% · Lower 95% interval 7.64% |
| Discharge to community | 44.98% |
50.57%
5.6 pts worse
|
No Different than the National Rate · Eligible stays 62 · Observed rate 40.32% · Lower 95% interval 33.41% |
| Medicare spending per beneficiary | 0.66 |
1.02
0.4 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 61 · Denominator 61 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 61 |
| Discharge self-care score | 49.06% |
53.69%
4.6 pts worse
|
Numerator 26 · Denominator 53 |
| Discharge mobility score | 32.08% |
50.94%
18.9 pts worse
|
Numerator 17 · Denominator 53 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 61 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 7.12% |
7.12%
About the same
|
No Different than the National Rate · Eligible stays 31 · Observed rate 6.45% · Lower 95% interval 3.85% |
| Staff COVID-19 vaccination coverage | 10.34% |
8.2%
2.1 pts better
|
Numerator 9 · Denominator 87 |
| Staff flu vaccination coverage | 22.22% |
42%
19.8 pts worse
|
Numerator 30 · Denominator 135 |
| Discharge function score | 43.4% |
56.45%
13.1 pts worse
|
Numerator 23 · Denominator 53 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 26 · Denominator 26 |
| Resident COVID-19 vaccinations up to date | 10.34% |
25.2%
14.9 pts worse
|
Numerator 3 · Denominator 29 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.1 |
1.7
0.6 pts better
|
1.9
0.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 0.9 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.6 |
1.2
0.4 pts worse
|
1.8
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 1.3 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.5% |
86.9%
10.6 pts better
|
93.4%
4.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.6% · Q2 94.4% · Q3 97.1% · Q4 100.0% · 4Q avg 97.5% |
| 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 | 3.2% |
3.2%
About the same
|
3.3%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 5.6% · Q3 2.9% · Q4 0.0% · 4Q avg 3.2% · 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 | 3.6% |
6.5%
2.9 pts better
|
5.4%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.8% · Q2 3.1% · Q3 4.9% · Q4 0.0% · 4Q avg 3.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 20.2% |
19.9%
0.3 pts worse
|
19.6%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.0% · Q2 20.0% · Q3 21.3% · Q4 21.5% · 4Q avg 20.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 18.7% |
18.7%
About the same
|
16.7%
2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.4% · Q2 26.9% · Q3 8.9% · Q4 14.3% · 4Q avg 18.7% · 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 | 7.6% |
19.6%
12 pts better
|
16.3%
8.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.5% · Q2 8.0% · Q3 0.0% · Q4 13.2% · 4Q avg 7.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 9.3% |
18.3%
9 pts better
|
14.9%
5.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.8% · Q2 6.5% · Q3 6.9% · Q4 8.5% · 4Q avg 9.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.4% |
0.9%
0.5 pts better
|
1.0%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.5% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.5% |
1.7%
0.8 pts worse
|
1.7%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 4.3% · Q3 2.9% · Q4 1.4% · 4Q avg 2.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 7.9% |
26.4%
18.5 pts better
|
19.8%
11.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.6% · Q2 5.0% · Q3 8.2% · Q4 9.6% · 4Q avg 7.9% |
| Percentage of long-stay residents with pressure ulcers | 2.7% |
5.3%
2.6 pts better
|
5.1%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 3.8% · Q3 1.2% · Q4 2.7% · 4Q avg 2.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.8% |
68.9%
28.9 pts better
|
81.7%
16.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 97.6% · Q2 96.6% · Q3 99.0% · Q4 97.8% · 4Q avg 97.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.7% |
9.8%
0.1 pts better
|
12.0%
2.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.7% · Observed 10.0% · Expected 11.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.1% |
1.5%
0.6 pts worse
|
1.6%
0.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 0.0% · Q3 2.0% · Q4 4.4% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 93.1% |
68.7%
24.4 pts better
|
79.7%
13.4 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 93.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 25.5% |
23.1%
2.4 pts worse
|
23.9%
1.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.5% · Observed 23.3% · Expected 21.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-06-06 · Fire 2024-06-06
15 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
4 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Cycle 3
Health 2023-07-27 · Fire 2023-07-27
11 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-05-22
K100 · Construction Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2025-07-01
F · Potential for more than minimal harm
2025-05-22
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-07-01
D · Potential for more than minimal harm
2025-05-22
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-07-01
C · Minimal harm
2025-05-22
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-07-01
C · Minimal harm
2025-05-22
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-07-01
C · Minimal harm
2025-05-22
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-07-01
F · Potential for more than minimal harm
2024-06-06
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-07-06
D · Potential for more than minimal harm
2024-06-06
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-07-06
B · Minimal harm
2024-06-06
K223 · Egress Deficiencies
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 2024-07-06
B · Minimal harm
2024-06-06
K912 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2024-07-06
F · Potential for more than minimal harm
2023-07-27
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-09-15
F · Potential for more than minimal harm
2023-07-27
K912 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2023-09-15
E · Potential for more than minimal harm
2023-07-27
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2023-09-15
E · Potential for more than minimal harm
2023-07-27
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-09-15
E · Potential for more than minimal harm
2023-07-27
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-09-15
C · Minimal harm
2023-07-27
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-09-15
C · Minimal harm
2023-07-27
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-09-15
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-05-22
F584 · Resident Rights Deficiencies
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 2025-07-01
E · Potential for more than minimal harm
2025-05-22
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2025-07-01
E · Potential for more than minimal harm
2025-05-22
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 2025-07-01
D · Potential for more than minimal harm
2025-05-22
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 2025-07-01
D · Potential for more than minimal harm
2025-05-22
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 2025-07-01
D · Potential for more than minimal harm
2025-05-22
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-07-01
D · Potential for more than minimal harm
2025-05-22
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-07-01
D · Potential for more than minimal harm
2025-05-22
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2025-07-01
F · Potential for more than minimal harm
2024-06-06
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 2024-07-15
E · Potential for more than minimal harm
2024-06-06
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-07-15
E · Potential for more than minimal harm
2024-06-06
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-07-15
E · Potential for more than minimal harm
2024-06-06
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2024-07-15
E · Potential for more than minimal harm
2024-06-06
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 2024-07-15
E · Potential for more than minimal harm
2024-06-06
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2024-07-15
D · Potential for more than minimal harm
2024-06-06
F557 · Resident Rights Deficiencies
Health
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Corrected 2024-07-15
D · Potential for more than minimal harm
2024-06-06
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-07-15
D · Potential for more than minimal harm
2024-06-06
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-07-15
D · Potential for more than minimal harm
2024-06-06
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 2024-07-15
D · Potential for more than minimal harm
2024-06-06
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 2024-07-15
D · Potential for more than minimal harm
2024-06-06
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-07-15
D · Potential for more than minimal harm
2024-06-06
F773 · Administration Deficiencies
Health
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Corrected 2024-07-15
D · Potential for more than minimal harm
2024-06-06
F805 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Corrected 2024-02-21
D · Potential for more than minimal harm
2024-06-06
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-07-15
E · Potential for more than minimal harm
2023-07-27
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-09-13
E · Potential for more than minimal harm
2023-07-27
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2023-09-13
E · Potential for more than minimal harm
2023-07-27
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2023-09-13
E · Potential for more than minimal harm
2023-07-27
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-09-13
E · Potential for more than minimal harm
2023-07-27
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 2023-09-13
D · Potential for more than minimal harm
2023-07-27
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-09-13
D · Potential for more than minimal harm
2023-07-27
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 2023-09-13
D · Potential for more than minimal harm
2023-07-27
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 2023-09-13
D · Potential for more than minimal harm
2023-07-27
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-09-13
D · Potential for more than minimal harm
2023-07-27
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 2023-09-13
D · Potential for more than minimal harm
2023-07-27
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-09-13
Penalties and ownership
What sits behind the stars
Ownership
Mcandrews, Leah
Operational/Managerial Control · Individual
Pennsylvania Mountains Care Network
Operational/Managerial Control · Organization
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