Cycle 1
Health 2025-07-31 · Fire 2025-07-31
8 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Dallas, PA
Meadows Nursing And Rehabilitation Center
2-star overall rating with 2-star inspections with abuse icon flag with $52,135 in total fines with 8 recent health deficiencies
4 East Center Street, Dallas, PA
(570) 675-8600
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
130
Certified beds
Average residents
114
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1983-08-29
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
0.76
Registered nurse staffing · state 0.78 · national 0.68
LPN hours / resident day
0.83
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
2.21
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.80
All reported nurse hours · state 3.89 · national 3.89
Licensed hours
1.58
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
0.39
Weekend registered nurse coverage · state 0.55 · national 0.47
Physical therapist
0.08
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.75
CMS adjusted RN staffing hours
Adjusted total hours
3.74
CMS adjusted total nurse staffing hours
Case-mix index
1.39
Higher values indicate more complex resident acuity
RN turnover
15%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
28%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
7,517
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
29.53
Composite VBP score used to determine payment impact.
Payment multiplier
0.9855
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.93
Baseline 16.99% · Performance 20.07% · Measure score 2.93 · Achievement 2.93 · Improvement 0
Healthcare-associated infections
0
Baseline 5.86% · Performance 9.61% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
6.33
Baseline 33.71% · Performance 37.81% · Measure score 6.33 · Achievement 6.33 · Improvement 0
Adjusted total nurse staffing
2.56
Baseline 3.73 hours · Performance 3.80 hours · Measure score 2.56 · Achievement 2.56 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.64% |
10.72%
1.1 pts better
|
No Different than the National Rate · Eligible stays 266 · Observed rate 7.52% · Lower 95% interval 6.6% |
| Discharge to community | 51.16% |
50.57%
0.6 pts better
|
No Different than the National Rate · Eligible stays 293 · Observed rate 44.71% · Lower 95% interval 45.46% |
| Medicare spending per beneficiary | 1.12 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 99.07% |
95.27%
3.8 pts better
|
Numerator 212 · Denominator 214 |
| Falls with major injury | 0.93% |
0.77%
0.2 pts worse
|
Numerator 2 · Denominator 214 |
| Discharge self-care score | 54.29% |
53.69%
0.6 pts better
|
Numerator 95 · Denominator 175 |
| Discharge mobility score | 48.57% |
50.94%
2.4 pts worse
|
Numerator 85 · Denominator 175 |
| Pressure ulcers or injuries, new or worsened | 5.61% |
2.29%
3.3 pts worse
|
Numerator 12 · Denominator 214 · Adjusted rate 4.42% |
| Healthcare-associated infections requiring hospitalization | 9.61% |
7.12%
2.5 pts worse
|
No Different than the National Rate · Eligible stays 202 · Observed rate 10.89% · Lower 95% interval 7.03% |
| Staff COVID-19 vaccination coverage | 3.08% |
8.2%
5.1 pts worse
|
Numerator 6 · Denominator 195 |
| Staff flu vaccination coverage | 11.81% |
42%
30.2 pts worse
|
Numerator 28 · Denominator 237 |
| Discharge function score | 49.71% |
56.45%
6.7 pts worse
|
Numerator 87 · Denominator 175 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 62 · Denominator 62 |
| Transfer of health information to patient | 98.97% |
96.28%
2.7 pts better
|
Numerator 96 · Denominator 97 |
| Resident COVID-19 vaccinations up to date | 16.38% |
25.2%
8.8 pts worse
|
Numerator 19 · Denominator 116 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.0 |
1.7
0.7 pts better
|
1.9
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 1.1 · Expected 2.2 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.5 |
1.2
0.7 pts better
|
1.8
1.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.5 · Observed 0.5 · Expected 1.7 · 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 | 97.5% |
93.5%
4 pts better
|
95.5%
2 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.5% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.3% |
3.2%
1.9 pts better
|
3.3%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 2.8% · Q3 0.0% · Q4 0.0% · 4Q avg 1.3% · 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 | 15.2% |
6.5%
8.7 pts worse
|
5.4%
9.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.2% · Q2 18.2% · Q3 17.4% · Q4 12.5% · 4Q avg 15.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 11.6% |
19.9%
8.3 pts better
|
19.6%
8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.7% · Q2 8.6% · Q3 8.3% · Q4 13.6% · 4Q avg 11.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 21.9% |
18.7%
3.2 pts worse
|
16.7%
5.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.2% · Q2 24.0% · Q3 24.1% · Q4 22.6% · 4Q avg 21.9% · 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 | 22.4% |
19.6%
2.8 pts worse
|
16.3%
6.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.1% · Q2 33.9% · Q3 18.6% · Q4 13.0% · 4Q avg 22.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 22.7% |
18.3%
4.4 pts worse
|
14.9%
7.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 31.8% · Q2 29.9% · Q3 16.9% · Q4 14.1% · 4Q avg 22.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.3% |
0.9%
0.4 pts worse
|
1.0%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 1.2% · Q3 0.9% · Q4 0.7% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.1% |
1.7%
1.4 pts worse
|
1.7%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.6% · Q2 1.5% · Q3 2.8% · Q4 2.4% · 4Q avg 3.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 31.0% |
26.4%
4.6 pts worse
|
19.8%
11.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.8% · Q2 33.7% · Q3 29.5% · Q4 33.6% · 4Q avg 31.0% |
| Percentage of long-stay residents with pressure ulcers | 9.3% |
5.3%
4 pts worse
|
5.1%
4.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.4% · Q2 6.7% · Q3 5.8% · Q4 14.2% · 4Q avg 9.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.8% |
68.9%
30.9 pts better
|
81.7%
18.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 99.5% · Q2 99.6% · Q3 100.0% · Q4 100.0% · 4Q avg 99.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.4% |
9.8%
2.4 pts better
|
12.0%
4.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.4% · Observed 7.2% · Expected 10.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.3% |
1.5%
0.2 pts better
|
1.6%
0.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 1.5% · Q3 1.3% · Q4 0.7% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 91.0% |
68.7%
22.3 pts better
|
79.7%
11.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 91.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 16.0% |
23.1%
7.1 pts better
|
23.9%
7.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 16.0% · Observed 16.7% · Expected 24.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-09-20 · Fire 2024-09-20
8 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2023-08-11 · Fire 2023-08-11
7 health deficiencies
Top issue: Resident Rights (3 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-09-20
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2024-11-05
E · Potential for more than minimal harm
2024-09-20
K321 · Smoke Deficiencies
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 2024-11-05
E · Potential for more than minimal harm
2024-09-20
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2024-11-05
E · Potential for more than minimal harm
2023-08-11
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-10-19
E · Potential for more than minimal harm
2023-08-11
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-10-19
E · Potential for more than minimal harm
2023-08-11
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-10-19
E · Potential for more than minimal harm
2023-08-11
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2023-10-19
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-07-31
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-09-29
D · Potential for more than minimal harm
2025-07-31
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 2025-09-29
D · Potential for more than minimal harm
2025-07-31
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 2025-09-29
D · Potential for more than minimal harm
2025-07-31
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 2025-09-29
D · Potential for more than minimal harm
2025-07-31
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 2025-09-29
D · Potential for more than minimal harm
2025-07-31
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 2025-09-29
B · Minimal harm
2025-07-31
F628 · Resident Rights Deficiencies
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2025-09-29
G · Actual harm
2025-05-30
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 2025-06-12
E · Potential for more than minimal harm
2024-09-20
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 2024-11-13
D · Potential for more than minimal harm
2024-09-20
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-11-13
D · Potential for more than minimal harm
2024-09-20
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-11-13
D · Potential for more than minimal harm
2024-09-20
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2024-11-13
B · Minimal harm
2024-09-20
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 2024-11-13
B · Minimal harm
2024-09-20
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 2024-11-13
G · Actual harm
2024-05-21
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-06-26
E · Potential for more than minimal harm
2024-05-21
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 2024-06-26
E · Potential for more than minimal harm
2023-08-11
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-10-10
D · Potential for more than minimal harm
2023-08-11
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 2023-10-10
D · Potential for more than minimal harm
2023-08-11
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-10-10
D · Potential for more than minimal harm
2023-08-11
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2023-10-10
B · Minimal harm
2023-08-11
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 2023-10-10
D · Potential for more than minimal harm
2023-03-29
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 2023-05-23
B · Minimal harm
2023-03-29
F557 · Resident Rights Deficiencies
Health
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Corrected 2023-05-23
Penalties and ownership
What sits behind the stars
$52,135
2024-05-21
Fine
Fine · fine $52,135
Fine
Ownership
Ecumenical Enterprises Inc
5% Or Greater Direct Ownership Interest · Organization
Cadora-Cox, Jennifer
Operational/Managerial Control · Individual
Ecumenical Enterprises Inc
Operational/Managerial Control · Organization
Tarbox, Cristina
Corporate Director · Individual
Zamber, Lisa
Corporate Director · Individual
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#2
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#3
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