13 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Wellsboro, PA
3-star overall rating with 2-star inspections with 13 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
37 Central Avenue, Wellsboro, PA
(570) 724-3131
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
Beds
120
Certified beds
Average residents
79
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Upmc Senior Communities
Operator or chain grouping
Approved since
1974-10-28
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
RN hours / resident day
0.90
Registered nurse staffing
LPN hours / resident day
1.17
Licensed practical nurse staffing
Aide hours / resident day
2.14
Nurse aide staffing
Weekend hours
3.45
Weekend nurse staffing
RN turnover
44%
Annual RN turnover
Total nurse turnover
52%
Annual nurse turnover
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.7 |
1.7
1 pts better
|
1.9
1.2 pts better
|
Long Stay · 20240701-20250630 |
| 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 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
86.9%
13.1 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 95.8% |
93.5%
2.3 pts better
|
95.5%
0.3 pts better
|
Long Stay · 2024Q3-2025Q2 |
| 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 |
| 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 |
| Percentage of long-stay residents who lose too much weight | 2.0% |
6.5%
4.5 pts better
|
5.4%
3.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 22.4% |
19.9%
2.5 pts worse
|
19.6%
2.8 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 11.4% |
18.7%
7.3 pts better
|
16.7%
5.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents whose ability to walk independently worsened | 12.0% |
19.6%
7.6 pts better
|
16.3%
4.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 5.6% |
18.3%
12.7 pts better
|
14.9%
9.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents with a urinary tract infection | 0.7% |
1.7%
1 pts better
|
1.7%
1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 22.5% |
26.4%
3.9 pts better
|
19.8%
2.7 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 6.3% |
5.3%
1 pts worse
|
5.1%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 93.7% |
68.9%
24.8 pts better
|
81.7%
12 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.4% |
9.8%
1.6 pts worse
|
12.0%
0.6 pts better
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.5%
1.5 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 89.2% |
68.7%
20.5 pts better
|
79.7%
9.5 pts better
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 10.5% |
23.1%
12.6 pts better
|
23.9%
13.4 pts better
|
Short Stay · 20240701-20250630 |
Survey summary
Top issue: Quality of Life and Care (4 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Top issue: Quality of Life and Care (4 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
4 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Fire safety
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2025-02-04
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 2025-02-04
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-02-04
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-02-04
Fire Safety
Use approved construction type or materials.
Corrected 2024-03-01
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 2024-03-01
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-03-01
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-03-01
Fire Safety
Meet requirements for the installation and maintenance of medical gas and medical vacuum systems.
Corrected 2024-03-01
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2024-03-01
Fire Safety
Establish policies and procedures for volunteers.
Corrected 2024-03-01
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-03-01
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 2023-02-28
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-02-28
Fire Safety
Ensure gas and vacuum piping is labeled.
Corrected 2023-02-28
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2023-02-28
Inspection history
Health
Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
Corrected 2025-01-28
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 2025-01-28
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2025-01-28
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-01-28
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2025-01-28
Health
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Corrected 2025-01-28
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2025-01-28
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-01-28
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2025-01-28
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-01-28
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2025-01-28
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 2025-01-28
Health
Provide or obtain dental services for each resident.
Corrected 2025-01-28
Health
Provide and implement an infection prevention and control program.
Corrected 2024-02-21
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-02-20
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2024-02-20
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-02-20
Health
Keep residents' personal and medical records private and confidential.
Corrected 2024-02-20
Health
Respond appropriately to all alleged violations.
Corrected 2024-02-20
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 2024-02-20
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2024-02-20
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2024-02-20
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2023-02-28
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2023-02-28
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-02-28
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2023-02-28
Penalties and ownership
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Direct Ownership Interest · Organization
Operational/Managerial Control · Individual
Corporate Director · Individual
Corporate Officer · Individual
Corporate Director · Individual
Corporate Officer · Individual
Corporate Officer · Individual
Corporate Officer · Individual
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