11 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
6 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Hazleton, PA
1-star overall rating with 2-star inspections with 11 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
1711 East Broad Street, Hazleton, PA
(570) 453-5122
Overall
1 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Beds
104
Certified beds
Average residents
89
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Avardis Health
Operator or chain grouping
Approved since
1984-04-02
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
14 facilities
Chain averages 2 overall / 2 health / 2 staffing / 3 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
RN hours / resident day
0.00
Registered nurse staffing
LPN hours / resident day
0.00
Licensed practical nurse staffing
Aide hours / resident day
0.00
Nurse aide staffing
Total nurse hours
0.00
All reported nurse hours
Licensed hours
0.00
RN + LPN hours
Weekend hours
0.00
Weekend nurse staffing
Weekend RN hours
0.00
Weekend registered nurse coverage
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
0.00
CMS adjusted RN staffing hours
Adjusted total hours
0.00
CMS adjusted total nurse staffing hours
Case-mix index
0.00
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
SNF VBP
Program rank
3,546
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
43.81
Composite VBP score used to determine payment impact.
Payment multiplier
0.9968
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
10
Baseline 21.07% · Performance 16.68% · Measure score 10 · Achievement 10 · Improvement 9
Healthcare-associated infections
1.73
Baseline 6.48% · Performance 7.32% · Measure score 1.73 · Achievement 1.73 · Improvement 0
Total nurse turnover
5.79
Baseline 36.00% · Performance 40.00% · Measure score 5.79 · Achievement 5.79 · Improvement 0
Adjusted total nurse staffing
0
Baseline 3.25 hours · Performance 3.06 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.31% |
10.72%
1.4 pts better
|
No Different than the National Rate · Eligible stays 200 · Observed rate 7.5% · Lower 95% interval 6.45% |
| Discharge to community | 41.19% |
50.57%
9.4 pts worse
|
Worse than the National Rate · Eligible stays 218 · Observed rate 34.86% · Lower 95% interval 34.82% |
| Medicare spending per beneficiary | 1.11 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 96.77% |
95.27%
1.5 pts better
|
Numerator 90 · Denominator 93 |
| Falls with major injury | 1.08% |
0.77%
0.3 pts worse
|
Numerator 1 · Denominator 93 |
| Discharge self-care score | 37.5% |
53.69%
16.2 pts worse
|
Numerator 24 · Denominator 64 |
| Discharge mobility score | 48.44% |
50.94%
2.5 pts worse
|
Numerator 31 · Denominator 64 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 93 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 7.32% |
7.12%
0.2 pts worse
|
No Different than the National Rate · Eligible stays 114 · Observed rate 7.02% · Lower 95% interval 4.63% |
| Staff COVID-19 vaccination coverage | 2.67% |
8.2%
5.5 pts worse
|
Numerator 2 · Denominator 75 |
| Staff flu vaccination coverage | 14.15% |
42%
27.9 pts worse
|
Numerator 15 · Denominator 106 |
| Discharge function score | 54.69% |
56.45%
1.8 pts worse
|
Numerator 35 · Denominator 64 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 41 · Denominator 41 |
| Transfer of health information to patient | 87.5% |
96.28%
8.8 pts worse
|
Numerator 21 · Denominator 24 |
| Resident COVID-19 vaccinations up to date | 14.29% |
25.2%
10.9 pts worse
|
Numerator 7 · Denominator 49 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.7 |
1.7
About the same
|
1.9
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 1.4 · Expected 1.6 · 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 | 100.0% |
86.9%
13.1 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
93.5%
6.5 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.9% |
3.2%
0.3 pts better
|
3.3%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 3.9% · Q3 1.3% · Q4 1.3% · 4Q avg 2.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
6.5%
6.5 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 6.2% |
6.5%
0.3 pts better
|
5.4%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.3% · Q2 6.8% · Q3 8.6% · Q4 2.9% · 4Q avg 6.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 19.9% |
19.9%
About the same
|
19.6%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.5% · Q2 21.3% · Q3 17.8% · Q4 20.0% · 4Q avg 19.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 17.6% |
18.7%
1.1 pts better
|
16.7%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.7% · Q2 17.7% · Q3 19.7% · Q4 19.7% · 4Q avg 17.6% · 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 | 16.2% |
19.6%
3.4 pts better
|
16.3%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.2% · Q2 13.8% · Q3 14.9% · Q4 19.7% · 4Q avg 16.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 13.4% |
18.3%
4.9 pts better
|
14.9%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.5% · Q2 13.0% · Q3 20.6% · Q4 9.1% · 4Q avg 13.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.9%
0.9 pts better
|
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% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.3% |
1.7%
1.4 pts better
|
1.7%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.3% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 29.1% |
26.4%
2.7 pts worse
|
19.8%
9.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 32.3% · Q2 27.9% · Q3 28.3% · Q4 27.9% · 4Q avg 29.1% |
| Percentage of long-stay residents with pressure ulcers | 1.2% |
5.3%
4.1 pts better
|
5.1%
3.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.9% · Q3 0.9% · Q4 3.1% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.5% |
68.9%
29.6 pts better
|
81.7%
16.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 98.2% · Q2 98.8% · Q3 99.0% · Q4 97.9% · 4Q avg 98.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 6.1% |
9.8%
3.7 pts better
|
12.0%
5.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 6.1% · Observed 6.0% · Expected 11.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.6% |
1.5%
0.9 pts better
|
1.6%
1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.7% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 98.8% |
68.7%
30.1 pts better
|
79.7%
19.1 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 98.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.9% |
23.1%
0.8 pts worse
|
23.9%
About the same
|
Short Stay · 20240701-20250630 · Adjusted 23.9% · Observed 24.1% · Expected 24.1% · Used in QM five-star |
Survey summary
Top issue: Quality of Life and Care (5 deficiencies)
6 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Top issue: Quality of Life and Care (9 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2026-02-14
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2026-02-14
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2026-02-14
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2026-02-14
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2026-02-14
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2026-02-14
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-04-11
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2025-04-11
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2024-05-21
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 2024-05-21
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-05-21
Inspection history
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2026-02-16
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2026-02-16
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 2026-02-16
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2026-02-16
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2026-02-16
Health
Honor the resident's right to manage his or her financial affairs.
Corrected 2026-02-16
Health
Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
Corrected 2026-02-16
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2026-02-16
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-08-28
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 2026-02-16
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-07-15
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2025-04-22
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 2025-04-22
Health
Respond appropriately to all alleged violations.
Corrected 2025-04-22
Health
Plan the resident's discharge to meet the resident's goals and needs.
Corrected 2025-04-22
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-04-22
Health
Provide and implement an infection prevention and control program.
Corrected 2025-02-26
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 2024-09-23
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-09-23
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-08-08
Health
Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
Corrected 2024-08-08
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 2024-08-08
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-08-08
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 2024-08-08
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-08-08
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 2024-08-08
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2024-08-08
Health
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Corrected 2024-08-08
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2024-09-23
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2024-08-08
Health
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Corrected 2023-12-15
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2023-12-15
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-12-15
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-05-23
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-05-23
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 2023-05-23
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-05-23
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-05-23
Penalties and ownership
Payment Denial · denial start 2024-08-31 · 23 days
23 day denial
5% Or Greater Direct Ownership Interest · Organization
5% Or Greater Security Interest · Organization
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
5% Or Greater Indirect Ownership Interest · Organization
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 · Organization
Operational/Managerial Control · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
Nearby options
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