Cycle 1
Health 2025-01-24 · Fire 2025-01-24
2 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
7 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Lima, PA
Fair Acres Geriatric Center
5-star overall rating with 5-star inspections with 2 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
340 N. Middletown Road, Lima, PA
(610) 891-5700
Overall
5 / 5
CMS overall stars
Health inspections
5 / 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
778
Certified beds
Average residents
455
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1989-02-01
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
Hours and turnover
RN hours / resident day
0.59
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
2.31
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.92
All reported nurse hours · state 3.89 · national 3.89
Licensed hours
1.61
RN + LPN hours · state 1.69 · national 1.54
Weekend hours
3.58
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
0.00
Reported PT staffing
Adjusted RN hours
0.70
CMS adjusted RN staffing hours
Adjusted total hours
4.61
CMS adjusted total nurse staffing hours
Case-mix index
1.16
Higher values indicate more complex resident acuity
RN turnover
99%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
100%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
767
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
64.07
Composite VBP score used to determine payment impact.
Payment multiplier
1.0186
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
7.53
Baseline 17.88% · Performance 17.94% · Measure score 7.53 · Achievement 7.53 · Improvement 0
Healthcare-associated infections
2.99
Baseline 5.28% · Performance 6.94% · Measure score 2.99 · Achievement 2.99 · Improvement 0
Total nurse turnover
10
Baseline 27.03% · Performance 21.25% · Measure score 10 · Achievement 10 · Improvement 9
Adjusted total nurse staffing
5.11
Baseline 4.40 hours · Performance 4.53 hours · Measure score 5.11 · Achievement 5.11 · Improvement 0.47
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 8.49% |
10.72%
2.2 pts better
|
No Different than the National Rate · Eligible stays 171 · Observed rate 6.43% · Lower 95% interval 6.5% |
| Discharge to community | 34.06% |
50.57%
16.5 pts worse
|
Worse than the National Rate · Eligible stays 27 · Observed rate 18.52% · Lower 95% interval 20.93% |
| Medicare spending per beneficiary | 0.82 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 95.69% |
95.27%
0.4 pts better
|
Numerator 111 · Denominator 116 |
| Falls with major injury | 0.86% |
0.77%
0.1 pts worse
|
Numerator 1 · Denominator 116 |
| Discharge self-care score | 25.25% |
53.69%
28.4 pts worse
|
Numerator 25 · Denominator 99 |
| Discharge mobility score | 26.26% |
50.94%
24.7 pts worse
|
Numerator 26 · Denominator 99 |
| Pressure ulcers or injuries, new or worsened | 4.31% |
2.29%
2 pts worse
|
Numerator 5 · Denominator 116 · Adjusted rate 2.93% |
| Healthcare-associated infections requiring hospitalization | 6.94% |
7.12%
0.2 pts better
|
No Different than the National Rate · Eligible stays 76 · Observed rate 7.89% · Lower 95% interval 4.21% |
| Staff COVID-19 vaccination coverage | 0.99% |
8.2%
7.2 pts worse
|
Numerator 7 · Denominator 709 |
| Staff flu vaccination coverage | 23.06% |
42%
18.9 pts worse
|
Numerator 175 · Denominator 759 |
| Discharge function score | 34.34% |
56.45%
22.1 pts worse
|
Numerator 34 · Denominator 99 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| 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 | 60.94% |
25.2%
35.7 pts better
|
Numerator 39 · Denominator 64 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.9 |
1.7
0.2 pts worse
|
1.9
About the same
|
Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 1.3 · Expected 1.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.2 |
1.2
About the same
|
1.8
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.0 · Expected 1.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.2% |
86.9%
10.3 pts better
|
93.4%
3.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 93.2% · Q2 99.3% · Q3 98.6% · Q4 97.6% · 4Q avg 97.2% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.3% |
93.5%
4.8 pts better
|
95.5%
2.8 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.0% |
3.2%
1.2 pts better
|
3.3%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 2.0% · Q3 1.6% · Q4 2.0% · 4Q avg 2.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 4.8% |
6.5%
1.7 pts better
|
11.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.9% · Q2 4.3% · Q3 6.3% · Q4 4.9% · 4Q avg 4.8% |
| 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 3.8% · Q2 4.6% · Q3 5.4% · Q4 4.8% · 4Q avg 4.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 18.6% |
19.9%
1.3 pts better
|
19.6%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.6% · Q2 18.4% · Q3 18.8% · Q4 18.7% · 4Q avg 18.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 28.5% |
18.7%
9.8 pts worse
|
16.7%
11.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.5% · Q2 28.0% · Q3 29.8% · Q4 29.5% · 4Q avg 28.5% · 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 | 14.5% |
19.6%
5.1 pts better
|
16.3%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.7% · Q2 19.4% · Q3 13.8% · Q4 13.2% · 4Q avg 14.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 19.7% |
18.3%
1.4 pts worse
|
14.9%
4.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.2% · Q2 21.3% · Q3 17.9% · Q4 18.4% · 4Q avg 19.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.7% |
0.9%
0.2 pts better
|
1.0%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 0.4% · Q3 0.4% · Q4 0.5% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.2% |
1.7%
0.5 pts better
|
1.7%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 0.5% · Q3 1.4% · Q4 1.4% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 26.6% |
26.4%
0.2 pts worse
|
19.8%
6.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.0% · Q2 29.9% · Q3 21.7% · Q4 26.1% · 4Q avg 26.6% |
| Percentage of long-stay residents with pressure ulcers | 4.4% |
5.3%
0.9 pts better
|
5.1%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 5.1% · Q3 4.4% · Q4 4.2% · 4Q avg 4.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 75.9% |
68.9%
7 pts better
|
81.7%
5.8 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 64.7% · Q2 75.9% · Q3 77.9% · Q4 82.8% · 4Q avg 75.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.4% |
9.8%
0.4 pts better
|
12.0%
2.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.4% · Observed 8.7% · Expected 10.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 5.6% |
1.5%
4.1 pts worse
|
1.6%
4 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q4 8.7% · 4Q avg 5.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 92.6% |
68.7%
23.9 pts better
|
79.7%
12.9 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 92.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 17.3% |
23.1%
5.8 pts better
|
23.9%
6.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 17.3% · Observed 15.9% · Expected 21.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-02-08 · Fire 2024-02-08
0 health deficiencies
No concentrated health issue counts in this cycle.
7 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Cycle 3
Health 2023-03-23 · Fire 2023-03-23
0 health deficiencies
No concentrated health issue counts in this cycle.
11 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-01-24
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-02-19
F · Potential for more than minimal harm
2025-01-24
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-02-19
E · Potential for more than minimal harm
2025-01-24
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 2025-02-19
E · Potential for more than minimal harm
2025-01-24
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-02-19
E · Potential for more than minimal harm
2025-01-24
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2025-02-19
E · Potential for more than minimal harm
2025-01-24
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-02-19
E · Potential for more than minimal harm
2025-01-24
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-02-19
F · Potential for more than minimal harm
2024-02-08
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2024-03-15
E · Potential for more than minimal harm
2024-02-08
K131 · Construction Deficiencies
Fire Safety
Meet requirements for sections of health care facilities separated by fire resistive construction.
Corrected 2024-03-15
E · Potential for more than minimal harm
2024-02-08
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-03-15
E · Potential for more than minimal harm
2024-02-08
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2024-03-15
E · Potential for more than minimal harm
2024-02-08
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2024-03-15
E · Potential for more than minimal harm
2024-02-08
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-03-15
C · Minimal harm
2024-02-08
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-03-15
F · Potential for more than minimal harm
2023-03-23
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-04-19
E · Potential for more than minimal harm
2023-03-23
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-04-19
E · Potential for more than minimal harm
2023-03-23
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2023-04-19
E · Potential for more than minimal harm
2023-03-23
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2023-04-19
E · Potential for more than minimal harm
2023-03-23
K347 · Smoke Deficiencies
Fire Safety
Properly provide smoke detection systems in areas open to corridors.
Corrected 2023-04-19
E · Potential for more than minimal harm
2023-03-23
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-04-19
E · Potential for more than minimal harm
2023-03-23
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-04-19
E · Potential for more than minimal harm
2023-03-23
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-04-19
E · Potential for more than minimal harm
2023-03-23
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-04-19
E · Potential for more than minimal harm
2023-03-23
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-04-19
E · Potential for more than minimal harm
2023-03-23
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2023-04-19
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-07-18
F585 · Resident Rights Deficiencies
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 2025-08-18
D · Potential for more than minimal harm
2025-01-24
F756 · Pharmacy Service Deficiencies
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 2025-01-24
Penalties and ownership
What sits behind the stars
Ownership
County Of Delaware
5% Or Greater Direct Ownership Interest · Organization
Bonner, James
Operational/Managerial Control · Individual
Madden, Kevin
Operational/Managerial Control · Individual
Reuther, Christine
Operational/Managerial Control · Individual
Schaeffer, Elaine
Operational/Managerial Control · Individual
Taylor, Monica
Operational/Managerial Control · Individual
Travaglini, Joseph
Operational/Managerial Control · Individual
Womack, Richard
Operational/Managerial Control · Individual
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Other facilities in reach
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5-star overall rating with 5-star inspections
#2
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Media, PA
5-star overall rating with 5-star inspections with 9 fire-safety deficiencies in the latest cycle
#3
Sterling Health Care and Rehab Center
Media, PA
2-star overall rating with 2-star inspections with abuse icon flag with $25,625 in total fines with 10 recent health deficiencies
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