Cycle 1
Health 2025-12-19 · Fire 2025-12-19
43 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (10 deficiencies)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Pittsburgh, PA
Highland Hills Post Acute
1-star overall rating with 1-star inspections with Special Focus status with abuse icon flag with $37,516 in total fines with 43 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
1105 Perry Highway, Pittsburgh, PA
(412) 369-9955
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
200
Certified beds
Average residents
161
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Pacs Group
Operator or chain grouping
Approved since
1990-04-11
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
264 facilities
Chain averages 3 overall / 3 health / 2 staffing / 4 quality stars
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
0.93
Registered nurse staffing · state 0.78 · national 0.68
LPN hours / resident day
0.60
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
1.92
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.45
All reported nurse hours · state 3.89 · national 3.89
Licensed hours
1.53
RN + LPN hours · state 1.69 · national 1.54
Weekend hours
3.16
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.66
Weekend registered nurse coverage · state 0.55 · national 0.47
Physical therapist
0.10
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.91
CMS adjusted RN staffing hours
Adjusted total hours
3.38
CMS adjusted total nurse staffing hours
Case-mix index
1.39
Higher values indicate more complex resident acuity
RN turnover
44%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
46%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
11,800
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
15.22
Composite VBP score used to determine payment impact.
Payment multiplier
0.9814
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1.20
Baseline 18.89% · Performance 20.88% · Measure score 1.20 · Achievement 1.20 · Improvement 0
Healthcare-associated infections
1.77
Baseline 7.00% · Performance 7.31% · Measure score 1.77 · Achievement 1.77 · Improvement 0
Total nurse turnover
3.11
Baseline 63.85% · Performance 50.95% · Measure score 3.11 · Achievement 3.11 · Improvement 2.81
Adjusted total nurse staffing
0
Baseline 3.33 hours · Performance 3.05 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.63% |
10.72%
1.9 pts worse
|
No Different than the National Rate · Eligible stays 161 · Observed rate 16.77% · Lower 95% interval 10.16% |
| Discharge to community | 50.1% |
50.57%
0.5 pts worse
|
No Different than the National Rate · Eligible stays 159 · Observed rate 41.51% · Lower 95% interval 41.78% |
| Medicare spending per beneficiary | 0.93 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 95.56% |
95.27%
0.3 pts better
|
Numerator 129 · Denominator 135 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 135 |
| Discharge self-care score | 42.35% |
53.69%
11.3 pts worse
|
Numerator 36 · Denominator 85 |
| Discharge mobility score | 50.59% |
50.94%
0.3 pts worse
|
Numerator 43 · Denominator 85 |
| Pressure ulcers or injuries, new or worsened | 2.96% |
2.29%
0.7 pts worse
|
Numerator 4 · Denominator 135 · Adjusted rate 3.16% |
| Healthcare-associated infections requiring hospitalization | 7.3% |
7.12%
0.2 pts worse
|
No Different than the National Rate · Eligible stays 120 · Observed rate 8.33% · Lower 95% interval 4.68% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 137 |
| Staff flu vaccination coverage | 6.44% |
42%
35.6 pts worse
|
Numerator 21 · Denominator 326 |
| Discharge function score | 49.41% |
56.45%
7 pts worse
|
Numerator 42 · Denominator 85 |
| Transfer of health information to provider | 97.78% |
95.95%
1.8 pts better
|
Numerator 44 · Denominator 45 |
| Transfer of health information to patient | 98.44% |
96.28%
2.2 pts better
|
Numerator 63 · Denominator 64 |
| Resident COVID-19 vaccinations up to date | 29.69% |
25.2%
4.5 pts better
|
Numerator 19 · Denominator 64 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.4 |
1.7
0.3 pts better
|
1.9
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.6 · Expected 2.1 · 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 0.7 · Expected 1.8 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.6% |
86.9%
10.7 pts better
|
93.4%
4.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.5% · Q2 95.3% · Q3 96.6% · Q4 100.0% · 4Q avg 97.6% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 84.8% |
93.5%
8.7 pts worse
|
95.5%
10.7 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 84.8% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.7% |
3.2%
1.5 pts worse
|
3.3%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 4.7% · Q3 5.1% · Q4 6.8% · 4Q avg 4.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.5% |
6.5%
5 pts better
|
11.4%
9.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.1% · Q2 0.0% · Q3 0.0% · Q4 1.7% · 4Q avg 1.5% |
| Percentage of long-stay residents who lose too much weight | 3.5% |
6.5%
3 pts better
|
5.4%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 5.3% · Q3 3.7% · Q4 3.3% · 4Q avg 3.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 13.1% |
19.9%
6.8 pts better
|
19.6%
6.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.2% · Q2 13.2% · Q3 14.8% · Q4 12.3% · 4Q avg 13.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 30.2% |
18.7%
11.5 pts worse
|
16.7%
13.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.3% · Q2 28.2% · Q3 31.0% · Q4 30.9% · 4Q avg 30.2% · 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 | 17.6% |
19.6%
2 pts better
|
16.3%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.3% · Q2 23.7% · Q3 18.9% · Q4 5.7% · 4Q avg 17.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 15.4% |
18.3%
2.9 pts better
|
14.9%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.4% · Q2 10.9% · Q3 15.5% · Q4 17.4% · 4Q avg 15.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.1% |
0.9%
0.8 pts better
|
1.0%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.6% · Q4 0.0% · 4Q avg 0.1% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.6% |
1.7%
0.1 pts better
|
1.7%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 2.4% · Q3 1.7% · Q4 0.0% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 22.0% |
26.4%
4.4 pts better
|
19.8%
2.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 12.8% · Q2 30.6% · Q3 26.0% · Q4 19.6% · 4Q avg 22.0% |
| Percentage of long-stay residents with pressure ulcers | 5.3% |
5.3%
About the same
|
5.1%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.5% · Q2 8.3% · Q3 5.9% · Q4 2.0% · 4Q avg 5.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 95.6% |
68.9%
26.7 pts better
|
81.7%
13.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 91.5% · Q2 95.8% · Q3 97.1% · Q4 98.0% · 4Q avg 95.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 12.5% |
9.8%
2.7 pts worse
|
12.0%
0.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 12.5% · Observed 12.1% · Expected 10.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.8% |
1.5%
0.3 pts worse
|
1.6%
0.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 0.6% · Q2 3.8% · Q3 2.4% · Q4 0.0% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 81.7% |
68.7%
13 pts better
|
79.7%
2 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 81.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 33.2% |
23.1%
10.1 pts worse
|
23.9%
9.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 33.2% · Observed 33.6% · Expected 24.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-12-12 · Fire 2024-12-12
25 health deficiencies
Top issue: Quality of Life and Care (8 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cycle 3
Health 2024-01-12 · Fire 2024-01-12
32 health deficiencies
Top issue: Quality of Life and Care (9 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2025-12-19
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2026-01-31
D · Potential for more than minimal harm
2025-12-19
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2026-01-31
F · Potential for more than minimal harm
2024-12-12
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-01-17
E · Potential for more than minimal harm
2024-12-12
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-01-17
D · Potential for more than minimal harm
2024-12-12
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-01-17
D · Potential for more than minimal harm
2024-12-12
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2025-01-17
D · Potential for more than minimal harm
2024-12-12
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-01-17
E · Potential for more than minimal harm
2024-01-12
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-02-26
D · Potential for more than minimal harm
2024-01-12
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-02-26
C · Minimal harm
2024-01-12
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-02-26
C · Minimal harm
2024-01-12
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-04-05
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-12-30
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2026-01-28
E · Potential for more than minimal harm
2025-12-30
F688 · Quality of Life and Care Deficiencies
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 2026-01-28
D · Potential for more than minimal harm
2025-12-30
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2026-01-28
D · Potential for more than minimal harm
2025-12-30
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 2026-01-28
F · Potential for more than minimal harm
2025-12-19
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2026-01-28
F · Potential for more than minimal harm
2025-12-19
F922 · Environmental Deficiencies
Health
Have enough backup water supply for essential areas of the nursing home.
Corrected 2026-01-28
E · Potential for more than minimal harm
2025-12-19
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2026-01-28
E · Potential for more than minimal harm
2025-12-19
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2026-01-28
E · Potential for more than minimal harm
2025-12-19
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2026-01-28
E · Potential for more than minimal harm
2025-12-19
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2026-01-28
D · Potential for more than minimal harm
2025-12-19
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2026-01-28
D · Potential for more than minimal harm
2025-12-19
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2026-01-28
D · Potential for more than minimal harm
2025-12-19
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 2026-01-28
D · Potential for more than minimal harm
2025-12-19
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 2026-01-28
D · Potential for more than minimal harm
2025-12-19
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2026-01-28
D · Potential for more than minimal harm
2025-12-19
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2026-01-28
D · Potential for more than minimal harm
2025-12-19
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 2026-01-28
D · Potential for more than minimal harm
2025-12-19
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 2026-01-28
D · Potential for more than minimal harm
2025-12-19
F806 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2026-01-28
J · Immediate jeopardy
2025-09-25
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 2025-10-15
F · Potential for more than minimal harm
2025-09-25
F850 · Administration Deficiencies
Health
Hire a qualified full-time social worker in a facility with more than 120 beds.
Corrected 2025-10-15
E · Potential for more than minimal harm
2025-09-25
F944 · Administration Deficiencies
Health
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
Corrected 2025-10-15
D · Potential for more than minimal harm
2025-09-25
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 2025-10-15
D · Potential for more than minimal harm
2025-09-25
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2025-10-15
D · Potential for more than minimal harm
2025-09-25
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-10-15
D · Potential for more than minimal harm
2025-09-25
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-10-15
D · Potential for more than minimal harm
2025-09-25
F688 · Quality of Life and Care Deficiencies
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 2025-10-15
D · Potential for more than minimal harm
2025-09-25
F745 · Quality of Life and Care Deficiencies
Health
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Corrected 2025-10-15
D · Potential for more than minimal harm
2025-09-25
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2025-10-15
D · Potential for more than minimal harm
2025-09-25
F844 · Administration Deficiencies
Health
Follow rules about disclosure of ownership requirements and tell the state agency about changes in ownership and/or administrative personnel.
Corrected 2025-10-15
D · Potential for more than minimal harm
2025-09-25
F941 · Administration Deficiencies
Health
Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.
Corrected 2025-10-15
D · Potential for more than minimal harm
2025-07-16
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.
Not marked corrected
D · Potential for more than minimal harm
2025-05-05
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 2025-05-28
D · Potential for more than minimal harm
2025-05-05
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2025-05-28
D · Potential for more than minimal harm
2025-05-05
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-05-28
D · Potential for more than minimal harm
2025-05-05
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-05-28
D · Potential for more than minimal harm
2025-05-05
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-05-28
J · Immediate jeopardy
2025-03-06
F726 · Nursing and Physician Services Deficiencies
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 2025-03-27
D · Potential for more than minimal harm
2025-03-06
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2025-03-27
D · Potential for more than minimal harm
2025-03-06
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 2025-03-27
D · Potential for more than minimal harm
2025-03-06
F712 · Nursing and Physician Services Deficiencies
Health
Ensure that the resident and his/her doctor meet face-to-face at all required visits.
Corrected 2025-03-27
D · Potential for more than minimal harm
2025-03-06
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2025-03-27
D · Potential for more than minimal harm
2025-03-06
F838 · Administration Deficiencies
Health
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Corrected 2025-03-27
E · Potential for more than minimal harm
2025-01-28
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 2025-02-07
F · Potential for more than minimal harm
2024-12-12
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 2025-01-17
E · Potential for more than minimal harm
2024-12-12
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 2025-01-17
E · Potential for more than minimal harm
2024-12-12
F636 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2025-01-17
E · Potential for more than minimal harm
2024-12-12
F638 · Resident Assessment and Care Planning Deficiencies
Health
Assure that each resident’s assessment is updated at least once every 3 months.
Corrected 2025-01-17
E · Potential for more than minimal harm
2024-12-12
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 2025-01-17
E · Potential for more than minimal harm
2024-12-12
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-01-17
E · Potential for more than minimal harm
2024-12-12
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 2025-01-17
E · Potential for more than minimal harm
2024-12-12
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2025-01-17
E · Potential for more than minimal harm
2024-12-12
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2025-01-17
E · Potential for more than minimal harm
2024-12-12
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 2025-01-17
D · Potential for more than minimal harm
2024-12-12
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2025-01-17
D · Potential for more than minimal harm
2024-12-12
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2025-01-17
D · Potential for more than minimal harm
2024-12-12
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 2025-01-17
D · Potential for more than minimal harm
2024-12-12
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 2025-01-17
D · Potential for more than minimal harm
2024-12-12
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-01-17
D · Potential for more than minimal harm
2024-12-12
F699 · Quality of Life and Care Deficiencies
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2025-01-17
D · Potential for more than minimal harm
2024-12-12
F725 · Nursing and Physician Services Deficiencies
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 2025-01-17
D · Potential for more than minimal harm
2024-12-12
F810 · Nutrition and Dietary Deficiencies
Health
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
Corrected 2025-01-17
D · Potential for more than minimal harm
2024-12-12
F868 · Administration Deficiencies
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected 2025-01-17
D · Potential for more than minimal harm
2024-12-12
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-01-17
C · Minimal harm
2024-09-05
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2024-10-01
D · Potential for more than minimal harm
2024-04-30
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2024-06-17
D · Potential for more than minimal harm
2024-04-30
F806 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2024-06-17
D · Potential for more than minimal harm
2024-03-18
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-04-04
F · Potential for more than minimal harm
2024-01-12
F809 · Nutrition and Dietary Deficiencies
Health
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
Corrected 2024-03-06
E · Potential for more than minimal harm
2024-01-12
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-03-06
E · Potential for more than minimal harm
2024-01-12
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-03-06
E · Potential for more than minimal harm
2024-01-12
F726 · Nursing and Physician Services Deficiencies
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 2024-03-06
E · Potential for more than minimal harm
2024-01-12
F745 · Quality of Life and Care Deficiencies
Health
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Corrected 2024-03-06
E · Potential for more than minimal harm
2024-01-12
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-03-06
D · Potential for more than minimal harm
2024-01-12
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-03-06
D · Potential for more than minimal harm
2024-01-12
F553 · Resident Rights Deficiencies
Health
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Corrected 2024-03-06
D · Potential for more than minimal harm
2024-01-12
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2024-03-06
D · Potential for more than minimal harm
2024-01-12
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 2024-03-06
D · Potential for more than minimal harm
2024-01-12
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2024-03-06
D · Potential for more than minimal harm
2024-01-12
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-03-06
D · Potential for more than minimal harm
2024-01-12
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2024-03-06
D · Potential for more than minimal harm
2024-01-12
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-03-06
D · Potential for more than minimal harm
2024-01-12
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 2024-03-06
D · Potential for more than minimal harm
2024-01-12
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-03-06
D · Potential for more than minimal harm
2024-01-12
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-03-06
D · Potential for more than minimal harm
2024-01-12
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 2024-03-06
D · Potential for more than minimal harm
2024-01-12
F758 · Pharmacy Service Deficiencies
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 2024-03-06
D · Potential for more than minimal harm
2024-01-12
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 2024-03-06
D · Potential for more than minimal harm
2024-01-12
F868 · Administration Deficiencies
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected 2024-03-06
D · Potential for more than minimal harm
2024-01-12
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2024-03-06
D · Potential for more than minimal harm
2024-01-12
F943 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
Corrected 2024-03-06
D · Potential for more than minimal harm
2023-11-07
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2023-12-15
D · Potential for more than minimal harm
2023-11-07
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-12-15
F · Potential for more than minimal harm
2023-09-29
F802 · Nutrition and Dietary Deficiencies
Health
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Corrected 2023-10-18
D · Potential for more than minimal harm
2023-09-29
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2023-10-18
D · Potential for more than minimal harm
2023-09-29
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 2023-10-18
E · Potential for more than minimal harm
2023-07-11
F725 · Nursing and Physician Services Deficiencies
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 2023-08-22
E · Potential for more than minimal harm
2023-05-16
F802 · Nutrition and Dietary Deficiencies
Health
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Corrected 2023-07-06
E · Potential for more than minimal harm
2023-05-16
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 2023-07-06
D · Potential for more than minimal harm
2023-05-16
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 2023-07-06
Penalties and ownership
What sits behind the stars
$28,020
2025-09-25
Fine
Fine · fine $28,020
Fine
$9,496
2025-03-06
Fine
Fine · fine $9,496
Fine
$0
2023-05-16
Payment Denial
Payment Denial · denial start 2023-08-16 · 14 days
14 day denial
Ownership
Apt, Frederick
Operational/Managerial Control · Individual
Apt, Frederick
Corporate Officer · Individual
Hancock, Mark
5% Or Greater Indirect Ownership Interest · Individual
Jergensen, Joshua
Operational/Managerial Control · Individual
Mitchell, John
Operational/Managerial Control · Individual
Mitchell, John
Corporate Officer · Individual
Murray, Jason
5% Or Greater Indirect Ownership Interest · Individual
Pacs Group, Inc.
5% Or Greater Indirect Ownership Interest · Organization
Pacs Group, Inc.
Operational/Managerial Control · Organization
Pacs Holdings, LLC
5% Or Greater Indirect Ownership Interest · Organization
Pacs Holdings, LLC
Operational/Managerial Control · Organization
Providence Group Nh, LLC
Operational/Managerial Control · Organization
Williams, Cristine
Operational/Managerial Control · Individual
Nearby options
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#3
Perry Health & Rehab Center
Wexford, PA
1-star overall rating with 1-star inspections with $18,223 in total fines with 29 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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