16 health deficiencies
Top issue: Nutrition and Dietary (5 deficiencies)
2 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Lebanon, PA
1-star overall rating with 2-star inspections with 16 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
900 Tuck Street, Lebanon, PA
(717) 273-8595
Overall
1 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Beds
159
Certified beds
Average residents
134
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Genesis Healthcare
Operator or chain grouping
Approved since
1980-06-09
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
193 facilities
Chain averages 2 overall / 2 health / 3 staffing / 3 quality stars
Changed ownership
No
Within the last 12 months
Family council
No
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
RN hours / resident day
0.45
Registered nurse staffing · state 0.78 · national 0.68
LPN hours / resident day
0.95
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
2.17
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.57
All reported nurse hours · state 3.89 · national 3.89
Licensed hours
1.40
RN + LPN hours · state 1.69 · national 1.54
Weekend hours
3.34
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.26
Weekend registered nurse coverage · state 0.55 · national 0.47
Physical therapist
0.09
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.42
CMS adjusted RN staffing hours
Adjusted total hours
3.34
CMS adjusted total nurse staffing hours
Case-mix index
1.46
Higher values indicate more complex resident acuity
RN turnover
82%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
63%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Program rank
13,726
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
0
Composite VBP score used to determine payment impact.
Payment multiplier
0.9803
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
0
Baseline 17.84% · Performance 23.92% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 7.53% · Performance 8.56% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
0
Baseline 43.56% · Performance 64.66% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
0
Baseline 3.24 hours · Performance 3.01 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.39% |
10.72%
1.3 pts better
|
No Different than the National Rate · Eligible stays 218 · Observed rate 8.72% · Lower 95% interval 6.43% |
| Discharge to community | 55.17% |
50.57%
4.6 pts better
|
No Different than the National Rate · Eligible stays 225 · Observed rate 47.56% · Lower 95% interval 48.33% |
| Medicare spending per beneficiary | 0.89 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 85.23% |
95.27%
10 pts worse
|
Numerator 150 · Denominator 176 |
| Falls with major injury | 1.14% |
0.77%
0.4 pts worse
|
Numerator 2 · Denominator 176 |
| Discharge self-care score | 56.91% |
53.69%
3.2 pts better
|
Numerator 70 · Denominator 123 |
| Discharge mobility score | 59.35% |
50.94%
8.4 pts better
|
Numerator 73 · Denominator 123 |
| Pressure ulcers or injuries, new or worsened | 6.29% |
2.29%
4 pts worse
|
Numerator 11 · Denominator 175 · Adjusted rate 6.93% |
| Healthcare-associated infections requiring hospitalization | 8.56% |
7.12%
1.4 pts worse
|
No Different than the National Rate · Eligible stays 129 · Observed rate 10.85% · Lower 95% interval 5.49% |
| Staff COVID-19 vaccination coverage | 0.78% |
8.2%
7.4 pts worse
|
Numerator 1 · Denominator 129 |
| Staff flu vaccination coverage | 80.61% |
42%
38.6 pts better
|
Numerator 79 · Denominator 98 |
| Discharge function score | 63.41% |
56.45%
7 pts better
|
Numerator 78 · Denominator 123 |
| Transfer of health information to provider | 56.67% |
95.95%
39.3 pts worse
|
Numerator 34 · Denominator 60 |
| Transfer of health information to patient | 73.75% |
96.28%
22.5 pts worse
|
Numerator 59 · Denominator 80 |
| Resident COVID-19 vaccinations up to date | 8.14% |
25.2%
17.1 pts worse
|
Numerator 7 · Denominator 86 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.3 |
1.7
0.6 pts worse
|
1.9
0.4 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.3 · Observed 3.3 · Expected 2.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.4 |
1.2
0.8 pts better
|
1.8
1.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.4 · Observed 0.4 · Expected 1.8 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 69.2% |
86.9%
17.7 pts worse
|
93.4%
24.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 66.1% · Q2 54.5% · Q3 82.0% · Q4 74.3% · 4Q avg 69.2% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 89.0% |
93.5%
4.5 pts worse
|
95.5%
6.5 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 89.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.8% |
3.2%
0.6 pts worse
|
3.3%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 4.0% · Q3 4.0% · Q4 3.7% · 4Q avg 3.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 7.1% |
6.5%
0.6 pts worse
|
11.4%
4.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.9% · Q2 2.1% · Q3 8.5% · Q4 9.7% · 4Q avg 7.1% |
| Percentage of long-stay residents who lose too much weight | 5.6% |
6.5%
0.9 pts better
|
5.4%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 11.0% · Q3 3.4% · Q4 5.4% · 4Q avg 5.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 16.8% |
19.9%
3.1 pts better
|
19.6%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.9% · Q2 17.0% · Q3 19.8% · Q4 11.6% · 4Q avg 16.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 25.9% |
18.7%
7.2 pts worse
|
16.7%
9.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 31.1% · Q2 27.9% · Q3 22.7% · Q4 21.9% · 4Q avg 25.9% · 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 | 31.2% |
19.6%
11.6 pts worse
|
16.3%
14.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 31.1% · Q2 45.4% · Q3 25.8% · Q4 22.3% · 4Q avg 31.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 21.4% |
18.3%
3.1 pts worse
|
14.9%
6.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 15.7% · Q2 29.5% · Q3 21.7% · Q4 18.8% · 4Q avg 21.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.9% |
0.9%
1 pts worse
|
1.0%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 0.8% · Q3 1.6% · Q4 1.5% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.2% |
1.7%
0.5 pts worse
|
1.7%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 1.0% · Q3 2.1% · Q4 2.8% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 30.8% |
26.4%
4.4 pts worse
|
19.8%
11 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 43.4% · Q2 20.6% · Q3 15.2% · Q4 43.0% · 4Q avg 30.8% |
| Percentage of long-stay residents with pressure ulcers | 3.5% |
5.3%
1.8 pts better
|
5.1%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 5.8% · Q3 2.2% · Q4 2.7% · 4Q avg 3.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 33.7% |
68.9%
35.2 pts worse
|
81.7%
48 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 21.7% · Q2 16.8% · Q3 42.4% · Q4 58.5% · 4Q avg 33.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 14.5% |
9.8%
4.7 pts worse
|
12.0%
2.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 14.5% · Observed 13.7% · Expected 10.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.7% |
1.5%
0.2 pts worse
|
1.6%
0.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 1.6% · Q3 2.1% · Q4 1.4% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 34.3% |
68.7%
34.4 pts worse
|
79.7%
45.4 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 34.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.5% |
23.1%
1.4 pts worse
|
23.9%
0.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.5% · Observed 24.8% · Expected 24.1% · Used in QM five-star |
Survey summary
Top issue: Nutrition and Dietary (5 deficiencies)
2 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Top issue: Resident Assessment and Care Planning (6 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Top issue: Quality of Life and Care (3 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-04-30
Fire Safety
Provide properly sized and located linen or trash receptacles.
Corrected 2025-04-30
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 2024-05-29
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-05-29
Fire Safety
Meet other general requirements.
Corrected 2024-05-29
Fire Safety
Properly provide smoke detection systems in areas open to corridors.
Corrected 2024-05-29
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-05-29
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2024-05-29
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-06-08
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-06-08
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-06-08
Inspection history
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2025-06-10
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-05-21
Health
Provide and implement an infection prevention and control program.
Corrected 2025-05-21
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 2025-05-21
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-05-21
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2025-05-21
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-05-21
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2025-05-21
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-05-21
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 2025-05-21
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 2025-05-21
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 2025-05-21
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2025-05-21
Health
Implement a program that monitors antibiotic use.
Corrected 2025-05-21
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2025-05-21
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2025-06-10
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2025-01-29
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 2025-01-29
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-01-29
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-09-19
Health
Respond appropriately to all alleged violations.
Corrected 2024-09-19
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2024-05-29
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-05-29
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-05-29
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-05-29
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-05-29
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-05-29
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-05-29
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2024-05-29
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 2024-05-29
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2024-05-29
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 2024-05-29
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-03-12
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 2023-06-08
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 2023-06-08
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2023-06-08
Penalties and ownership
5% Or Greater Direct Ownership Interest · Organization
Corporate Officer · Individual
Corporate Officer · Individual
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Individual
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
Corporate Officer · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Individual
5% Or Greater Indirect Ownership Interest · Organization
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