Cycle 1
Health 2025-05-01 · Fire 2025-05-01
3 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Matamoras, PA
Delaware Valley Skilled Nursing & Rehabilitation C
3-star overall rating with 3-star inspections with $8,190 in total fines with 3 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
111 Rivers Edge Drive, Matamoras, PA
(570) 491-1010
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
Facility snapshot
Beds
70
Certified beds
Average residents
61
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2021-02-04
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
0.72
Registered nurse staffing · state 0.78 · national 0.68
LPN hours / resident day
1.01
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
2.01
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.75
All reported nurse hours · state 3.89 · national 3.89
Licensed hours
1.74
RN + LPN hours · state 1.69 · national 1.54
Weekend hours
3.38
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.43
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
0.74
CMS adjusted RN staffing hours
Adjusted total hours
3.82
CMS adjusted total nurse staffing hours
Case-mix index
1.34
Higher values indicate more complex resident acuity
RN turnover
71%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
40%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
5,566
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
35.74
Composite VBP score used to determine payment impact.
Payment multiplier
0.9893
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0.57
Baseline 18.08% · Performance 21.17% · Measure score 0.57 · Achievement 0.57 · Improvement 0
Healthcare-associated infections
6.29
Baseline 6.24% · Performance 5.95% · Measure score 6.29 · Achievement 6.29 · Improvement 1.82
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
3.86
Baseline 3.50 hours · Performance 4.18 hours · Measure score 3.86 · Achievement 3.86 · Improvement 2.46
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 13.19% |
10.72%
2.5 pts worse
|
No Different than the National Rate · Eligible stays 338 · Observed rate 14.2% · Lower 95% interval 9.87% |
| Discharge to community | 46.42% |
50.57%
4.1 pts worse
|
No Different than the National Rate · Eligible stays 347 · Observed rate 41.79% · Lower 95% interval 41.67% |
| Medicare spending per beneficiary | 0.88 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 80.29% |
95.27%
15 pts worse
|
Numerator 167 · Denominator 208 |
| Falls with major injury | 0.96% |
0.77%
0.2 pts worse
|
Numerator 2 · Denominator 208 |
| Discharge self-care score | 44.67% |
53.69%
9 pts worse
|
Numerator 67 · Denominator 150 |
| Discharge mobility score | 48% |
50.94%
2.9 pts worse
|
Numerator 72 · Denominator 150 |
| Pressure ulcers or injuries, new or worsened | 3.37% |
2.29%
1.1 pts worse
|
Numerator 7 · Denominator 208 · Adjusted rate 2.91% |
| Healthcare-associated infections requiring hospitalization | 5.95% |
7.12%
1.2 pts better
|
No Different than the National Rate · Eligible stays 204 · Observed rate 4.9% · Lower 95% interval 3.93% |
| Staff COVID-19 vaccination coverage | 7.69% |
8.2%
0.5 pts worse
|
Numerator 7 · Denominator 91 |
| Staff flu vaccination coverage | 25.38% |
42%
16.6 pts worse
|
Numerator 33 · Denominator 130 |
| Discharge function score | 50.67% |
56.45%
5.8 pts worse
|
Numerator 76 · Denominator 150 |
| Transfer of health information to provider | 94.64% |
95.95%
1.3 pts worse
|
Numerator 53 · Denominator 56 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 109 · Denominator 109 |
| Resident COVID-19 vaccinations up to date | 18.81% |
25.2%
6.4 pts worse
|
Numerator 19 · Denominator 101 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 3.5 |
1.7
1.8 pts worse
|
1.9
1.6 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.5 · Observed 4.4 · Expected 2.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.1 |
1.2
0.1 pts better
|
1.8
0.7 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 1.2 · Expected 1.9 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.4% |
86.9%
10.5 pts better
|
93.4%
4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 97.9% · Q3 95.7% · Q4 95.7% · 4Q avg 97.4% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 96.2% |
93.5%
2.7 pts better
|
95.5%
0.7 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 96.2% |
| 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 4.1% · Q2 2.1% · Q3 2.2% · Q4 4.3% · 4Q avg 3.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.9% |
6.5%
3.6 pts better
|
11.4%
8.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 0.0% · Q3 0.0% · Q4 7.9% · 4Q avg 2.9% |
| Percentage of long-stay residents who lose too much weight | 9.4% |
6.5%
2.9 pts worse
|
5.4%
4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.6% · Q2 20.5% · Q3 5.1% · Q4 2.8% · 4Q avg 9.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 31.0% |
19.9%
11.1 pts worse
|
19.6%
11.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.2% · Q2 27.9% · Q3 31.7% · Q4 38.1% · 4Q avg 31.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 22.0% |
18.7%
3.3 pts worse
|
16.7%
5.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.2% · Q2 23.1% · Q3 23.3% · Q4 24.2% · 4Q avg 22.0% · 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 | 22.7% |
19.6%
3.1 pts worse
|
16.3%
6.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 22.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 21.3% |
18.3%
3 pts worse
|
14.9%
6.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.6% · Q2 21.1% · Q3 8.1% · Q4 34.2% · 4Q avg 21.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.4% |
0.9%
1.5 pts worse
|
1.0%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 5.1% · Q3 1.3% · Q4 1.4% · 4Q avg 2.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 4.1% |
1.7%
2.4 pts worse
|
1.7%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 6.8% · Q4 9.8% · 4Q avg 4.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 27.7% |
26.4%
1.3 pts worse
|
19.8%
7.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 32.3% · Q2 21.6% · Q3 24.2% · Q4 33.5% · 4Q avg 27.7% |
| Percentage of long-stay residents with pressure ulcers | 8.8% |
5.3%
3.5 pts worse
|
5.1%
3.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.0% · Q2 14.4% · Q3 8.9% · Q4 3.4% · 4Q avg 8.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 79.8% |
68.9%
10.9 pts better
|
81.7%
1.9 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 82.7% · Q2 77.8% · Q3 79.8% · Q4 78.8% · 4Q avg 79.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.8% |
9.8%
2 pts worse
|
12.0%
0.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.8% · Observed 11.6% · Expected 11.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 3.0% |
1.5%
1.5 pts worse
|
1.6%
1.4 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 1.6% · Q3 3.2% · Q4 6.2% · 4Q avg 3.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 70.6% |
68.7%
1.9 pts better
|
79.7%
9.1 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 70.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 22.2% |
23.1%
0.9 pts better
|
23.9%
1.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 22.2% · Observed 21.6% · Expected 23.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-08-08 · Fire 2024-08-08
11 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2023-09-08 · Fire 2023-09-08
13 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2025-05-01
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-05-28
E · Potential for more than minimal harm
2024-08-08
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 2024-08-30
E · Potential for more than minimal harm
2024-08-08
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 2024-08-30
E · Potential for more than minimal harm
2024-08-08
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-08-30
E · Potential for more than minimal harm
2024-08-08
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-08-30
E · Potential for more than minimal harm
2023-09-08
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 2023-09-19
E · Potential for more than minimal harm
2023-09-08
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-09-19
E · Potential for more than minimal harm
2023-09-08
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2023-09-19
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-05-01
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 2025-05-20
D · Potential for more than minimal harm
2025-05-01
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 2025-05-20
D · Potential for more than minimal harm
2025-05-01
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 2025-05-20
E · Potential for more than minimal harm
2024-08-08
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-09-10
E · Potential for more than minimal harm
2024-08-08
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-09-10
E · Potential for more than minimal harm
2024-08-08
F809 · Nutrition and Dietary Deficiencies
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 2024-09-10
D · Potential for more than minimal harm
2024-08-08
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-09-10
D · Potential for more than minimal harm
2024-08-08
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-09-10
D · Potential for more than minimal harm
2024-08-08
F791 · Quality of Life and Care Deficiencies
Health
Provide or obtain dental services for each resident.
Corrected 2024-09-10
D · Potential for more than minimal harm
2024-08-08
F865 · Administration Deficiencies
Health
Have a plan that describes the process for conducting QAPI and QAA activities.
Corrected 2024-09-10
E · Potential for more than minimal harm
2024-03-27
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 2024-04-23
D · Potential for more than minimal harm
2024-03-27
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-02-09
D · Potential for more than minimal harm
2024-03-27
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2024-02-26
D · Potential for more than minimal harm
2024-03-27
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-04-23
F · Potential for more than minimal harm
2023-09-08
F801 · Nutrition and Dietary Deficiencies
Health
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Corrected 2023-10-03
F · Potential for more than minimal harm
2023-09-08
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 2023-10-03
E · Potential for more than minimal harm
2023-09-08
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-10-03
E · Potential for more than minimal harm
2023-09-08
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2023-10-03
D · Potential for more than minimal harm
2023-09-08
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-10-03
D · Potential for more than minimal harm
2023-09-08
F660 · Resident Assessment and Care Planning Deficiencies
Health
Plan the resident's discharge to meet the resident's goals and needs.
Corrected 2023-10-03
D · Potential for more than minimal harm
2023-09-08
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 2023-10-03
D · Potential for more than minimal harm
2023-09-08
F773 · Administration Deficiencies
Health
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Corrected 2023-10-03
D · Potential for more than minimal harm
2023-09-08
F849 · Administration Deficiencies
Health
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Corrected 2023-10-03
D · Potential for more than minimal harm
2023-09-08
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2023-10-03
G · Actual harm
2023-06-06
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 2023-10-03
D · Potential for more than minimal harm
2023-06-06
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 2023-08-16
B · Minimal harm
2023-06-06
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2023-08-16
Penalties and ownership
What sits behind the stars
$8,190
2023-06-06
Fine
Fine · fine $8,190
Fine
$0
2023-06-06
Payment Denial
Payment Denial · denial start 2023-09-06 · 27 days
27 day denial
Ownership
Pa Tenant 3 Holdings, LLC
5% Or Greater Direct Ownership Interest · Organization
2020 Gsr Dynasty LLC
5% Or Greater Indirect Ownership Interest · Organization
Eaz Operating Company, LLC
5% Or Greater Indirect Ownership Interest · Organization
Estell, Kaitlin
Operational/Managerial Control · Individual
Falco, Michael
Operational/Managerial Control · Individual
Fedorka, Kelly
Operational/Managerial Control · Individual
George S. Repchick 2020 Family Dynasty Trust
5% Or Greater Indirect Ownership Interest · Organization
Hanrahan, Stepanie
Operational/Managerial Control · Individual
Help For The Kids, LLC
5% Or Greater Indirect Ownership Interest · Organization
Hentschel, Kathleen
Operational/Managerial Control · Individual
Keefer, Susan
5% Or Greater Indirect Ownership Interest · Individual
Keefer, Susan
Operational/Managerial Control · Individual
Kelly, Michael
5% Or Greater Indirect Ownership Interest · Individual
Kelly, Michael
Operational/Managerial Control · Individual
Lederer, Brenda
Operational/Managerial Control · Individual
Malloy, Catherine
Operational/Managerial Control · Individual
Oxford Finance LLC
5% Or Greater Security Interest · Organization
Oxford Finance LLC
5% Or Greater Mortgage Interest · Organization
Pa Tenant 3 Mezz Holdings, LLC
5% Or Greater Indirect Ownership Interest · Organization
Pa Tenant 3 Mezz, LLC
5% Or Greater Indirect Ownership Interest · Organization
Palovitz, Tracy
Operational/Managerial Control · Individual
Pascal, Sandra
Operational/Managerial Control · Individual
Rogers, Heather
Operational/Managerial Control · Individual
Senior Health Care Solutions LLC
Operational/Managerial Control · Organization
Verde, Rachel
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
St Josephs Place
Port Jervis, NY
5-star overall rating with 5-star inspections with 2 fire-safety deficiencies in the latest cycle
#2
Milford Rehabilitation And Healthcare Center
Milford, PA
2-star overall rating with 2-star inspections with $61,593 in total fines with 4 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#3
Homestead Rehabilitation & Health Care Center
Newton, NJ
2-star overall rating with 1-star inspections with $111,754 in total fines with 19 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
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