2 health deficiencies
Top issue: Infection Control (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Wilkes-Barre, PA
5-star overall rating with 4-star inspections with 2 recent health deficiencies
150 Mundy Street, Wilkes-Barre, PA
(570) 830-8995
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Beds
44
Certified beds
Average residents
33
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2007-05-11
CMS approved date
Coverage
Medicare
Participation flags
Changed ownership
No
Within the last 12 months
Family council
No
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Hospital-based
Yes
CMS reports the provider resides in a hospital
Staffing
RN hours / resident day
2.18
Registered nurse staffing · state 0.78 · national 0.68
LPN hours / resident day
0.87
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
2.53
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
5.58
All reported nurse hours · state 3.89 · national 3.89
Licensed hours
3.05
RN + LPN hours · state 1.69 · national 1.54
Weekend hours
4.86
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
1.37
Weekend registered nurse coverage · state 0.55 · national 0.47
Physical therapist
0.31
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
2.07
CMS adjusted RN staffing hours
Adjusted total hours
5.29
CMS adjusted total nurse staffing hours
Case-mix index
1.44
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
23%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Program rank
1,889
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
53.24
Composite VBP score used to determine payment impact.
Payment multiplier
1.0079
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
0
Baseline 20.50% · Performance 23.67% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
2.86
Baseline 4.70% · Performance 6.98% · Measure score 2.86 · Achievement 2.86 · Improvement 0
Total nurse turnover
10
Baseline 34.78% · Performance 21.05% · Measure score 10 · Achievement 10 · Improvement 9
Adjusted total nurse staffing
8.44
Baseline 5.73 hours · Performance 5.48 hours · Measure score 8.44 · Achievement 8.44 · Improvement 0
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.1% |
10.72%
0.6 pts better
|
No Different than the National Rate · Eligible stays 396 · Observed rate 7.58% · Lower 95% interval 7.61% |
| Discharge to community | 72.1% |
50.57%
21.5 pts better
|
Better than the National Rate · Eligible stays 403 · Observed rate 75.43% · Lower 95% interval 68.16% |
| Medicare spending per beneficiary | 0.66 |
1.02
0.4 pts better
|
|
| Drug regimen review with follow-up | 99.62% |
95.27%
4.4 pts better
|
Numerator 260 · Denominator 261 |
| Falls with major injury | 0.77% |
0.77%
About the same
|
Numerator 2 · Denominator 261 |
| Discharge self-care score | 78.3% |
53.69%
24.6 pts better
|
Numerator 166 · Denominator 212 |
| Discharge mobility score | 80.66% |
50.94%
29.7 pts better
|
Numerator 171 · Denominator 212 |
| Pressure ulcers or injuries, new or worsened | 0.38% |
2.29%
1.9 pts better
|
Numerator 1 · Denominator 261 · Adjusted rate 0.53% |
| Healthcare-associated infections requiring hospitalization | 6.98% |
7.12%
0.1 pts better
|
No Different than the National Rate · Eligible stays 231 · Observed rate 5.19% · Lower 95% interval 4.44% |
| Staff COVID-19 vaccination coverage | 17.02% |
8.2%
8.8 pts better
|
Numerator 16 · Denominator 94 |
| Staff flu vaccination coverage | 63.55% |
42%
21.5 pts better
|
Numerator 68 · Denominator 107 |
| Discharge function score | 73.11% |
56.45%
16.7 pts better
|
Numerator 155 · Denominator 212 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 53 · Denominator 53 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 204 · Denominator 204 |
| Resident COVID-19 vaccinations up to date | 13.49% |
25.2%
11.7 pts worse
|
Numerator 17 · Denominator 126 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.7% |
68.9%
30.8 pts better
|
81.7%
18 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 99.0% · Q2 99.7% · Q3 100.0% · Q4 100.0% · 4Q avg 99.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.6% |
9.8%
1.8 pts worse
|
12.0%
0.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.6% · Observed 10.0% · Expected 9.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.4% |
1.5%
1.1 pts better
|
1.6%
1.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.4% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 98.3% |
68.7%
29.6 pts better
|
79.7%
18.6 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 98.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 25.3% |
23.1%
2.2 pts worse
|
23.9%
1.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.3% · Observed 20.4% · Expected 19.2% · Used in QM five-star |
Survey summary
Top issue: Infection Control (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Top issue: Quality of Life and Care (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Top issue: Quality of Life and Care (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Inspection history
Health
Provide and implement an infection prevention and control program.
Corrected 2025-10-22
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-10-22
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-01-07
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-01-07
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-02-14
Health
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Corrected 2024-02-14
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2024-02-14
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-02-14
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-02-14
Health
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Corrected 2024-02-14
Penalties and ownership
5% Or Greater Direct Ownership Interest · Organization
Operational/Managerial Control · Organization
Operational/Managerial Control · Organization
Operational/Managerial Control · Individual
Corporate Officer · Individual
Corporate Director · Individual
Operational/Managerial Control · Individual
Corporate Director · Individual
Corporate Officer · Individual
Corporate Director · Individual
Operational/Managerial Control · Organization
Corporate Officer · Individual
Corporate Director · Individual
Corporate Director · Individual
W-2 Managing Employee · Individual
W-2 Managing Employee · Individual
Corporate Director · Individual
Corporate Director · Individual
Nearby options
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