9 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
13 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Edinboro, PA
3-star overall rating with 3-star inspections with $3,145 in total fines with 9 recent health deficiencies with 13 fire-safety deficiencies in the latest cycle
419 Waterford Street, Edinboro, PA
(814) 734-5021
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Beds
121
Certified beds
Average residents
113
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Hcf Management
Operator or chain grouping
Approved since
1984-03-27
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
22 facilities
Chain averages 3 overall / 3 health / 3 staffing / 4 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
RN hours / resident day
0.40
Registered nurse staffing · state 0.78 · national 0.68
LPN hours / resident day
0.92
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
2.13
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
1.33
RN + LPN hours · state 1.69 · national 1.54
Weekend hours
2.93
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.14
Weekend registered nurse coverage · state 0.55 · national 0.47
Physical therapist
0.03
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.42
CMS adjusted RN staffing hours
Adjusted total hours
3.56
CMS adjusted total nurse staffing hours
Case-mix index
1.33
Higher values indicate more complex resident acuity
RN turnover
67%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
49%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Program rank
9,142
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
24.66
Composite VBP score used to determine payment impact.
Payment multiplier
0.9835
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
1.39
Baseline 20.59% · Performance 20.79% · Measure score 1.39 · Achievement 1.39 · Improvement 0
Healthcare-associated infections
2
Baseline 5.73% · Performance 7.24% · Measure score 2 · Achievement 2 · Improvement 0
Total nurse turnover
5.30
Baseline 50.00% · Performance 42.00% · Measure score 5.30 · Achievement 5.30 · Improvement 2.68
Adjusted total nurse staffing
1.16
Baseline 3.54 hours · Performance 3.41 hours · Measure score 1.16 · Achievement 1.16 · Improvement 0
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.71% |
10.72%
About the same
|
No Different than the National Rate · Eligible stays 53 · Observed rate 11.32% · Lower 95% interval 6.99% |
| Discharge to community | 41.64% |
50.57%
8.9 pts worse
|
No Different than the National Rate · Eligible stays 58 · Observed rate 32.76% · Lower 95% interval 30.56% |
| Medicare spending per beneficiary | 0.77 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 97.73% |
95.27%
2.5 pts better
|
Numerator 43 · Denominator 44 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 44 |
| Discharge self-care score | 25.81% |
53.69%
27.9 pts worse
|
Numerator 8 · Denominator 31 |
| Discharge mobility score | 38.71% |
50.94%
12.2 pts worse
|
Numerator 12 · Denominator 31 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 44 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 7.24% |
7.12%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 41 · Observed rate 7.32% · Lower 95% interval 3.76% |
| Staff COVID-19 vaccination coverage | 2.14% |
8.2%
6.1 pts worse
|
Numerator 3 · Denominator 140 |
| Staff flu vaccination coverage | 54.35% |
42%
12.4 pts better
|
Numerator 75 · Denominator 138 |
| Discharge function score | 38.71% |
56.45%
17.7 pts worse
|
Numerator 12 · Denominator 31 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 23 · Denominator 23 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 29.17% |
25.2%
4 pts better
|
Numerator 7 · Denominator 24 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.8% |
86.9%
12.9 pts better
|
93.4%
6.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 99.0% · 4Q avg 99.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.2% |
93.5%
4.7 pts better
|
95.5%
2.7 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.2% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.7% |
3.2%
0.5 pts better
|
3.3%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 1.9% · Q3 2.0% · Q4 3.0% · 4Q avg 2.7% · 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 1.0% · Q2 0.0% · Q3 0.0% · Q4 4.2% · 4Q avg 1.3% |
| Percentage of long-stay residents who lose too much weight | 4.6% |
6.5%
1.9 pts better
|
5.4%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.0% · Q2 4.1% · Q3 6.0% · Q4 3.1% · 4Q avg 4.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 15.2% |
19.9%
4.7 pts better
|
19.6%
4.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.6% · Q2 13.9% · Q3 15.8% · Q4 16.7% · 4Q avg 15.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 30.9% |
18.7%
12.2 pts worse
|
16.7%
14.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.9% · Q2 30.9% · Q3 34.1% · Q4 32.5% · 4Q avg 30.9% · 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 | 3.3% |
19.6%
16.3 pts better
|
16.3%
13 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 0.0% · Q3 4.1% · Q4 6.7% · 4Q avg 3.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 3.8% |
18.3%
14.5 pts better
|
14.9%
11.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.2% · Q3 6.5% · Q4 6.7% · 4Q avg 3.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.8% |
0.9%
0.1 pts better
|
1.0%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.8% · Q2 1.4% · Q3 0.8% · Q4 0.0% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.2% |
1.7%
1.5 pts better
|
1.7%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.0% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 19.2% |
26.4%
7.2 pts better
|
19.8%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 23.1% · Q2 19.6% · Q3 15.6% · Q4 18.2% · 4Q avg 19.2% |
| Percentage of long-stay residents with pressure ulcers | 6.5% |
5.3%
1.2 pts worse
|
5.1%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.7% · Q2 9.4% · Q3 5.6% · Q4 4.3% · 4Q avg 6.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.1% |
68.9%
28.2 pts better
|
81.7%
15.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 97.0% · Q2 97.1% · Q3 96.1% · Q4 98.0% · 4Q avg 97.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 19.1% |
9.8%
9.3 pts worse
|
12.0%
7.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 19.1% · Observed 21.2% · Expected 12.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.6% |
1.5%
1.1 pts worse
|
1.6%
1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 5.0% · Q2 5.7% · Q3 0.0% · Q4 0.0% · 4Q avg 2.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 48.6% |
68.7%
20.1 pts worse
|
79.7%
31.1 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 48.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 28.8% |
23.1%
5.7 pts worse
|
23.9%
4.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 28.8% · Observed 30.3% · Expected 25.1% · Used in QM five-star |
Survey summary
Top issue: Resident Assessment and Care Planning (3 deficiencies)
13 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Top issue: Resident Assessment and Care Planning (3 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Top issue: Resident Assessment and Care Planning (5 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2026-02-17
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2026-02-17
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2026-02-17
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 2026-02-17
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2026-02-17
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 2026-02-17
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2026-02-17
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2026-02-17
Fire Safety
Establish emergency prep training and testing.
Corrected 2026-02-17
Fire Safety
Conduct testing and exercise requirements.
Corrected 2026-02-17
Fire Safety
Provide properly protected cooking facilities.
Corrected 2026-02-17
Fire Safety
Meet other general requirements.
Corrected 2026-02-17
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2026-02-17
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-03-26
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2025-03-26
Fire Safety
Conduct testing and exercise requirements.
Corrected 2025-03-26
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-03-26
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-04-15
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-04-15
Inspection history
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.
Not marked corrected
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.
Not marked corrected
Health
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Not marked corrected
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Not marked corrected
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Not marked corrected
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Not marked corrected
Health
Provide safe and appropriate respiratory care for a resident when needed.
Not marked corrected
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Not marked corrected
Health
Provide and implement an infection prevention and control program.
Not marked corrected
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2025-03-28
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-03-28
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 2025-03-28
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 2025-03-28
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 2025-03-28
Health
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Corrected 2024-04-15
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 2024-04-15
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-04-15
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 2024-04-15
Health
Respond appropriately to all alleged violations.
Corrected 2024-04-15
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-04-15
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2024-04-15
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 2024-04-15
Health
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Corrected 2024-04-15
Health
Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency.
Corrected 2024-04-15
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 2023-11-20
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2023-04-05
Penalties and ownership
Fine · fine $3,145
Fine
5% Or Greater Direct Ownership Interest · Organization
Corporate Director · Individual
W-2 Managing Employee · Individual
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
Operational/Managerial Control · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
Corporate Officer · Individual
W-2 Managing Employee · Individual
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
Corporate Director · Individual
Corporate Officer · Individual
W-2 Managing Employee · Individual
Corporate Officer · Individual
W-2 Managing Employee · Individual
Corporate Director · Individual
Corporate Officer · Individual
W-2 Managing Employee · Individual
Nearby options
Saegertown, PA
1-star overall rating with 2-star inspections with $158,696 in total fines with 10 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
Erie, PA
5-star overall rating with 5-star inspections with 1 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
Girard, PA
3-star overall rating with 3-star inspections with $10,033 in total fines with 7 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
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