Saint Marys, PA
5-star overall rating with 4-star inspections with $8,018 in total fines with 2 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
785 Johnsonburg Road, Saint Marys, PA
(814) 234-2618
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Beds
120
Certified beds
Average residents
92
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1975-08-13
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
0.97
Registered nurse staffing · state 0.78 · national 0.68
LPN hours / resident day
0.61
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
2.50
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
4.08
All reported nurse hours · state 3.89 · national 3.89
Licensed hours
1.58
RN + LPN hours · state 1.69 · national 1.54
Weekend hours
3.60
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.60
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
1.01
CMS adjusted RN staffing hours
Adjusted total hours
4.23
CMS adjusted total nurse staffing hours
Case-mix index
1.32
Higher values indicate more complex resident acuity
RN turnover
17%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
37%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Program rank
5,682
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
35.32
Composite VBP score used to determine payment impact.
Payment multiplier
0.9890
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
2.37
Baseline 19.62% · Performance 20.34% · Measure score 2.37 · Achievement 2.37 · Improvement 0
Healthcare-associated infections
0
Baseline 5.57% · Performance 8.14% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
6.84
Baseline 33.33% · Performance 35.71% · Measure score 6.84 · Achievement 6.84 · Improvement 0
Adjusted total nurse staffing
4.92
Baseline 3.41 hours · Performance 4.48 hours · Measure score 4.92 · Achievement 4.92 · Improvement 4.01
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.35% |
10.72%
1.4 pts better
|
No Different than the National Rate · Eligible stays 107 · Observed rate 5.61% · Lower 95% interval 6.42% |
| Discharge to community | 32.23% |
50.57%
18.3 pts worse
|
Worse than the National Rate · Eligible stays 102 · Observed rate 25.49% · Lower 95% interval 25.37% |
| Medicare spending per beneficiary | 0.93 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 98.92% |
95.27%
3.7 pts better
|
Numerator 92 · Denominator 93 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 93 |
| Discharge self-care score | 43.42% |
53.69%
10.3 pts worse
|
Numerator 33 · Denominator 76 |
| Discharge mobility score | 47.37% |
50.94%
3.6 pts worse
|
Numerator 36 · Denominator 76 |
| Pressure ulcers or injuries, new or worsened | 8.6% |
2.29%
6.3 pts worse
|
Numerator 8 · Denominator 93 · Adjusted rate 7.23% |
| Healthcare-associated infections requiring hospitalization | 8.14% |
7.12%
1 pts worse
|
No Different than the National Rate · Eligible stays 68 · Observed rate 8.82% · Lower 95% interval 4.73% |
| Staff COVID-19 vaccination coverage | 1.75% |
8.2%
6.4 pts worse
|
Numerator 3 · Denominator 171 |
| Staff flu vaccination coverage | 28.57% |
42%
13.4 pts worse
|
Numerator 42 · Denominator 147 |
| Discharge function score | 44.74% |
56.45%
11.7 pts worse
|
Numerator 34 · Denominator 76 |
| Transfer of health information to provider | 97.3% |
95.95%
1.3 pts better
|
Numerator 36 · Denominator 37 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 30.77% |
25.2%
5.6 pts better
|
Numerator 16 · Denominator 52 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.8 |
1.7
0.9 pts better
|
1.9
1.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.8 · Observed 0.8 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.3 |
1.2
2.1 pts worse
|
1.8
1.5 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.3 · Observed 3.0 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.4% |
86.9%
12.5 pts better
|
93.4%
6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.7% · Q2 100.0% · Q3 100.0% · Q4 98.8% · 4Q avg 99.4% |
| 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 | 8.2% |
3.2%
5 pts worse
|
3.3%
4.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.6% · Q2 7.3% · Q3 7.8% · Q4 9.9% · 4Q avg 8.2% · 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 | 5.5% |
6.5%
1 pts better
|
5.4%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.5% · Q2 6.4% · Q3 2.7% · Q4 6.2% · 4Q avg 5.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 17.4% |
19.9%
2.5 pts better
|
19.6%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.7% · Q2 18.3% · Q3 18.7% · Q4 14.8% · 4Q avg 17.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 13.6% |
18.7%
5.1 pts better
|
16.7%
3.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.2% · Q2 10.9% · Q3 13.6% · Q4 14.5% · 4Q avg 13.6% · 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 | 15.0% |
19.6%
4.6 pts better
|
16.3%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.7% · Q2 12.5% · Q3 13.9% · Q4 18.2% · 4Q avg 15.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 12.3% |
18.3%
6 pts better
|
14.9%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.1% · Q2 14.5% · Q3 6.2% · Q4 13.7% · 4Q avg 12.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.3% |
0.9%
0.6 pts better
|
1.0%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.1% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 4.8% |
1.7%
3.1 pts worse
|
1.7%
3.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.1% · Q2 2.6% · Q3 2.6% · Q4 5.0% · 4Q avg 4.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 23.5% |
26.4%
2.9 pts better
|
19.8%
3.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.5% · Q2 22.5% · Q3 28.9% · Q4 22.6% · 4Q avg 23.5% |
| 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 6.9% · Q2 6.7% · Q3 5.2% · Q4 4.8% · 4Q avg 5.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.6% |
68.9%
28.7 pts better
|
81.7%
15.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 94.0% · Q2 98.4% · Q3 100.0% · Q4 98.3% · 4Q avg 97.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 29.3% |
9.8%
19.5 pts worse
|
12.0%
17.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 29.3% · Observed 27.1% · Expected 10.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.8% |
1.5%
1.3 pts worse
|
1.6%
1.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 5.7% · Q2 2.6% · Q3 2.9% · Q4 0.0% · 4Q avg 2.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 96.8% |
68.7%
28.1 pts better
|
79.7%
17.1 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 96.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 17.0% |
23.1%
6.1 pts better
|
23.9%
6.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 17.0% · Observed 14.3% · Expected 20.1% · Used in QM five-star |
Survey summary
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Top issue: Pharmacy Service (1 deficiency)
3 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2025-06-18
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-07-10
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2024-07-10
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-08-31
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-08-31
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2023-08-31
Inspection history
Health
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Corrected 2025-06-18
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 2025-06-18
Health
Keep residents' personal and medical records private and confidential.
Corrected 2024-07-10
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-07-10
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-07-10
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-05-07
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 2023-09-19
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 2023-09-19
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 2023-09-19
Penalties and ownership
Fine · fine $8,018
Fine
Operational/Managerial Control · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Officer · Individual
Corporate Director · Individual
Corporate Officer · Individual
Operational/Managerial Control · Individual
Corporate Officer · Individual
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