Cycle 1
Health 2025-03-07 · Fire 2025-03-07
27 health deficiencies
Top issue: Quality of Life and Care (11 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Lower Burrell, PA
Hillcrest Rehabilitation & Healthcare Center
1-star overall rating with 1-star inspections with abuse icon flag with $3,145 in total fines with 27 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
100 Little Drive, Lower Burrell, PA
(724) 339-1071
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
103
Certified beds
Average residents
64
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1967-06-06
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
0.80
Registered nurse staffing · state 0.78 · national 0.68
LPN hours / resident day
0.79
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
1.95
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.53
All reported nurse hours · state 3.89 · national 3.89
Licensed hours
1.59
RN + LPN hours · state 1.69 · national 1.54
Weekend hours
3.50
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.80
Weekend registered nurse coverage · state 0.55 · national 0.47
Physical therapist
0.07
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.78
CMS adjusted RN staffing hours
Adjusted total hours
3.45
CMS adjusted total nurse staffing hours
Case-mix index
1.40
Higher values indicate more complex resident acuity
RN turnover
59%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
54%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
9,610
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
23.12
Composite VBP score used to determine payment impact.
Payment multiplier
0.9831
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
2.30
Baseline 52.38% · Performance 54.29% · Measure score 2.30 · Achievement 2.30 · Improvement 0
Adjusted total nurse staffing
2.33
Baseline 3.45 hours · Performance 3.74 hours · Measure score 2.33 · Achievement 2.33 · Improvement 0.75
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.67% |
10.72%
0.1 pts better
|
No Different than the National Rate · Eligible stays 36 · Observed rate 13.89% · Lower 95% interval 6.98% |
| Discharge to community | 49.9% |
50.57%
0.7 pts worse
|
No Different than the National Rate · Eligible stays 32 · Observed rate 40.63% · Lower 95% interval 30.51% |
| Medicare spending per beneficiary | 0.67 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 31 · Denominator 31 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 31 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 31 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 17 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 3.66% |
8.2%
4.5 pts worse
|
Numerator 3 · Denominator 82 |
| Staff flu vaccination coverage | 17.44% |
42%
24.6 pts worse
|
Numerator 15 · Denominator 86 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 9.09% |
25.2%
16.1 pts worse
|
Numerator 2 · Denominator 22 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.5 |
1.7
0.8 pts worse
|
1.9
0.6 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.5 · Observed 2.5 · Expected 1.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.3 |
1.2
0.1 pts worse
|
1.8
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.2 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 93.3% |
86.9%
6.4 pts better
|
93.4%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 95.8% · Q3 87.0% · Q4 91.1% · 4Q avg 93.3% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 94.1% |
93.5%
0.6 pts better
|
95.5%
1.4 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 94.1% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.9% |
3.2%
1.3 pts better
|
3.3%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 2.1% · Q3 1.9% · Q4 1.8% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.0% |
6.5%
3.5 pts better
|
11.4%
8.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 11.5% · 4Q avg 3.0% |
| Percentage of long-stay residents who lose too much weight | 9.7% |
6.5%
3.2 pts worse
|
5.4%
4.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.3% · Q2 6.5% · Q3 4.3% · Q4 11.1% · 4Q avg 9.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 25.9% |
19.9%
6 pts worse
|
19.6%
6.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.0% · Q2 25.5% · Q3 24.5% · Q4 25.5% · 4Q avg 25.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 21.7% |
18.7%
3 pts worse
|
16.7%
5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.6% · Q2 19.4% · Q3 26.8% · Q4 18.9% · 4Q avg 21.7% · 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 | 9.4% |
19.6%
10.2 pts better
|
16.3%
6.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.7% · Q3 8.3% · Q4 12.5% · 4Q avg 9.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 5.8% |
18.3%
12.5 pts better
|
14.9%
9.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.2% · Q2 4.7% · Q3 8.0% · Q4 4.1% · 4Q avg 5.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.5% |
0.9%
0.6 pts worse
|
1.0%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.6% · Q2 0.0% · Q3 0.0% · Q4 1.3% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.5% |
1.7%
1.2 pts better
|
1.7%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 26.9% |
26.4%
0.5 pts worse
|
19.8%
7.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 36.6% · Q2 22.9% · Q3 21.2% · Q4 27.5% · 4Q avg 26.9% |
| Percentage of long-stay residents with pressure ulcers | 5.1% |
5.3%
0.2 pts better
|
5.1%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 3.9% · Q2 2.4% · Q3 8.0% · Q4 6.0% · 4Q avg 5.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 79.9% |
68.9%
11 pts better
|
81.7%
1.8 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 92.8% · Q2 84.8% · Q3 75.6% · Q4 66.7% · 4Q avg 79.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 19.7% |
9.8%
9.9 pts worse
|
12.0%
7.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 19.7% · Observed 22.7% · Expected 12.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.2% |
1.5%
0.3 pts better
|
1.6%
0.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 2.4% · Q3 0.0% · Q4 0.0% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 76.3% |
68.7%
7.6 pts better
|
79.7%
3.4 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 76.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 29.1% |
23.1%
6 pts worse
|
23.9%
5.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 29.1% · Observed 36.4% · Expected 29.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-05-17 · Fire 2024-05-17
28 health deficiencies
Top issue: Quality of Life and Care (8 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2023-06-09 · Fire 2023-06-09
12 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-03-07
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-03-28
E · Potential for more than minimal harm
2024-05-17
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-05-31
E · Potential for more than minimal harm
2024-05-17
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-05-31
E · Potential for more than minimal harm
2023-06-09
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-07-11
C · Minimal harm
2023-06-09
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-07-11
C · Minimal harm
2023-06-09
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-07-11
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-12-17
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2026-01-07
D · Potential for more than minimal harm
2025-12-02
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-12-09
E · Potential for more than minimal harm
2025-07-31
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 2025-08-12
G · Actual harm
2025-06-05
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 2025-06-19
G · Actual harm
2025-06-05
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 2025-06-19
D · Potential for more than minimal harm
2025-05-07
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 2025-06-03
D · Potential for more than minimal harm
2025-05-07
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2025-06-03
D · Potential for more than minimal harm
2025-05-07
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-06-03
F · Potential for more than minimal harm
2025-03-07
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 2025-04-16
E · Potential for more than minimal harm
2025-03-07
F553 · Resident Rights Deficiencies
Health
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Corrected 2025-04-16
E · Potential for more than minimal harm
2025-03-07
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2025-04-16
E · Potential for more than minimal harm
2025-03-07
F700 · Quality of Life and Care Deficiencies
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2025-04-16
D · Potential for more than minimal harm
2025-03-07
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 2025-04-16
D · Potential for more than minimal harm
2025-03-07
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 2025-04-16
D · Potential for more than minimal harm
2025-03-07
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-04-16
D · Potential for more than minimal harm
2025-03-07
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 2025-04-16
D · Potential for more than minimal harm
2025-03-07
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-04-16
D · Potential for more than minimal harm
2025-03-07
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 2025-04-16
D · Potential for more than minimal harm
2025-03-07
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-04-16
D · Potential for more than minimal harm
2025-03-07
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-04-16
D · Potential for more than minimal harm
2025-03-07
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2025-04-16
D · Potential for more than minimal harm
2025-03-07
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 2025-04-16
D · Potential for more than minimal harm
2025-03-07
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-04-16
D · Potential for more than minimal harm
2025-03-07
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 2025-04-16
D · Potential for more than minimal harm
2025-03-07
F825 · Quality of Life and Care Deficiencies
Health
Provide or get specialized rehabilitative services as required for a resident.
Corrected 2025-04-16
D · Potential for more than minimal harm
2025-03-07
F868 · Administration Deficiencies
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected 2025-04-16
D · Potential for more than minimal harm
2025-03-07
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-04-16
D · Potential for more than minimal harm
2025-02-05
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-03-04
D · Potential for more than minimal harm
2024-11-26
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2024-12-11
D · Potential for more than minimal harm
2024-11-26
F620 · Resident Rights Deficiencies
Health
Not require residents to give up Medicare or Medicaid benefits, or pay privately as a condition of admission; and must tell residents what care they do not provide.
Corrected 2024-12-11
F · Potential for more than minimal harm
2024-05-17
F801 · Nutrition and Dietary Deficiencies
Health
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Corrected 2024-07-16
F · Potential for more than minimal harm
2024-05-17
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 2024-07-16
E · Potential for more than minimal harm
2024-05-17
F622 · Resident Rights Deficiencies
Health
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Corrected 2024-07-16
E · Potential for more than minimal harm
2024-05-17
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 2024-07-16
E · Potential for more than minimal harm
2024-05-17
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2024-07-16
E · Potential for more than minimal harm
2024-05-17
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 2024-07-16
D · Potential for more than minimal harm
2024-05-17
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2024-07-16
D · Potential for more than minimal harm
2024-05-17
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 2024-07-16
D · Potential for more than minimal harm
2024-05-17
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2024-07-16
D · Potential for more than minimal harm
2024-05-17
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2024-07-16
D · Potential for more than minimal harm
2024-05-17
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-07-16
D · Potential for more than minimal harm
2024-05-17
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 2024-07-16
D · Potential for more than minimal harm
2024-05-17
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-07-16
D · Potential for more than minimal harm
2024-05-17
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 2024-07-16
D · Potential for more than minimal harm
2024-05-17
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-07-16
D · Potential for more than minimal harm
2024-05-17
F699 · Quality of Life and Care Deficiencies
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2024-07-16
D · Potential for more than minimal harm
2024-05-17
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 2024-07-16
D · Potential for more than minimal harm
2024-05-17
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 2024-07-16
D · Potential for more than minimal harm
2024-05-17
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 2024-07-16
D · Potential for more than minimal harm
2024-05-17
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 2024-07-16
D · Potential for more than minimal harm
2024-05-17
F790 · Quality of Life and Care Deficiencies
Health
Provide routine and 24-hour emergency dental care for each resident.
Corrected 2024-07-16
D · Potential for more than minimal harm
2024-05-17
F941 · Administration Deficiencies
Health
Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.
Corrected 2024-07-16
D · Potential for more than minimal harm
2024-05-17
F944 · Administration Deficiencies
Health
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
Corrected 2024-07-16
D · Potential for more than minimal harm
2024-05-17
F949 · Administration Deficiencies
Health
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
Corrected 2024-07-16
D · Potential for more than minimal harm
2024-04-17
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 2024-05-10
L · Immediate jeopardy
2024-01-10
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2021-12-30
D · Potential for more than minimal harm
2023-12-20
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-02-14
D · Potential for more than minimal harm
2023-12-20
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 2024-02-14
E · Potential for more than minimal harm
2023-06-09
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-07-11
E · Potential for more than minimal harm
2023-06-09
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 2023-07-11
E · Potential for more than minimal harm
2023-06-09
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 2023-07-11
E · Potential for more than minimal harm
2023-06-09
F691 · Quality of Life and Care Deficiencies
Health
Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.
Corrected 2023-07-11
E · Potential for more than minimal harm
2023-06-09
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2023-07-11
E · Potential for more than minimal harm
2023-06-09
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2023-07-11
D · Potential for more than minimal harm
2023-06-09
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 2023-07-11
D · Potential for more than minimal harm
2023-06-09
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-07-11
D · Potential for more than minimal harm
2023-06-09
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-07-11
Penalties and ownership
What sits behind the stars
$3,145
2023-06-12
Fine
Fine · fine $3,145
Fine
Ownership
Core Pennsylvania Holdco LLC
5% Or Greater Direct Ownership Interest · Organization
Berdugo, Shai
5% Or Greater Indirect Ownership Interest · Individual
Bish, Charles
Operational/Managerial Control · Individual
Core Tbd Holdco LLC
5% Or Greater Indirect Ownership Interest · Organization
Eisen, Joshua
5% Or Greater Indirect Ownership Interest · Individual
Eisen, Joshua
Operational/Managerial Control · Individual
Raintree Consulting Group LLC
Operational/Managerial Control · Organization
Zdrale, Nikolai
Operational/Managerial Control · Individual
Nearby options
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1-star overall rating with 1-star inspections with abuse icon flag with $119,423 in total fines with 20 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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Harmar Village Health & Rehab Center
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1-star overall rating with 1-star inspections with Special Focus status with abuse icon flag with $71,840 in total fines with 49 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
#3
Willows Of Presbyterian Senior
Oakmont, PA
1-star overall rating with 1-star inspections with abuse icon flag with $57,886 in total fines with 21 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
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