5 health deficiencies
Top issue: Resident Rights (3 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Monongahela, PA
3-star overall rating with 3-star inspections with 5 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
200 Stoops Drive, Monongahela, PA
(724) 310-1111
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Beds
60
Certified beds
Average residents
50
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2003-01-06
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
RN hours / resident day
0.81
Registered nurse staffing · state 0.78 · national 0.68
LPN hours / resident day
0.89
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
2.04
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.74
All reported nurse hours · state 3.89 · national 3.89
Licensed hours
1.70
RN + LPN hours · state 1.69 · national 1.54
Weekend hours
3.25
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.55
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
0.89
CMS adjusted RN staffing hours
Adjusted total hours
4.11
CMS adjusted total nurse staffing hours
Case-mix index
1.24
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
SNF VBP
Program rank
11,259
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
17.49
Composite VBP score used to determine payment impact.
Payment multiplier
0.9818
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
0
Baseline 21.28% · Performance 21.43% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
1.97
Baseline 8.74% · Performance 7.82% · Measure score 1.97 · Achievement 0 · Improvement 1.97
Total nurse turnover
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Adjusted total nurse staffing
3.28
Baseline 3.96 hours · Performance 4.01 hours · Measure score 3.28 · Achievement 3.28 · Improvement 0
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.73% |
10.72%
1 pts worse
|
No Different than the National Rate · Eligible stays 97 · Observed rate 13.4% · Lower 95% interval 8.58% |
| Discharge to community | 65.12% |
50.57%
14.6 pts better
|
Better than the National Rate · Eligible stays 91 · Observed rate 63.74% · Lower 95% interval 56.57% |
| Medicare spending per beneficiary | 0.82 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 95.59% |
95.27%
0.3 pts better
|
Numerator 65 · Denominator 68 |
| Falls with major injury | 2.94% |
0.77%
2.2 pts worse
|
Numerator 2 · Denominator 68 |
| Discharge self-care score | 39.22% |
53.69%
14.5 pts worse
|
Numerator 20 · Denominator 51 |
| Discharge mobility score | 39.22% |
50.94%
11.7 pts worse
|
Numerator 20 · Denominator 51 |
| Pressure ulcers or injuries, new or worsened | 10.29% |
2.29%
8 pts worse
|
Numerator 7 · Denominator 68 · Adjusted rate 9.93% |
| Healthcare-associated infections requiring hospitalization | 7.82% |
7.12%
0.7 pts worse
|
No Different than the National Rate · Eligible stays 45 · Observed rate 8.89% · Lower 95% interval 3.96% |
| Staff COVID-19 vaccination coverage | 11.04% |
8.2%
2.8 pts better
|
Numerator 18 · Denominator 163 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 37.25% |
56.45%
19.2 pts worse
|
Numerator 19 · Denominator 51 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 97.44% |
96.28%
1.2 pts better
|
Numerator 38 · Denominator 39 |
| Resident COVID-19 vaccinations up to date | 0% |
25.2%
25.2 pts worse
|
Numerator 0 · Denominator 31 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 96.3% |
86.9%
9.4 pts better
|
93.4%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 93.3% · Q2 94.6% · Q3 97.0% · Q4 100.0% · 4Q avg 96.3% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.4% |
93.5%
3.9 pts better
|
95.5%
1.9 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.4% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.5% |
3.2%
1.7 pts better
|
3.3%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 0.0% · Q3 0.0% · Q4 2.9% · 4Q avg 1.5% · 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 | 4.7% |
6.5%
1.8 pts better
|
5.4%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 7.4% · Q3 3.7% · Q4 3.4% · 4Q avg 4.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 22.9% |
19.9%
3 pts worse
|
19.6%
3.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.0% · Q2 25.0% · Q3 22.2% · Q4 17.2% · 4Q avg 22.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 5.2% |
18.7%
13.5 pts better
|
16.7%
11.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.1% · Q2 8.7% · Q3 4.0% · Q4 0.0% · 4Q avg 5.2% · 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 · 4Q avg 16.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 11.9% |
18.3%
6.4 pts better
|
14.9%
3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.0% · Q2 17.9% · Q3 11.1% · Q4 3.4% · 4Q avg 11.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.6% |
0.9%
0.3 pts better
|
1.0%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.3% |
1.7%
0.6 pts worse
|
1.7%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.3% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 2.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 35.3% |
26.4%
8.9 pts worse
|
19.8%
15.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 39.8% · Q2 39.9% · Q3 21.6% · Q4 39.6% · 4Q avg 35.3% |
| Percentage of long-stay residents with pressure ulcers | 15.4% |
5.3%
10.1 pts worse
|
5.1%
10.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.5% · Q2 16.6% · Q3 14.1% · Q4 14.6% · 4Q avg 15.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 92.7% |
68.9%
23.8 pts better
|
81.7%
11 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 87.3% · Q2 93.3% · Q3 96.9% · Q4 94.9% · 4Q avg 92.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 19.1% |
9.8%
9.3 pts worse
|
12.0%
7.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 19.1% · Observed 17.4% · Expected 10.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.1% |
1.5%
0.4 pts better
|
1.6%
0.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 1.0% · Q3 0.0% · Q4 1.4% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 85.3% |
68.7%
16.6 pts better
|
79.7%
5.6 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 85.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 30.7% |
23.1%
7.6 pts worse
|
23.9%
6.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 30.7% · Observed 26.1% · Expected 20.3% · Used in QM five-star |
Survey summary
Top issue: Resident Rights (3 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Top issue: Administration (4 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Top issue: Quality of Life and Care (1 deficiency)
3 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-09-20
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-10-10
Fire Safety
Have properly installed hallway dispensers for alcohol-based hand rub.
Corrected 2023-10-10
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-10-10
Inspection history
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2025-12-04
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 2025-12-04
Health
Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency.
Corrected 2025-09-08
Health
Provide information about how to apply for and use Medicare and Medicaid benefits.
Corrected 2025-09-08
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2025-09-08
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-07-24
Health
Provide and implement an infection prevention and control program.
Corrected 2024-07-24
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-07-24
Health
Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
Corrected 2024-07-24
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-07-24
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2024-07-24
Health
Implement a program that monitors antibiotic use.
Corrected 2024-07-24
Health
Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.
Corrected 2024-07-24
Health
Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.
Corrected 2024-07-24
Health
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
Corrected 2024-07-24
Health
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
Corrected 2024-07-24
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2023-08-14
Penalties and ownership
5% Or Greater Direct Ownership Interest · Organization
Corporate Director · Individual
W-2 Managing Employee · Individual
Operational/Managerial Control · Individual
Corporate Director · Individual
Operational/Managerial Control · Individual
Corporate Director · Individual
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