Cycle 1
Health 2024-12-06 · Fire 2024-12-06
2 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Bradford, PA
Pavilion At Brmc, The
3-star overall rating with 2-star inspections with abuse icon flag with $16,036 in total fines with 2 recent health deficiencies
200 Pleasant Street, Bradford, PA
(814) 362-8293
Overall
3 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
95
Certified beds
Average residents
66
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1976-07-01
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
Hospital-based
Yes
CMS reports the provider resides in a hospital
Staffing
Hours and turnover
RN hours / resident day
1.02
Registered nurse staffing · state 0.78 · national 0.68
LPN hours / resident day
1.05
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
2.88
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
4.95
All reported nurse hours · state 3.89 · national 3.89
Licensed hours
2.07
RN + LPN hours · state 1.69 · national 1.54
Weekend hours
4.32
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.73
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
1.20
CMS adjusted RN staffing hours
Adjusted total hours
5.82
CMS adjusted total nurse staffing hours
Case-mix index
1.16
Higher values indicate more complex resident acuity
RN turnover
56%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
42%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
872
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
62.71
Composite VBP score used to determine payment impact.
Payment multiplier
1.0176
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
8.86
Baseline 17.45% · Performance 17.32% · Measure score 8.86 · Achievement 8.86 · Improvement 2.45
Healthcare-associated infections
6.59
Baseline 7.33% · Performance 5.87% · Measure score 6.59 · Achievement 6.59 · Improvement 5.77
Total nurse turnover
3.93
Baseline 49.18% · Performance 47.62% · Measure score 3.93 · Achievement 3.93 · Improvement 0.14
Adjusted total nurse staffing
5.7
Baseline 4.14 hours · Performance 4.7 hours · Measure score 5.7 · Achievement 5.7 · Improvement 2.91
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.21% |
10.72%
0.5 pts worse
|
No Different than the National Rate · Eligible stays 85 · Observed rate 11.76% · Lower 95% interval 7.76% |
| Discharge to community | 46.38% |
50.57%
4.2 pts worse
|
No Different than the National Rate · Eligible stays 81 · Observed rate 41.98% · Lower 95% interval 34.31% |
| Medicare spending per beneficiary | 0.92 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 90.32% |
95.27%
5 pts worse
|
Numerator 56 · Denominator 62 |
| Falls with major injury | 1.61% |
0.77%
0.8 pts worse
|
Numerator 1 · Denominator 62 |
| Discharge self-care score | 42% |
53.69%
11.7 pts worse
|
Numerator 21 · Denominator 50 |
| Discharge mobility score | 42% |
50.94%
8.9 pts worse
|
Numerator 21 · Denominator 50 |
| Pressure ulcers or injuries, new or worsened | 1.61% |
2.29%
0.7 pts better
|
Numerator 1 · Denominator 62 · Adjusted rate 1.51% |
| Healthcare-associated infections requiring hospitalization | 5.87% |
7.12%
1.2 pts better
|
No Different than the National Rate · Eligible stays 52 · Observed rate 1.92% · Lower 95% interval 3.08% |
| Staff COVID-19 vaccination coverage | 3.9% |
8.2%
4.3 pts worse
|
Numerator 3 · Denominator 77 |
| Staff flu vaccination coverage | 98.28% |
42%
56.3 pts better
|
Numerator 114 · Denominator 116 |
| Discharge function score | 36% |
56.45%
20.5 pts worse
|
Numerator 18 · Denominator 50 |
| Transfer of health information to provider | 96.55% |
95.95%
0.6 pts better
|
Numerator 28 · Denominator 29 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 6.25% |
25.2%
18.9 pts worse
|
Numerator 2 · Denominator 32 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.8 |
1.7
0.9 pts better
|
1.9
1.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.8 · Observed 0.8 · Expected 1.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.0 |
1.2
0.8 pts worse
|
1.8
0.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.0 · Observed 2.0 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.0% |
86.9%
11.1 pts better
|
93.4%
4.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.4% · Q2 98.4% · Q3 96.6% · Q4 98.3% · 4Q avg 98.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.1% |
93.5%
3.6 pts better
|
95.5%
1.6 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.1% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 6.9% |
3.2%
3.7 pts worse
|
3.3%
3.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 6.3% · Q3 6.9% · Q4 11.7% · 4Q avg 6.9% · 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 | 7.4% |
6.5%
0.9 pts worse
|
5.4%
2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 11.5% · Q2 5.4% · Q3 5.6% · Q4 6.8% · 4Q avg 7.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 23.3% |
19.9%
3.4 pts worse
|
19.6%
3.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.6% · Q2 25.4% · Q3 20.7% · Q4 20.0% · 4Q avg 23.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 20.4% |
18.7%
1.7 pts worse
|
16.7%
3.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.8% · Q2 20.9% · Q3 21.7% · Q4 20.4% · 4Q avg 20.4% · 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 | 26.4% |
19.6%
6.8 pts worse
|
16.3%
10.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.5% · Q2 43.7% · Q3 3.2% · Q4 28.8% · 4Q avg 26.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 23.9% |
18.3%
5.6 pts worse
|
14.9%
9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.6% · Q2 37.7% · Q3 17.9% · Q4 19.0% · 4Q avg 23.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.1% |
0.9%
1.2 pts worse
|
1.0%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 2.1% · Q3 2.5% · Q4 2.5% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.7% |
1.7%
About the same
|
1.7%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 4.9% · Q2 0.0% · Q3 1.9% · Q4 0.0% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 26.8% |
26.4%
0.4 pts worse
|
19.8%
7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.1% · Q2 40.3% · Q3 21.2% · Q4 23.0% · 4Q avg 26.8% |
| Percentage of long-stay residents with pressure ulcers | 8.5% |
5.3%
3.2 pts worse
|
5.1%
3.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 14.8% · Q2 9.4% · Q3 7.6% · Q4 2.2% · 4Q avg 8.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 91.8% |
68.9%
22.9 pts better
|
81.7%
10.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 88.2% · Q2 95.1% · Q3 96.1% · Q4 88.5% · 4Q avg 91.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 21.0% |
9.8%
11.2 pts worse
|
12.0%
9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 21.0% · Observed 21.4% · Expected 11.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.6% |
1.5%
1.1 pts worse
|
1.6%
1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 4.2% · Q4 5.4% · 4Q avg 2.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 81.8% |
68.7%
13.1 pts better
|
79.7%
2.1 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 81.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 13.6% |
23.1%
9.5 pts better
|
23.9%
10.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 13.6% · Observed 12.5% · Expected 21.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-01-05 · Fire 2024-01-05
7 health deficiencies
Top issue: Resident Rights (3 deficiencies)
2 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Cycle 3
Health 2023-02-16 · Fire 2023-02-16
3 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
6 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-01-05
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-02-16
C · Minimal harm
2024-01-05
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2024-02-16
E · Potential for more than minimal harm
2023-02-16
K133 · Construction Deficiencies
Fire Safety
Install a two-hour-resistant firewall separation.
Corrected 2023-04-17
E · Potential for more than minimal harm
2023-02-16
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-04-17
E · Potential for more than minimal harm
2023-02-16
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-04-17
E · Potential for more than minimal harm
2023-02-16
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 2023-04-17
D · Potential for more than minimal harm
2023-02-16
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 2023-04-17
B · Minimal harm
2023-02-16
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-04-17
Inspection history
Recent health citations
G · Actual harm
2024-12-06
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 2025-02-04
G · Actual harm
2024-12-06
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 2025-02-04
E · Potential for more than minimal harm
2024-01-05
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 2024-03-01
D · Potential for more than minimal harm
2024-01-05
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 2024-03-01
D · Potential for more than minimal harm
2024-01-05
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 2024-03-01
D · Potential for more than minimal harm
2024-01-05
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 2024-03-01
D · Potential for more than minimal harm
2024-01-05
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-03-01
D · Potential for more than minimal harm
2024-01-05
F700 · Quality of Life and Care Deficiencies
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2024-03-01
D · Potential for more than minimal harm
2024-01-05
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-03-01
D · Potential for more than minimal harm
2023-02-16
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-04-04
D · Potential for more than minimal harm
2023-02-16
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 2023-04-04
D · Potential for more than minimal harm
2023-02-16
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 2023-04-04
Penalties and ownership
What sits behind the stars
$8,018
2024-12-06
Fine
Fine · fine $8,018
Fine
$8,018
2024-12-06
Fine
Fine · fine $8,018
Fine
Ownership
Belt, Jeffrey
Corporate Director · Individual
Boutillette, Marc
Corporate Director · Individual
Derose, Daniel
Corporate Director · Individual
Ferguson, David
Corporate Director · Individual
Fiorentino, Lisa
Corporate Director · Individual
Javed, Muhammed
Corporate Director · Individual
Klass, Cheryl
Corporate Officer · Individual
Marasco, Julie
Corporate Director · Individual
O'connell, Katie
Operational/Managerial Control · Individual
O'connell, Katie
Corporate Officer · Individual
Pisano, Douglas
Corporate Director · Individual
Pradhan, Anil
Corporate Director · Individual
Prince, David
Corporate Director · Individual
Ridley, Paul
Corporate Director · Individual
Schoenecker, Jeannine
Corporate Director · Individual
Scholl, Melissa
Corporate Director · Individual
Upper Allegheny Health System
Operational/Managerial Control · Organization
Witte, Gilbert
Corporate Director · Individual
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