Orbisonia, PA

Embassy Of Woodland Park

3-star overall rating with 2-star inspections with $8,155 in total fines with 15 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle

18889 Croghan Pike, Orbisonia, PA

(814) 447-0300

Compare this facility

Overall

3 / 5

CMS overall stars

Health inspections

2 / 5

Survey and complaint cycles

Staffing

3 / 5

RN + nurse staffing

Quality measures

5 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

125

Certified beds

Average residents

117

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Embassy Healthcare

Operator or chain grouping

Approved since

1985-05-14

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

37 facilities

Chain averages 3 overall / 2 health / 2 staffing / 5 quality stars

Changed ownership

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

0.36

Registered nurse staffing · state 0.78 · national 0.68

LPN hours / resident day

1.08

Licensed practical nurse staffing · state 0.91 · national 0.87

Aide hours / resident day

2.24

Nurse aide staffing · state 2.20 · national 2.35

Total nurse hours

3.68

All reported nurse hours · state 3.89 · national 3.89

Licensed hours

1.44

RN + LPN hours · state 1.69 · national 1.54

Weekend hours

3.44

Weekend nurse staffing · state 3.51 · national 3.43

Weekend RN hours

0.23

Weekend registered nurse coverage · state 0.55 · national 0.47

Physical therapist

0.02

Reported PT staffing · state 0.10 · national 0.07

Adjusted RN hours

0.40

CMS adjusted RN staffing hours

Adjusted total hours

4.08

CMS adjusted total nurse staffing hours

Case-mix index

1.23

Higher values indicate more complex resident acuity

RN turnover

11%

Annual RN turnover · state 43% · national 45%

Total nurse turnover

24%

Annual nurse turnover · state 47% · national 46%

SNF VBP

Value-based purchasing

Program rank

918

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

62.09

Composite VBP score used to determine payment impact.

Payment multiplier

1.0171

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

7.04

Baseline 17.14% · Performance 18.17% · Measure score 7.04 · Achievement 7.04 · Improvement 0

Healthcare-associated infections

5.73

Baseline 5.59% · Performance 6.12% · Measure score 5.73 · Achievement 5.73 · Improvement 0

Total nurse turnover

8.59

Performance 28.57% · Measure score 8.59 · Achievement 8.59 · This facility did not have sufficient data to calculate a baseline period measure result.

Adjusted total nurse staffing

3.48

Baseline 2.63 hours · Performance 3.88 hours · Measure score 3.48 · Achievement 2.82 · Improvement 3.48

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	10.28%	10.72% 0.4 pts better	No Different than the National Rate · Eligible stays 89 · Observed rate 8.99% · Lower 95% interval 6.4%
Discharge to community	46.37%	50.57% 4.2 pts worse	No Different than the National Rate · Eligible stays 79 · Observed rate 41.77% · Lower 95% interval 34%
Medicare spending per beneficiary	0.77	1.02 0.2 pts better
Drug regimen review with follow-up	100%	95.27% 4.7 pts better	Numerator 50 · Denominator 50
Falls with major injury	2%	0.77% 1.2 pts worse	Numerator 1 · Denominator 50
Discharge self-care score	46.51%	53.69% 7.2 pts worse	Numerator 20 · Denominator 43
Discharge mobility score	37.21%	50.94% 13.7 pts worse	Numerator 16 · Denominator 43
Pressure ulcers or injuries, new or worsened	0%	2.29% 2.3 pts better	Numerator 0 · Denominator 50 · Adjusted rate 0%
Healthcare-associated infections requiring hospitalization	6.12%	7.12% 1 pts better	No Different than the National Rate · Eligible stays 46 · Observed rate 2.17% · Lower 95% interval 3.44%
Staff COVID-19 vaccination coverage	0%	8.2% 8.2 pts worse	Numerator 0 · Denominator 168
Staff flu vaccination coverage	4.12%	42% 37.9 pts worse	Numerator 7 · Denominator 170
Discharge function score	46.51%	56.45% 9.9 pts worse	Numerator 20 · Denominator 43
Transfer of health information to provider	95.24%	95.95% 0.7 pts worse	Numerator 20 · Denominator 21
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date	13.79%	25.2% 11.4 pts worse	Numerator 4 · Denominator 29

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	0.5	1.7 1.2 pts better	1.9 1.4 pts better	Long Stay · 20240701-20250630 · Adjusted 0.5 · Observed 0.5 · Expected 1.8 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	0.6	1.2 0.6 pts better	1.8 1.2 pts better	Long Stay · 20240701-20250630 · Adjusted 0.6 · Observed 0.6 · Expected 1.6 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	94.1%	86.9% 7.2 pts better	93.4% 0.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 92.4% · Q2 92.7% · Q3 98.2% · Q4 92.9% · 4Q avg 94.1%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	99.1%	93.5% 5.6 pts better	95.5% 3.6 pts better	Long Stay · 2024Q3-2025Q2 · 4Q avg 99.1%
Percentage of long-stay residents experiencing one or more falls with major injury	1.8%	3.2% 1.4 pts better	3.3% 1.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 1.8% · Q3 0.9% · Q4 2.7% · 4Q avg 1.8% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	5.2%	6.5% 1.3 pts better	11.4% 6.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 6.7% · Q2 1.9% · Q3 2.8% · Q4 9.6% · 4Q avg 5.2%
Percentage of long-stay residents who lose too much weight	4.0%	6.5% 2.5 pts better	5.4% 1.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 6.2% · Q2 3.1% · Q3 4.0% · Q4 2.9% · 4Q avg 4.0%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	21.0%	19.9% 1.1 pts worse	19.6% 1.4 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 19.6% · Q2 19.2% · Q3 18.8% · Q4 26.2% · 4Q avg 21.0%
Percentage of long-stay residents who received an antipsychotic medication	25.7%	18.7% 7 pts worse	16.7% 9 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 25.6% · Q2 22.9% · Q3 28.2% · Q4 26.1% · 4Q avg 25.7% · 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	13.6%	19.6% 6 pts better	16.3% 2.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 18.2% · Q2 12.3% · Q3 10.1% · Q4 12.9% · 4Q avg 13.6% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	6.4%	18.3% 11.9 pts better	14.9% 8.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 7.4% · Q2 6.2% · Q3 3.1% · Q4 8.7% · 4Q avg 6.4% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	1.0%	0.9% 0.1 pts worse	1.0% About the same	Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 2.0% · Q3 0.0% · Q4 0.0% · 4Q avg 1.0% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	1.4%	1.7% 0.3 pts better	1.7% 0.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.8% · Q3 0.9% · Q4 1.8% · 4Q avg 1.4% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	28.5%	26.4% 2.1 pts worse	19.8% 8.7 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 34.6% · Q2 30.1% · Q3 21.6% · Q4 28.4% · 4Q avg 28.5%
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 2.5% · Q2 3.8% · Q3 1.5% · Q4 2.9% · 4Q avg 2.7% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	66.5%	68.9% 2.4 pts worse	81.7% 15.2 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 73.9% · Q2 63.2% · Q3 66.2% · Q4 62.1% · 4Q avg 66.5%
Percentage of short-stay residents who had an outpatient emergency department visit	5.8%	9.8% 4 pts better	12.0% 6.2 pts better	Short Stay · 20240701-20250630 · Adjusted 5.8% · Observed 6.1% · Expected 11.8% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	0.9%	1.5% 0.6 pts better	1.6% 0.7 pts better	Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.4% · Q3 0.0% · Q4 0.0% · 4Q avg 0.9% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	84.3%	68.7% 15.6 pts better	79.7% 4.6 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 84.3%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	17.9%	23.1% 5.2 pts better	23.9% 6 pts better	Short Stay · 20240701-20250630 · Adjusted 17.9% · Observed 18.4% · Expected 24.5% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-12-04 · Fire 2025-12-04

15 health deficiencies

Top issue: Quality of Life and Care (5 deficiencies)

2 fire-safety deficiencies

Top issue: Services (1 deficiency)

Cycle 2 Health 2024-10-03 · Fire 2024-10-03

16 health deficiencies

Top issue: Quality of Life and Care (3 deficiencies)

11 fire-safety deficiencies

Top issue: Smoke (4 deficiencies)

Cycle 3 Health 2023-11-30 · Fire 2023-11-30

19 health deficiencies

Top issue: Quality of Life and Care (5 deficiencies)

9 fire-safety deficiencies

Top issue: Smoke (5 deficiencies)

Fire safety

Fire-safety citations

C · Minimal harm 2025-12-04

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2026-01-15

C · Minimal harm 2025-12-04

K521 · Services Deficiencies

Fire Safety

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Corrected 2026-01-15

F · Potential for more than minimal harm 2024-10-03

K100 · Construction Deficiencies

Fire Safety

Meet other general requirements.

Corrected 2024-10-28

F · Potential for more than minimal harm 2024-10-03

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2024-10-28

E · Potential for more than minimal harm 2024-10-03

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 2024-10-28

E · Potential for more than minimal harm 2024-10-03

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2024-10-28

E · Potential for more than minimal harm 2024-10-03

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2024-10-28

E · Potential for more than minimal harm 2024-10-03

K374 · Smoke Deficiencies

Fire Safety

Install smoke barrier doors that can resist smoke for at least 20 minutes.

Corrected 2024-10-28

E · Potential for more than minimal harm 2024-10-03

K754 · Miscellaneous Deficiencies

Fire Safety

Provide properly sized and located linen or trash receptacles.

Corrected 2024-10-28

E · Potential for more than minimal harm 2024-10-03

K911 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Meet requirements for the installation and maintenance of electrical systems.

Corrected 2024-10-28

E · Potential for more than minimal harm 2024-10-03

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2024-10-28

D · Potential for more than minimal harm 2024-10-03

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2024-10-28

C · Minimal harm 2024-10-03

E41 · Emergency Preparedness Deficiencies

Fire Safety

Implement emergency and standby power systems.

Corrected 2024-10-28

E · Potential for more than minimal harm 2023-11-30

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 2024-01-19

E · Potential for more than minimal harm 2023-11-30

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 2024-01-19

E · Potential for more than minimal harm 2023-11-30

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2024-01-19

E · Potential for more than minimal harm 2023-11-30

K355 · Smoke Deficiencies

Fire Safety

Properly select, install, inspect, or maintain portable fire extinguishes.

Corrected 2024-01-19

E · Potential for more than minimal harm 2023-11-30

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2024-01-19

E · Potential for more than minimal harm 2023-11-30

K912 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have power receptacles that are properly grounded.

Corrected 2024-01-19

C · Minimal harm 2023-11-30

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2024-01-19

C · Minimal harm 2023-11-30

K761 · Miscellaneous Deficiencies

Fire Safety

To conduct inspection, testing and maintenance of fire doors by qualified individuals.

Corrected 2024-01-19

C · Minimal harm 2023-11-30

K914 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.

Corrected 2024-01-19

Inspection history

Recent health citations

E · Potential for more than minimal harm 2025-12-04

F552 · Resident Rights Deficiencies

Health

Ensure that residents are fully informed and understand their health status, care and treatments.

Corrected 2026-01-22

E · Potential for more than minimal harm 2025-12-04

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 2026-01-22

D · Potential for more than minimal harm 2025-12-04

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 2026-01-22

D · Potential for more than minimal harm 2025-12-04

F605 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.

Corrected 2026-01-22

D · Potential for more than minimal harm 2025-12-04

F628 · Resident Rights Deficiencies

Health

Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.

Corrected 2026-01-22

D · Potential for more than minimal harm 2025-12-04

F637 · Resident Assessment and Care Planning Deficiencies

Health

Assess the resident when there is a significant change in condition

Corrected 2026-01-22

D · Potential for more than minimal harm 2025-12-04

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2026-01-22

D · Potential for more than minimal harm 2025-12-04

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 2026-01-22

D · Potential for more than minimal harm 2025-12-04

F694 · Quality of Life and Care Deficiencies

Health

Provide for the safe, appropriate administration of IV fluids for a resident when needed.

Corrected 2026-01-22

D · Potential for more than minimal harm 2025-12-04

F699 · Quality of Life and Care Deficiencies

Health

Provide care or services that was trauma informed and/or culturally competent.

Corrected 2026-01-22

D · Potential for more than minimal harm 2025-12-04

F867 · Administration Deficiencies

Health

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Corrected 2026-01-22

D · Potential for more than minimal harm 2025-08-19

F804 · Nutrition and Dietary Deficiencies

Health

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Corrected 2025-09-30

D · Potential for more than minimal harm 2025-07-07

F580 · Resident Rights Deficiencies

Health

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Corrected 2025-08-11

D · Potential for more than minimal harm 2025-04-01

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2025-05-09

D · Potential for more than minimal harm 2025-04-01

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 2025-05-09

E · Potential for more than minimal harm 2024-10-03

F803 · Nutrition and Dietary Deficiencies

Health

Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.

Corrected 2024-11-12

E · Potential for more than minimal harm 2024-10-03

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 2024-11-12

D · Potential for more than minimal harm 2024-10-03

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 2024-11-12

D · Potential for more than minimal harm 2024-10-03

F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Corrected 2024-11-12

D · Potential for more than minimal harm 2024-10-03

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 2024-11-12

D · Potential for more than minimal harm 2024-10-03

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 2024-11-12

D · Potential for more than minimal harm 2024-10-03

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 2024-11-12

D · Potential for more than minimal harm 2024-10-03

F729 · Nursing and Physician Services Deficiencies

Health

Verify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining.

Corrected 2024-11-12

D · Potential for more than minimal harm 2024-10-03

F744 · Quality of Life and Care Deficiencies

Health

Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

Corrected 2024-11-12

D · Potential for more than minimal harm 2024-10-03

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 2024-11-12

D · Potential for more than minimal harm 2024-10-03

F761 · Pharmacy Service Deficiencies

Health

Corrected 2024-11-12

D · Potential for more than minimal harm 2024-10-03

F867 · Administration Deficiencies

Health

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Corrected 2024-11-12

B · Minimal harm 2024-10-03

F582 · Resident Rights Deficiencies

Health

Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

Corrected 2024-11-12

G · Actual harm 2024-07-10

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 2024-08-01

D · Potential for more than minimal harm 2024-04-30

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 2024-05-29

D · Potential for more than minimal harm 2024-04-30

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 2024-05-29

D · Potential for more than minimal harm 2024-01-29

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 2024-02-14

E · Potential for more than minimal harm 2023-11-30

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2024-01-24

E · Potential for more than minimal harm 2023-11-30

F686 · Quality of Life and Care Deficiencies

Health

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected 2024-01-24

E · Potential for more than minimal harm 2023-11-30

F760 · Pharmacy Service Deficiencies

Health

Ensure that residents are free from significant medication errors.

Corrected 2024-01-24

E · Potential for more than minimal harm 2023-11-30

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 2024-01-24