Cycle 1
Health 2025-02-07 · Fire 2025-02-07
9 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Hazleton, PA
Mountain City Nursing & Rehabilitation Center
1-star overall rating with 1-star inspections with abuse icon flag with $179,593 in total fines with 9 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
403 Hazle Township Boulevard, Hazleton, PA
(570) 454-8888
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
297
Certified beds
Average residents
220
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Saber Healthcare Group
Operator or chain grouping
Approved since
1983-06-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.32
Registered nurse staffing
LPN hours / resident day
1.02
Licensed practical nurse staffing
Aide hours / resident day
2.05
Nurse aide staffing
Weekend hours
3.08
Weekend nurse staffing
RN turnover
55%
Annual RN turnover
Total nurse turnover
41%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.0 |
1.7
0.3 pts worse
|
1.9
0.1 pts worse
|
Long Stay · 20240701-20250630 |
| 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 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.0% |
86.9%
12.1 pts better
|
93.4%
5.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 99.5% |
93.5%
6 pts better
|
95.5%
4 pts better
|
Long Stay · 2024Q3-2025Q2 |
| 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 |
| Percentage of long-stay residents who have depressive symptoms | 2.6% |
6.5%
3.9 pts better
|
11.4%
8.8 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 5.7% |
6.5%
0.8 pts better
|
5.4%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 33.0% |
19.9%
13.1 pts worse
|
19.6%
13.4 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 11.8% |
18.7%
6.9 pts better
|
16.7%
4.9 pts better
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents whose ability to walk independently worsened | 20.5% |
19.6%
0.9 pts worse
|
16.3%
4.2 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 19.2% |
18.3%
0.9 pts worse
|
14.9%
4.3 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.8% |
0.9%
0.1 pts better
|
1.0%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 0.5% |
1.7%
1.2 pts better
|
1.7%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 20.2% |
26.4%
6.2 pts better
|
19.8%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 3.9% |
5.3%
1.4 pts better
|
5.1%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 96.7% |
68.9%
27.8 pts better
|
81.7%
15 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.9% |
9.8%
1.1 pts worse
|
12.0%
1.1 pts better
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.0% |
1.5%
0.5 pts worse
|
1.6%
0.4 pts worse
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 94.2% |
68.7%
25.5 pts better
|
79.7%
14.5 pts better
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 20.9% |
23.1%
2.2 pts better
|
23.9%
3 pts better
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-04-19 · Fire 2024-04-19
26 health deficiencies
Top issue: Quality of Life and Care (8 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2023-05-12 · Fire 2023-05-12
17 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
3 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-02-07
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2025-03-11
E · Potential for more than minimal harm
2025-02-07
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2025-03-11
E · Potential for more than minimal harm
2025-02-07
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-03-11
E · Potential for more than minimal harm
2025-02-07
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-03-11
E · Potential for more than minimal harm
2024-04-19
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2024-05-14
E · Potential for more than minimal harm
2024-04-19
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-05-14
E · Potential for more than minimal harm
2024-04-19
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-05-14
E · Potential for more than minimal harm
2023-05-12
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2023-06-12
C · Minimal harm
2023-05-12
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-06-12
C · Minimal harm
2023-05-12
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-06-12
Inspection history
Recent health citations
G · Actual harm
2026-01-12
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 2026-01-27
D · Potential for more than minimal harm
2025-03-27
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 2025-03-31
D · Potential for more than minimal harm
2025-03-27
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2025-03-31
E · Potential for more than minimal harm
2025-02-07
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 2025-03-27
E · Potential for more than minimal harm
2025-02-07
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 2025-03-31
D · Potential for more than minimal harm
2025-02-07
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-03-27
D · Potential for more than minimal harm
2025-02-07
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 2024-09-02
D · Potential for more than minimal harm
2025-02-07
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 2025-03-27
D · Potential for more than minimal harm
2025-02-07
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2025-03-27
D · Potential for more than minimal harm
2025-01-03
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-03-27
G · Actual harm
2024-07-10
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 2024-07-29
E · Potential for more than minimal harm
2024-07-10
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2024-07-29
E · Potential for more than minimal harm
2024-07-10
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 2024-07-29
E · Potential for more than minimal harm
2024-07-10
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2024-07-29
E · Potential for more than minimal harm
2024-07-10
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2024-07-29
K · Immediate jeopardy
2024-05-31
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-07-29
G · Actual harm
2024-05-31
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 2024-07-10
E · Potential for more than minimal harm
2024-05-31
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2024-07-10
D · Potential for more than minimal harm
2024-05-31
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-07-10
D · Potential for more than minimal harm
2024-05-31
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 2024-07-10
D · Potential for more than minimal harm
2024-05-31
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 2024-07-10
H · Actual harm
2024-04-19
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 2024-07-29
F · Potential for more than minimal harm
2024-04-19
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 2024-07-10
E · Potential for more than minimal harm
2024-04-19
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 2024-07-10
E · Potential for more than minimal harm
2024-04-19
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 2024-07-10
E · Potential for more than minimal harm
2024-04-19
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-07-10
E · Potential for more than minimal harm
2024-04-19
F741 · Quality of Life and Care Deficiencies
Health
Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents.
Corrected 2024-07-10
E · Potential for more than minimal harm
2024-04-19
F744 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2024-07-10
E · Potential for more than minimal harm
2024-04-19
F838 · Administration Deficiencies
Health
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Corrected 2024-07-10
D · Potential for more than minimal harm
2024-04-19
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2024-07-10
D · Potential for more than minimal harm
2024-04-19
F699 · Quality of Life and Care Deficiencies
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2024-07-10
D · Potential for more than minimal harm
2024-04-19
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-07-10
D · Potential for more than minimal harm
2024-04-19
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2024-07-10
E · Potential for more than minimal harm
2024-03-20
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 2024-04-19
E · Potential for more than minimal harm
2024-03-20
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 2024-07-10
E · Potential for more than minimal harm
2023-11-21
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 2023-12-19
E · Potential for more than minimal harm
2023-11-21
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 2023-12-19
D · Potential for more than minimal harm
2023-09-28
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 2023-09-17
D · Potential for more than minimal harm
2023-09-28
F622 · Resident Rights Deficiencies
Health
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Corrected 2023-10-17
D · Potential for more than minimal harm
2023-09-28
F626 · Resident Rights Deficiencies
Health
Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.
Corrected 2023-10-17
E · Potential for more than minimal harm
2023-09-06
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 2023-10-17
E · Potential for more than minimal harm
2023-09-06
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 2023-10-17
D · Potential for more than minimal harm
2023-09-06
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 2023-10-17
G · Actual harm
2023-06-21
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-06-08
F · Potential for more than minimal harm
2023-05-12
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 2023-06-08
E · Potential for more than minimal harm
2023-05-12
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2023-06-08
E · Potential for more than minimal harm
2023-05-12
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 2023-06-08
E · Potential for more than minimal harm
2023-05-12
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-06-08
D · Potential for more than minimal harm
2023-05-12
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 2023-06-08
D · Potential for more than minimal harm
2023-05-12
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 2023-06-08
D · Potential for more than minimal harm
2023-05-12
F740 · Quality of Life and Care Deficiencies
Health
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected 2023-06-08
D · Potential for more than minimal harm
2023-05-12
F744 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2023-06-08
Penalties and ownership
What sits behind the stars
$171,403
2024-03-20
Fine
Fine · fine $171,403
Fine
$0
2024-03-20
Payment Denial
Payment Denial · denial start 2024-06-20 · 39 days
39 day denial
$8,190
2023-05-12
Fine
Fine · fine $8,190
Fine
Ownership
Shg Recs, 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
Benyo, Philip
Contracted Managing Employee · Individual
Bnv Dynasty LLC
5% Or Greater Indirect Ownership Interest · Organization
Decanted William I. Weisberg Family Dynasty Trust (Dated Sept 30, 2020
5% Or Greater Indirect Ownership Interest · Organization
Meenan, Cody
Operational/Managerial Control · Individual
Nicoluzakis, Gregory
Corporate Officer · Individual
Saber Governance LLC
Operational/Managerial Control · Organization
Saber Healthcare Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Saber Pa Holdings, LLC
5% Or Greater Indirect Ownership Interest · Organization
Shh Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Shutt, Patrice
W-2 Managing Employee · Individual
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
Wwbv Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
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#2
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Hazleton, PA
1-star overall rating with 2-star inspections with 11 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#3
Kadima Rehabilitation & Nursing At Luzerne
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1-star overall rating with 1-star inspections with Special Focus status with $86,122 in total fines with 16 recent health deficiencies
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