5 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Bellefonte, PA
3-star overall rating with 3-star inspections with 5 recent health deficiencies
250 Persia Road, Bellefonte, PA
(814) 278-6000
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Beds
240
Certified beds
Average residents
224
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1989-01-01
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
0.46
Registered nurse staffing · state 0.78 · national 0.68
LPN hours / resident day
0.85
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
2.15
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.45
All reported nurse hours · state 3.89 · national 3.89
Licensed hours
1.31
RN + LPN hours · state 1.69 · national 1.54
Weekend hours
3.01
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.19
Weekend registered nurse coverage · state 0.55 · national 0.47
Physical therapist
0.06
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.51
CMS adjusted RN staffing hours
Adjusted total hours
3.85
CMS adjusted total nurse staffing hours
Case-mix index
1.23
Higher values indicate more complex resident acuity
RN turnover
15%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
42%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Program rank
564
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
67.40
Composite VBP score used to determine payment impact.
Payment multiplier
1.0209
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
10
Baseline 17.90% · Performance 16.88% · Measure score 10 · Achievement 10 · Improvement 9
Healthcare-associated infections
8.85
Baseline 4.87% · Performance 5.19% · Measure score 8.85 · Achievement 8.85 · Improvement 0
Total nurse turnover
5.77
Baseline 50.57% · Performance 40.10% · Measure score 5.77 · Achievement 5.77 · Improvement 3.57
Adjusted total nurse staffing
2.34
Baseline 3.58 hours · Performance 3.74 hours · Measure score 2.34 · Achievement 2.34 · Improvement 0.26
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.91% |
10.72%
0.2 pts worse
|
No Different than the National Rate · Eligible stays 144 · Observed rate 11.11% · Lower 95% interval 8.13% |
| Discharge to community | 34.2% |
50.57%
16.4 pts worse
|
Worse than the National Rate · Eligible stays 146 · Observed rate 27.4% · Lower 95% interval 26.91% |
| Medicare spending per beneficiary | 0.64 |
1.02
0.4 pts better
|
|
| Drug regimen review with follow-up | 96.47% |
95.27%
1.2 pts better
|
Numerator 82 · Denominator 85 |
| Falls with major injury | 2.35% |
0.77%
1.6 pts worse
|
Numerator 2 · Denominator 85 |
| Discharge self-care score | 36.49% |
53.69%
17.2 pts worse
|
Numerator 27 · Denominator 74 |
| Discharge mobility score | 45.95% |
50.94%
5 pts worse
|
Numerator 34 · Denominator 74 |
| Pressure ulcers or injuries, new or worsened | 2.35% |
2.29%
0.1 pts worse
|
Numerator 2 · Denominator 85 · Adjusted rate 2.25% |
| Healthcare-associated infections requiring hospitalization | 5.19% |
7.12%
1.9 pts better
|
No Different than the National Rate · Eligible stays 97 · Observed rate 2.06% · Lower 95% interval 2.75% |
| Staff COVID-19 vaccination coverage | 10.48% |
8.2%
2.3 pts better
|
Numerator 26 · Denominator 248 |
| Staff flu vaccination coverage | 57.1% |
42%
15.1 pts better
|
Numerator 173 · Denominator 303 |
| Discharge function score | 37.84% |
56.45%
18.6 pts worse
|
Numerator 28 · Denominator 74 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 97.78% |
96.28%
1.5 pts better
|
Numerator 44 · Denominator 45 |
| Resident COVID-19 vaccinations up to date | 34.48% |
25.2%
9.3 pts better
|
Numerator 10 · Denominator 29 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.3 |
1.7
0.4 pts better
|
1.9
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 0.9 · Expected 1.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.4 |
1.2
0.8 pts better
|
1.8
1.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.4 · Observed 0.4 · Expected 1.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 96.4% |
86.9%
9.5 pts better
|
93.4%
3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 95.6% · Q2 95.0% · Q3 96.5% · Q4 98.5% · 4Q avg 96.4% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.7% |
93.5%
4.2 pts better
|
95.5%
2.2 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.7% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.7% |
3.2%
2.5 pts worse
|
3.3%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.8% · Q2 5.4% · Q3 5.5% · Q4 4.0% · 4Q avg 5.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.1% |
6.5%
4.4 pts better
|
11.4%
9.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 2.8% · Q3 1.1% · Q4 1.7% · 4Q avg 2.1% |
| Percentage of long-stay residents who lose too much weight | 7.4% |
6.5%
0.9 pts worse
|
5.4%
2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 12.6% · Q2 9.2% · Q3 4.7% · Q4 3.1% · 4Q avg 7.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 19.6% |
19.9%
0.3 pts better
|
19.6%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 21.1% · Q2 21.5% · Q3 16.9% · Q4 18.9% · 4Q avg 19.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 20.4% |
18.7%
1.7 pts worse
|
16.7%
3.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.2% · Q2 21.3% · Q3 20.1% · Q4 19.9% · 4Q avg 20.4% · 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 | 24.8% |
19.6%
5.2 pts worse
|
16.3%
8.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 36.9% · Q2 25.6% · Q3 18.0% · Q4 18.0% · 4Q avg 24.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 24.5% |
18.3%
6.2 pts worse
|
14.9%
9.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.3% · Q2 25.0% · Q3 19.8% · Q4 23.6% · 4Q avg 24.5% · 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 1.0% · Q2 0.5% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.3% |
1.7%
1.6 pts worse
|
1.7%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.9% · Q2 3.5% · Q3 2.5% · Q4 2.5% · 4Q avg 3.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 21.7% |
26.4%
4.7 pts better
|
19.8%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.2% · Q2 25.5% · Q3 15.5% · Q4 23.7% · 4Q avg 21.7% |
| Percentage of long-stay residents with pressure ulcers | 8.1% |
5.3%
2.8 pts worse
|
5.1%
3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.3% · Q2 11.1% · Q3 6.8% · Q4 7.2% · 4Q avg 8.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 96.9% |
68.9%
28 pts better
|
81.7%
15.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 95.5% · Q2 96.1% · Q3 98.9% · Q4 97.0% · 4Q avg 96.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.5% |
9.8%
1.3 pts better
|
12.0%
3.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.5% · Observed 8.3% · Expected 10.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.5% |
1.5%
1 pts better
|
1.6%
1.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.9% · Q4 0.8% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 92.4% |
68.7%
23.7 pts better
|
79.7%
12.7 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 92.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 27.2% |
23.1%
4.1 pts worse
|
23.9%
3.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 27.2% · Observed 23.3% · Expected 20.4% · Used in QM five-star |
Survey summary
Top issue: Quality of Life and Care (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Top issue: Quality of Life and Care (3 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Top issue: Quality of Life and Care (5 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Fire safety
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-11-08
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-10-03
Inspection history
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2025-09-16
Health
Respond appropriately to all alleged violations.
Corrected 2025-09-16
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-09-16
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-09-16
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-09-16
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-11-19
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 2024-11-19
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2024-11-19
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-11-19
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-11-19
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-11-19
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-11-19
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 2024-11-19
Health
Provide and implement an infection prevention and control program.
Corrected 2024-11-19
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2024-11-19
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2024-05-14
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 2024-05-14
Health
Provide and implement an infection prevention and control program.
Corrected 2024-05-14
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-03-26
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-11-07
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 2023-11-07
Health
Provide and implement an infection prevention and control program.
Corrected 2023-11-07
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2023-11-07
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-11-07
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-11-07
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-08-29
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2023-05-22
Penalties and ownership
Corporate Officer · Individual
Corporate Officer · Individual
W-2 Managing Employee · Individual
Corporate Officer · Individual
Corporate Officer · Individual
Nearby options
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