Cycle 1
Health 2025-11-20 · Fire 2025-11-20
7 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
10 fire-safety deficiencies
Top issue: Emergency Preparedness (3 deficiencies)
Monroeville, PA
Monroeville Post Acute
2-star overall rating with 2-star inspections with abuse icon flag with $39,416 in total fines with 7 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
885 Macbeth Drive, Monroeville, PA
(412) 856-7071
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
131
Certified beds
Average residents
117
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Pacs Group
Operator or chain grouping
Approved since
1996-08-13
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
264 facilities
Chain averages 3 overall / 3 health / 2 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
0.90
Registered nurse staffing · state 0.78 · national 0.68
LPN hours / resident day
0.56
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
1.89
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.35
All reported nurse hours · state 3.89 · national 3.89
Licensed hours
1.46
RN + LPN hours · state 1.69 · national 1.54
Weekend hours
3.06
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.59
Weekend registered nurse coverage · state 0.55 · national 0.47
Physical therapist
0.10
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.90
CMS adjusted RN staffing hours
Adjusted total hours
3.33
CMS adjusted total nurse staffing hours
Case-mix index
1.38
Higher values indicate more complex resident acuity
RN turnover
42%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
48%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
11,825
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
15.09
Composite VBP score used to determine payment impact.
Payment multiplier
0.9814
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 19.96% · Performance 21.78% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
2.16
Baseline 5.98% · Performance 7.19% · Measure score 2.16 · Achievement 2.16 · Improvement 0
Total nurse turnover
3.88
Baseline 54.92% · Performance 47.83% · Measure score 3.88 · Achievement 3.88 · Improvement 1.86
Adjusted total nurse staffing
0
Baseline 3.27 hours · Performance 3.20 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.19% |
10.72%
0.5 pts worse
|
No Different than the National Rate · Eligible stays 120 · Observed rate 13.33% · Lower 95% interval 8.38% |
| Discharge to community | 54.12% |
50.57%
3.5 pts better
|
No Different than the National Rate · Eligible stays 100 · Observed rate 44% · Lower 95% interval 43.42% |
| Medicare spending per beneficiary | 0.91 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 80 · Denominator 80 |
| Falls with major injury | 1.25% |
0.77%
0.5 pts worse
|
Numerator 1 · Denominator 80 |
| Discharge self-care score | 44.64% |
53.69%
9 pts worse
|
Numerator 25 · Denominator 56 |
| Discharge mobility score | 53.57% |
50.94%
2.6 pts better
|
Numerator 30 · Denominator 56 |
| Pressure ulcers or injuries, new or worsened | 7.5% |
2.29%
5.2 pts worse
|
Numerator 6 · Denominator 80 · Adjusted rate 6.9% |
| Healthcare-associated infections requiring hospitalization | 7.19% |
7.12%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 78 · Observed rate 8.97% · Lower 95% interval 4.05% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 152 |
| Staff flu vaccination coverage | 34.15% |
42%
7.9 pts worse
|
Numerator 70 · Denominator 205 |
| Discharge function score | 37.5% |
56.45%
19 pts worse
|
Numerator 21 · Denominator 56 |
| Transfer of health information to provider | 84% |
95.95%
12 pts worse
|
Numerator 42 · Denominator 50 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 48.65% |
25.2%
23.4 pts better
|
Numerator 18 · Denominator 37 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.9 |
1.7
0.2 pts worse
|
1.9
About the same
|
Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 1.6 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.4 |
1.2
0.2 pts worse
|
1.8
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.3 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.3% |
86.9%
11.4 pts better
|
93.4%
4.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 97.2% · Q2 99.0% · Q3 98.0% · Q4 99.0% · 4Q avg 98.3% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 99.1% |
93.5%
5.6 pts better
|
95.5%
3.6 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 99.1% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 7.3% |
3.2%
4.1 pts worse
|
3.3%
4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.6% · Q2 7.8% · Q3 8.2% · Q4 8.7% · 4Q avg 7.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 7.8% |
6.5%
1.3 pts worse
|
11.4%
3.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.3% · Q2 7.0% · Q3 13.3% · Q4 2.3% · 4Q avg 7.8% |
| Percentage of long-stay residents who lose too much weight | 5.8% |
6.5%
0.7 pts better
|
5.4%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 6.8% · Q3 7.1% · Q4 6.5% · 4Q avg 5.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 14.8% |
19.9%
5.1 pts better
|
19.6%
4.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.5% · Q2 14.4% · Q3 11.4% · Q4 17.5% · 4Q avg 14.8% |
| 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 18.5% · Q2 20.5% · Q3 16.9% · Q4 14.7% · 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 | 19.7% |
19.6%
0.1 pts worse
|
16.3%
3.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.7% · Q2 34.1% · Q3 12.3% · Q4 5.5% · 4Q avg 19.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 19.7% |
18.3%
1.4 pts worse
|
14.9%
4.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 34.7% · Q2 21.1% · Q3 13.8% · Q4 8.6% · 4Q avg 19.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.0% |
0.9%
0.1 pts worse
|
1.0%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 0.9% · Q2 0.0% · Q3 1.8% · Q4 1.5% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.2% |
1.7%
1.5 pts better
|
1.7%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 19.1% |
26.4%
7.3 pts better
|
19.8%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.3% · Q2 18.8% · Q3 22.6% · Q4 21.2% · 4Q avg 19.1% |
| Percentage of long-stay residents with pressure ulcers | 6.8% |
5.3%
1.5 pts worse
|
5.1%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.4% · Q2 6.7% · Q3 6.6% · Q4 7.5% · 4Q avg 6.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 84.7% |
68.9%
15.8 pts better
|
81.7%
3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 88.9% · Q2 82.6% · Q3 83.1% · Q4 84.5% · 4Q avg 84.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.3% |
9.8%
0.5 pts worse
|
12.0%
1.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.3% · Observed 10.5% · Expected 11.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.7% |
1.5%
0.8 pts better
|
1.6%
0.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.9% · Q2 0.9% · Q3 0.9% · Q4 0.0% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 75.1% |
68.7%
6.4 pts better
|
79.7%
4.6 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 75.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.4% |
23.1%
1.3 pts worse
|
23.9%
0.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.4% · Observed 26.3% · Expected 25.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-12-20 · Fire 2024-12-20
41 health deficiencies
Top issue: Resident Rights (13 deficiencies)
13 fire-safety deficiencies
Top issue: Smoke (7 deficiencies)
Cycle 3
Health 2024-01-12 · Fire 2024-01-12
29 health deficiencies
Top issue: Quality of Life and Care (8 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-11-20
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-12-24
F · Potential for more than minimal harm
2025-11-20
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-12-24
F · Potential for more than minimal harm
2025-11-20
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-12-24
E · Potential for more than minimal harm
2025-11-20
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-12-24
C · Minimal harm
2025-11-20
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2025-12-24
C · Minimal harm
2025-11-20
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2025-12-24
C · Minimal harm
2025-11-20
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2025-12-24
C · Minimal harm
2025-11-20
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2025-12-24
C · Minimal harm
2025-11-20
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-12-24
C · Minimal harm
2025-11-20
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-12-24
F · Potential for more than minimal harm
2024-12-20
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-03-06
F · Potential for more than minimal harm
2024-12-20
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-01-28
F · Potential for more than minimal harm
2024-12-20
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-03-06
E · Potential for more than minimal harm
2024-12-20
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 2025-01-28
E · Potential for more than minimal harm
2024-12-20
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-01-28
E · Potential for more than minimal harm
2024-12-20
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-01-28
D · Potential for more than minimal harm
2024-12-20
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-03-06
D · Potential for more than minimal harm
2024-12-20
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-01-28
D · Potential for more than minimal harm
2024-12-20
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-01-28
C · Minimal harm
2024-12-20
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2025-01-28
C · Minimal harm
2024-12-20
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2025-01-28
C · Minimal harm
2024-12-20
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2025-01-28
C · Minimal harm
2024-12-20
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-01-28
F · Potential for more than minimal harm
2024-01-12
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-03-17
F · Potential for more than minimal harm
2024-01-12
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-03-17
E · Potential for more than minimal harm
2024-01-12
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-03-17
E · Potential for more than minimal harm
2024-01-12
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-03-17
E · Potential for more than minimal harm
2024-01-12
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-03-17
C · Minimal harm
2024-01-12
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2024-03-17
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-11-20
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 2026-01-05
B · Minimal harm
2025-11-20
F628 · Resident Rights Deficiencies
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2026-01-05
B · Minimal harm
2025-11-20
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 2026-01-05
E · Potential for more than minimal harm
2025-08-13
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 2025-08-28
D · Potential for more than minimal harm
2025-08-13
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 2025-07-17
G · Actual harm
2025-05-16
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 2025-05-29
G · Actual harm
2025-05-16
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 2025-05-29
G · Actual harm
2025-02-13
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 2025-03-03
E · Potential for more than minimal harm
2025-02-13
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 2025-03-03
E · Potential for more than minimal harm
2025-02-13
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-03-03
E · Potential for more than minimal harm
2025-02-13
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 2025-03-03
E · Potential for more than minimal harm
2025-02-13
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 2025-03-03
D · Potential for more than minimal harm
2025-02-13
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 2025-03-03
D · Potential for more than minimal harm
2025-02-13
F745 · Quality of Life and Care Deficiencies
Health
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Corrected 2025-03-03
D · Potential for more than minimal harm
2025-02-13
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 2025-03-03
F · Potential for more than minimal harm
2024-12-20
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 2025-01-28
E · Potential for more than minimal harm
2024-12-20
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 2025-01-28
E · Potential for more than minimal harm
2024-12-20
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 2025-01-28
E · Potential for more than minimal harm
2024-12-20
F809 · Nutrition and Dietary Deficiencies
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 2025-01-28
E · Potential for more than minimal harm
2024-12-20
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 2025-01-28
E · Potential for more than minimal harm
2024-12-20
F849 · Administration Deficiencies
Health
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Corrected 2025-01-28
D · Potential for more than minimal harm
2024-12-20
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 2025-01-28
D · Potential for more than minimal harm
2024-12-20
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 2025-01-28
D · Potential for more than minimal harm
2024-12-20
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-01-28
D · Potential for more than minimal harm
2024-12-20
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-01-28
D · Potential for more than minimal harm
2024-12-20
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 2025-01-28
C · Minimal harm
2024-12-20
F575 · Resident Rights Deficiencies
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 2025-01-28
C · Minimal harm
2024-12-20
F577 · Resident Rights Deficiencies
Health
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Corrected 2025-01-28
C · Minimal harm
2024-12-20
F579 · Resident Rights Deficiencies
Health
Provide information about how to apply for and use Medicare and Medicaid benefits.
Corrected 2025-01-28
B · Minimal harm
2024-12-20
F941 · Administration Deficiencies
Health
Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.
Corrected 2025-01-28
B · Minimal harm
2024-12-20
F942 · Resident Rights Deficiencies
Health
Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.
Corrected 2025-01-28
B · Minimal harm
2024-12-20
F944 · Administration Deficiencies
Health
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
Corrected 2025-01-28
B · Minimal harm
2024-12-20
F946 · Administration Deficiencies
Health
Provide training in compliance and ethics.
Corrected 2025-01-28
B · Minimal harm
2024-12-20
F949 · Administration Deficiencies
Health
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
Corrected 2025-01-28
F · Potential for more than minimal harm
2024-10-30
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 2024-11-19
F · Potential for more than minimal harm
2024-10-30
F563 · Resident Rights Deficiencies
Health
Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing.
Corrected 2024-11-19
F · Potential for more than minimal harm
2024-10-30
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 2024-11-19
E · Potential for more than minimal harm
2024-10-30
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 2024-11-19
E · Potential for more than minimal harm
2024-10-30
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2024-11-19
D · Potential for more than minimal harm
2024-10-30
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 2024-11-19
D · Potential for more than minimal harm
2024-10-30
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 2024-11-19
E · Potential for more than minimal harm
2024-08-08
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 2024-08-27
E · Potential for more than minimal harm
2024-08-08
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-08-27
E · Potential for more than minimal harm
2024-08-08
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-08-27
E · Potential for more than minimal harm
2024-08-08
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 2024-08-27
D · Potential for more than minimal harm
2024-08-08
F809 · Nutrition and Dietary Deficiencies
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 2024-08-27
E · Potential for more than minimal harm
2024-03-26
F745 · Quality of Life and Care Deficiencies
Health
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Corrected 2024-04-09
E · Potential for more than minimal harm
2024-03-11
F836 · Administration Deficiencies
Health
Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards.
Corrected 2024-03-18
D · Potential for more than minimal harm
2024-02-23
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 2024-03-05
E · Potential for more than minimal harm
2024-01-12
F575 · Resident Rights Deficiencies
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 2024-02-20
E · Potential for more than minimal harm
2024-01-12
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 2024-02-20
E · Potential for more than minimal harm
2024-01-12
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-02-20
E · Potential for more than minimal harm
2024-01-12
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2024-02-20
E · Potential for more than minimal harm
2024-01-12
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-02-20
E · Potential for more than minimal harm
2024-01-12
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 2024-02-20
E · Potential for more than minimal harm
2024-01-12
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-02-20
E · Potential for more than minimal harm
2024-01-12
F943 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
Corrected 2024-02-20
E · Potential for more than minimal harm
2024-01-12
F945 · Infection Control Deficiencies
Health
Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.
Corrected 2024-02-20
E · Potential for more than minimal harm
2024-01-12
F947 · Nursing and Physician Services Deficiencies
Health
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Corrected 2024-02-20
D · Potential for more than minimal harm
2024-01-12
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 2024-02-20
D · Potential for more than minimal harm
2024-01-12
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 2024-02-20
D · Potential for more than minimal harm
2024-01-12
F868 · Administration Deficiencies
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected 2024-02-20
C · Minimal harm
2024-01-12
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2024-02-20
B · Minimal harm
2024-01-12
F941 · Administration Deficiencies
Health
Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.
Corrected 2024-02-20
B · Minimal harm
2024-01-12
F942 · Resident Rights Deficiencies
Health
Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.
Corrected 2024-02-20
B · Minimal harm
2024-01-12
F944 · Administration Deficiencies
Health
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
Corrected 2024-02-20
B · Minimal harm
2024-01-12
F946 · Administration Deficiencies
Health
Provide training in compliance and ethics.
Corrected 2024-02-20
B · Minimal harm
2024-01-12
F949 · Administration Deficiencies
Health
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
Corrected 2024-02-20
F · Potential for more than minimal harm
2023-12-22
F801 · Nutrition and Dietary Deficiencies
Health
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Corrected 2024-02-01
E · Potential for more than minimal harm
2023-12-22
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 2024-02-01
E · Potential for more than minimal harm
2023-12-22
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2024-02-01
E · Potential for more than minimal harm
2023-11-01
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 2023-12-05
D · Potential for more than minimal harm
2023-11-01
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 2023-12-05
D · Potential for more than minimal harm
2023-08-30
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2023-10-05
D · Potential for more than minimal harm
2023-08-30
F800 · Nutrition and Dietary Deficiencies
Health
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
Corrected 2023-10-05
E · Potential for more than minimal harm
2023-07-21
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-08-21
E · Potential for more than minimal harm
2023-07-21
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 2023-08-21
Penalties and ownership
What sits behind the stars
$39,416
2023-04-20
Fine
Fine · fine $39,416
Fine
Ownership
Providence Group Nh, LLC
5% Or Greater Direct Ownership Interest · Organization
Apt, Frederick
Operational/Managerial Control · Individual
Apt, Frederick
Corporate Officer · Individual
Hancock, Mark
5% Or Greater Indirect Ownership Interest · Individual
Jergensen, Joshua
Operational/Managerial Control · Individual
Jergensen, Joshua
Corporate Officer · Individual
Mitchell, John
Operational/Managerial Control · Individual
Mitchell, John
Corporate Officer · Individual
Murray, Jason
5% Or Greater Indirect Ownership Interest · Individual
Pacs Group, Inc.
5% Or Greater Indirect Ownership Interest · Organization
Pacs Group, Inc.
Operational/Managerial Control · Organization
Pacs Holdings, LLC
5% Or Greater Indirect Ownership Interest · Organization
Pacs Holdings, LLC
Operational/Managerial Control · Organization
Providence Group Nh, LLC
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
#1
Woodhaven Health & Rehab Center
Monroeville, PA
1-star overall rating with 1-star inspections with $37,480 in total fines with 25 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
Concordia At The Cedars
Monroeville, PA
5-star overall rating with 4-star inspections with 4 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Harmony Physical Rehabilitation
Monroeville, PA
5-star overall rating with 4-star inspections with 1 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
Jump out