Cycle 1
Health 2025-09-11 · Fire 2025-09-11
20 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Altoona, PA
Midtown Oaks Health & Rehab Center
0-star overall rating with 0-star inspections with Special Focus status with $106,485 in total fines with 20 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
1020 Green Avenue, Altoona, PA
(814) 946-2700
Overall
0 / 5
CMS overall stars
Health inspections
0 / 5
Survey and complaint cycles
Staffing
0 / 5
RN + nurse staffing
Quality measures
0 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
120
Certified beds
Average residents
95
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Saber Healthcare Group
Operator or chain grouping
Approved since
1996-04-18
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
126 facilities
Chain averages 3 overall / 3 health / 3 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
0.72
Registered nurse staffing · state 0.78 · national 0.68
LPN hours / resident day
0.80
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
2.00
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.52
All reported nurse hours · state 3.89 · national 3.89
Licensed hours
1.51
RN + LPN hours · state 1.69 · national 1.54
Weekend hours
3.10
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.37
Weekend registered nurse coverage · state 0.55 · national 0.47
Physical therapist
0.05
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.77
CMS adjusted RN staffing hours
Adjusted total hours
3.79
CMS adjusted total nurse staffing hours
Case-mix index
1.27
Higher values indicate more complex resident acuity
RN turnover
72%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
63%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
7,881
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
28.52
Composite VBP score used to determine payment impact.
Payment multiplier
0.9850
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Performance 22.91% · Measure score 0 · Achievement 0 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
4.93
Baseline 5.98% · Performance 6.36% · Measure score 4.93 · Achievement 4.93 · Improvement 0
Total nurse turnover
3.35
Baseline 35.62% · Performance 50.00% · Measure score 3.35 · Achievement 3.35 · Improvement 0
Adjusted total nurse staffing
3.13
Baseline 3.70 hours · Performance 3.97 hours · Measure score 3.13 · Achievement 3.13 · Improvement 0.79
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.34% |
10.72%
0.6 pts worse
|
No Different than the National Rate · Eligible stays 49 · Observed rate 20.41% · Lower 95% interval 7.87% |
| Discharge to community | 31.15% |
50.57%
19.4 pts worse
|
Worse than the National Rate · Eligible stays 48 · Observed rate 14.58% · Lower 95% interval 17.98% |
| Medicare spending per beneficiary | 0.72 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 18.18% |
95.27%
77.1 pts worse
|
Numerator 10 · Denominator 55 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 55 |
| Discharge self-care score | 26.47% |
53.69%
27.2 pts worse
|
Numerator 9 · Denominator 34 |
| Discharge mobility score | 32.35% |
50.94%
18.6 pts worse
|
Numerator 11 · Denominator 34 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 55 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.36% |
7.12%
0.8 pts better
|
No Different than the National Rate · Eligible stays 36 · Observed rate 5.56% · Lower 95% interval 3.76% |
| Staff COVID-19 vaccination coverage | 1.26% |
8.2%
6.9 pts worse
|
Numerator 2 · Denominator 159 |
| Staff flu vaccination coverage | 20.66% |
42%
21.3 pts worse
|
Numerator 25 · Denominator 121 |
| Discharge function score | 26.47% |
56.45%
30 pts worse
|
Numerator 9 · Denominator 34 |
| Transfer of health information to provider | 10% |
95.95%
86 pts worse
|
Numerator 2 · Denominator 20 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 0% |
25.2%
25.2 pts worse
|
Numerator 0 · Denominator 24 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 41.2% |
86.9%
45.7 pts worse
|
93.4%
52.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 44.4% · Q2 41.5% · Q3 44.4% · Q4 34.5% · 4Q avg 41.2% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 70.2% |
93.5%
23.3 pts worse
|
95.5%
25.3 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 70.2% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.3% |
3.2%
0.1 pts worse
|
3.3%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.4% · Q3 4.9% · Q4 6.0% · 4Q avg 3.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 7.3% |
6.5%
0.8 pts worse
|
11.4%
4.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.6% · Q3 5.7% · Q4 22.2% · 4Q avg 7.3% |
| Percentage of long-stay residents who lose too much weight | 8.6% |
6.5%
2.1 pts worse
|
5.4%
3.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.9% · Q2 11.3% · Q3 10.7% · Q4 7.9% · 4Q avg 8.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 24.0% |
19.9%
4.1 pts worse
|
19.6%
4.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.7% · Q2 27.4% · Q3 21.3% · Q4 22.8% · 4Q avg 24.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 20.7% |
18.7%
2 pts worse
|
16.7%
4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.1% · Q2 17.3% · Q3 16.9% · Q4 24.6% · 4Q avg 20.7% · 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 | 23.7% |
19.6%
4.1 pts worse
|
16.3%
7.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.7% · Q2 16.9% · Q3 36.2% · Q4 16.9% · 4Q avg 23.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 22.9% |
18.3%
4.6 pts worse
|
14.9%
8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.0% · Q2 10.6% · Q3 33.3% · Q4 23.9% · 4Q avg 22.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.7% |
0.9%
0.8 pts worse
|
1.0%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.1% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.2% |
1.7%
0.5 pts better
|
1.7%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 3.7% · Q4 1.2% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 20.4% |
26.4%
6 pts better
|
19.8%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.4% · Q2 17.3% · Q3 24.1% · Q4 17.8% · 4Q avg 20.4% |
| Percentage of long-stay residents with pressure ulcers | 10.2% |
5.3%
4.9 pts worse
|
5.1%
5.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 12.9% · Q2 12.5% · Q3 6.7% · Q4 8.5% · 4Q avg 10.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 14.5% |
68.9%
54.4 pts worse
|
81.7%
67.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 16.9% · Q2 15.3% · Q3 15.4% · Q4 11.1% · 4Q avg 14.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.8% |
9.8%
About the same
|
12.0%
2.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.8% · Observed 12.5% · Expected 14.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 4.7% |
1.5%
3.2 pts worse
|
1.6%
3.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 6.1% · Q2 7.0% · Q3 4.2% · Q4 2.2% · 4Q avg 4.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 33.3% |
68.7%
35.4 pts worse
|
79.7%
46.4 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 33.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 30.6% |
23.1%
7.5 pts worse
|
23.9%
6.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 30.6% · Observed 43.8% · Expected 34.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-08-22 · Fire 2024-08-22
61 health deficiencies
Top issue: Quality of Life and Care (18 deficiencies)
12 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Cycle 3
Health 2023-09-08 · Fire 2023-09-08
40 health deficiencies
Top issue: Quality of Life and Care (15 deficiencies)
9 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2025-09-11
K912 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2025-10-14
D · Potential for more than minimal harm
2025-09-11
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-10-14
E · Potential for more than minimal harm
2024-08-22
K100 · Construction Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2024-09-16
E · Potential for more than minimal harm
2024-08-22
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2024-09-16
E · Potential for more than minimal harm
2024-08-22
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 2024-09-16
E · Potential for more than minimal harm
2024-08-22
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-09-16
E · Potential for more than minimal harm
2024-08-22
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-09-16
D · Potential for more than minimal harm
2024-08-22
K352 · Smoke Deficiencies
Fire Safety
Properly install and monitor supervisory attachments on automatic sprinkler systems.
Corrected 2024-09-16
D · Potential for more than minimal harm
2024-08-22
K754 · Miscellaneous Deficiencies
Fire Safety
Provide properly sized and located linen or trash receptacles.
Corrected 2024-09-16
D · Potential for more than minimal harm
2024-08-22
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2024-09-16
D · Potential for more than minimal harm
2024-08-22
K912 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2024-09-16
C · Minimal harm
2024-08-22
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-09-16
C · Minimal harm
2024-08-22
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2024-09-16
C · Minimal harm
2024-08-22
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-09-16
E · Potential for more than minimal harm
2023-09-08
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2023-09-25
E · Potential for more than minimal harm
2023-09-08
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 2023-09-25
E · Potential for more than minimal harm
2023-09-08
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-09-25
D · Potential for more than minimal harm
2023-09-08
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-09-25
D · Potential for more than minimal harm
2023-09-08
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-09-25
D · Potential for more than minimal harm
2023-09-08
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-09-25
D · Potential for more than minimal harm
2023-09-08
K912 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2023-09-25
D · Potential for more than minimal harm
2023-09-08
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2023-09-25
C · Minimal harm
2023-09-08
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-09-25
Inspection history
Recent health citations
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 2026-01-15
F · Potential for more than minimal harm
2025-09-11
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 2025-10-14
E · Potential for more than minimal harm
2025-09-11
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-10-14
E · Potential for more than minimal harm
2025-09-11
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2025-10-14
D · Potential for more than minimal harm
2025-09-11
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 2025-10-14
D · Potential for more than minimal harm
2025-09-11
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 2025-10-14
D · Potential for more than minimal harm
2025-09-11
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 2025-10-14
D · Potential for more than minimal harm
2025-09-11
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 2025-10-14
D · Potential for more than minimal harm
2025-09-11
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 2025-10-14
E · Potential for more than minimal harm
2025-08-06
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-08-26
E · Potential for more than minimal harm
2025-08-06
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-08-26
E · Potential for more than minimal harm
2025-08-06
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2025-08-26
E · Potential for more than minimal harm
2025-08-06
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2025-08-26
D · Potential for more than minimal harm
2025-08-06
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 2025-08-26
D · Potential for more than minimal harm
2025-06-25
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 2025-07-10
E · Potential for more than minimal harm
2025-06-16
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2025-07-01
F · Potential for more than minimal harm
2025-04-22
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 2025-05-13
D · Potential for more than minimal harm
2025-04-22
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-05-13
D · Potential for more than minimal harm
2025-04-22
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-05-13
E · Potential for more than minimal harm
2025-03-04
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 2025-03-25
D · Potential for more than minimal harm
2025-01-28
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-02-14
D · Potential for more than minimal harm
2025-01-28
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-02-14
D · Potential for more than minimal harm
2025-01-28
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-02-14
D · Potential for more than minimal harm
2024-12-23
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 2025-01-23
D · Potential for more than minimal harm
2024-12-23
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 2025-01-23
G · Actual harm
2024-08-22
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-11-05
G · Actual harm
2024-08-22
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-10-01
F · Potential for more than minimal harm
2024-08-22
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2024-10-01
F · Potential for more than minimal harm
2024-08-22
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-10-01
F · Potential for more than minimal harm
2024-08-22
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 2024-10-01
F · Potential for more than minimal harm
2024-08-22
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2024-10-01
E · Potential for more than minimal harm
2024-08-22
F553 · Resident Rights Deficiencies
Health
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Corrected 2024-10-01
E · Potential for more than minimal harm
2024-08-22
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-10-01
E · Potential for more than minimal harm
2024-08-22
F685 · Quality of Life and Care Deficiencies
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2024-10-01
E · Potential for more than minimal harm
2024-08-22
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 2024-10-01
E · Potential for more than minimal harm
2024-08-22
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 2024-11-05
E · Potential for more than minimal harm
2024-08-22
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-10-01
D · Potential for more than minimal harm
2024-08-22
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2024-10-01
D · Potential for more than minimal harm
2024-08-22
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-11-05
D · Potential for more than minimal harm
2024-08-22
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2024-10-01
D · Potential for more than minimal harm
2024-08-22
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 2024-10-01
D · Potential for more than minimal harm
2024-08-22
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 2024-10-01
D · Potential for more than minimal harm
2024-08-22
F661 · Resident Assessment and Care Planning Deficiencies
Health
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Corrected 2024-10-01
D · Potential for more than minimal harm
2024-08-22
F676 · Quality of Life and Care Deficiencies
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2024-11-05
D · Potential for more than minimal harm
2024-08-22
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 2024-10-01
D · Potential for more than minimal harm
2024-08-22
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 2024-10-01
D · Potential for more than minimal harm
2024-08-22
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 2024-11-05
D · Potential for more than minimal harm
2024-08-22
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-10-01
D · Potential for more than minimal harm
2024-08-22
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 2024-10-01
D · Potential for more than minimal harm
2024-08-22
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 2024-11-05
D · Potential for more than minimal harm
2024-08-22
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-10-01
D · Potential for more than minimal harm
2024-08-22
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 2024-11-05
D · Potential for more than minimal harm
2024-08-22
F810 · Nutrition and Dietary Deficiencies
Health
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
Corrected 2024-11-05
D · Potential for more than minimal harm
2024-08-22
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2024-10-01
D · Potential for more than minimal harm
2024-08-22
F868 · Administration Deficiencies
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected 2024-10-01
D · Potential for more than minimal harm
2024-08-22
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2024-10-01
D · Potential for more than minimal harm
2024-08-22
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2024-10-01
K · Immediate jeopardy
2024-07-03
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2024-08-01
E · Potential for more than minimal harm
2024-07-03
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 2024-08-01
E · Potential for more than minimal harm
2024-07-03
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 2024-08-01
E · Potential for more than minimal harm
2024-07-03
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-08-01
E · Potential for more than minimal harm
2024-07-03
F803 · Nutrition and Dietary Deficiencies
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 2024-08-01
E · Potential for more than minimal harm
2024-07-03
F808 · Nutrition and Dietary Deficiencies
Health
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
Corrected 2024-08-01
E · Potential for more than minimal harm
2024-07-03
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-08-01
D · Potential for more than minimal harm
2024-07-03
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 2024-08-01
D · Potential for more than minimal harm
2024-07-03
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 2024-08-01
D · Potential for more than minimal harm
2024-07-03
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 2024-08-01
D · Potential for more than minimal harm
2024-07-03
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 2024-08-01
D · Potential for more than minimal harm
2024-07-03
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-08-01
D · Potential for more than minimal harm
2024-07-03
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-08-01
D · Potential for more than minimal harm
2024-07-03
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-08-01
D · Potential for more than minimal harm
2024-07-03
F810 · Nutrition and Dietary Deficiencies
Health
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
Corrected 2024-08-01
D · Potential for more than minimal harm
2024-07-03
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2024-08-01
D · Potential for more than minimal harm
2024-06-18
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-08-01
E · Potential for more than minimal harm
2024-04-18
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 2024-05-16
D · Potential for more than minimal harm
2024-04-18
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-05-16
D · Potential for more than minimal harm
2024-04-18
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 2024-05-16
D · Potential for more than minimal harm
2024-04-18
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 2024-05-16
D · Potential for more than minimal harm
2024-04-18
F742 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
Corrected 2024-05-16
D · Potential for more than minimal harm
2024-04-18
F743 · Quality of Life and Care Deficiencies
Health
Ensure that a resident does not develop patterns of decreased social interaction and/or increased withdrawn, angry, or depressive behaviors, unless unavoidable.
Corrected 2024-05-16
D · Potential for more than minimal harm
2024-03-20
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 2024-04-11
D · Potential for more than minimal harm
2024-01-05
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 2024-02-02
D · Potential for more than minimal harm
2024-01-05
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-02-02
D · Potential for more than minimal harm
2024-01-05
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 2024-02-02
D · Potential for more than minimal harm
2024-01-05
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-02-02
D · Potential for more than minimal harm
2024-01-05
F772 · Administration Deficiencies
Health
Have an agreement with an approved laboratory to obtain services, if on-site laboratory services aren't provided.
Corrected 2024-02-02
E · Potential for more than minimal harm
2023-11-15
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 2023-12-13
E · Potential for more than minimal harm
2023-11-15
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 2023-12-13
E · Potential for more than minimal harm
2023-11-15
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-12-13
E · Potential for more than minimal harm
2023-11-15
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2023-12-13
D · Potential for more than minimal harm
2023-11-15
F675 · Quality of Life and Care Deficiencies
Health
Honor each resident's preferences, choices, values and beliefs.
Corrected 2023-12-13
D · Potential for more than minimal harm
2023-11-15
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 2023-12-13
D · Potential for more than minimal harm
2023-11-15
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 2023-12-13
D · Potential for more than minimal harm
2023-11-15
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2023-12-13
E · Potential for more than minimal harm
2023-09-08
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 2023-10-06
E · Potential for more than minimal harm
2023-09-08
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-10-06
E · Potential for more than minimal harm
2023-09-08
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2023-10-06
E · Potential for more than minimal harm
2023-09-08
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 2023-10-06
E · Potential for more than minimal harm
2023-09-08
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 2023-10-06
D · Potential for more than minimal harm
2023-09-08
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-10-06
D · Potential for more than minimal harm
2023-09-08
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 2023-10-06
D · Potential for more than minimal harm
2023-09-08
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 2023-10-06
D · Potential for more than minimal harm
2023-09-08
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 2023-10-06
D · Potential for more than minimal harm
2023-09-08
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-10-06
D · Potential for more than minimal harm
2023-09-08
F675 · Quality of Life and Care Deficiencies
Health
Honor each resident's preferences, choices, values and beliefs.
Corrected 2023-10-06
D · Potential for more than minimal harm
2023-09-08
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-10-06
D · Potential for more than minimal harm
2023-09-08
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 2023-10-06
D · Potential for more than minimal harm
2023-09-08
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-10-06
D · Potential for more than minimal harm
2023-09-08
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 2023-10-06
D · Potential for more than minimal harm
2023-09-08
F805 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Corrected 2023-10-06
D · Potential for more than minimal harm
2023-09-08
F810 · Nutrition and Dietary Deficiencies
Health
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
Corrected 2023-10-06
D · Potential for more than minimal harm
2023-09-08
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2023-10-06
D · Potential for more than minimal harm
2023-09-08
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2023-10-06
D · Potential for more than minimal harm
2023-09-08
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-10-06
D · Potential for more than minimal harm
2023-09-08
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-10-06
B · Minimal harm
2023-09-08
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-10-06
G · Actual harm
2023-05-30
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 2023-06-22
D · Potential for more than minimal harm
2023-05-30
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 2023-06-22
D · Potential for more than minimal harm
2023-05-30
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2023-06-22
D · Potential for more than minimal harm
2023-03-07
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 2023-04-23
D · Potential for more than minimal harm
2023-03-07
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 2023-04-23
Penalties and ownership
What sits behind the stars
$76,811
2024-08-22
Fine
Fine · fine $76,811
Fine
$22,231
2024-06-18
Fine
Fine · fine $22,231
Fine
$7,443
2023-05-30
Fine
Fine · fine $7,443
Fine
Ownership
Saber Pa Holdings, LLC
5% Or Greater Direct Ownership Interest · Organization
Benjamin N. Volpe Family Dynasty Trust (Dated December 29, 2020)
5% Or Greater Indirect Ownership Interest · Organization
Bnv Dynasty LLC
5% Or Greater Indirect Ownership Interest · Organization
Bobitski, Nicole
Operational/Managerial Control · Individual
Decanted William I. Weisberg Family Dynasty Trust (Dated Sept 30, 2020
5% Or Greater Indirect Ownership Interest · Organization
Folckemer, Jessica
Operational/Managerial Control · Individual
Nicoluzakis, Gregory
Corporate Officer · Individual
Saber Healthcare Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Shg Management LLC
Operational/Managerial Control · Organization
Volpe, Benjamin
Corporate Director · Individual
Volpe, Benjamin
Corporate Officer · Individual
Weisberg, William
Corporate Director · Individual
Weisberg, William
Corporate Officer · Individual
Wiw Dynasty LLC
5% Or Greater Indirect Ownership Interest · Organization
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#2
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#3
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