Hazleton, PA

Pavilion At St Luke Village, The

2-star overall rating with 2-star inspections with $65,478 in total fines with 10 recent health deficiencies

1000 Stacie Drive, Hazleton, PA

(570) 453-5100

Compare this facility

Overall

2 / 5

CMS overall stars

Health inspections

2 / 5

Survey and complaint cycles

Staffing

4 / 5

RN + nurse staffing

Quality measures

3 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

120

Certified beds

Average residents

100

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Avardis Health

Operator or chain grouping

Approved since

1969-05-29

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

14 facilities

Chain averages 2 overall / 2 health / 2 staffing / 3 quality stars

Changed ownership

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

0.58

Registered nurse staffing · state 0.78 · national 0.68

LPN hours / resident day

0.82

Licensed practical nurse staffing · state 0.91 · national 0.87

Aide hours / resident day

2.10

Nurse aide staffing · state 2.20 · national 2.35

Total nurse hours

3.50

All reported nurse hours · state 3.89 · national 3.89

Licensed hours

1.40

RN + LPN hours · state 1.69 · national 1.54

Weekend hours

3.20

Weekend nurse staffing · state 3.51 · national 3.43

Weekend RN hours

0.40

Weekend registered nurse coverage · state 0.55 · national 0.47

Physical therapist

0.03

Reported PT staffing · state 0.10 · national 0.07

Adjusted RN hours

0.63

CMS adjusted RN staffing hours

Adjusted total hours

3.82

CMS adjusted total nurse staffing hours

Case-mix index

1.25

Higher values indicate more complex resident acuity

RN turnover

33%

Annual RN turnover · state 43% · national 45%

Total nurse turnover

49%

Annual nurse turnover · state 47% · national 46%

SNF VBP

Value-based purchasing

Program rank

1,403

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

56.95

Composite VBP score used to determine payment impact.

Payment multiplier

1.0121

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

9.23

Baseline 17.72% · Performance 17.16% · Measure score 9.23 · Achievement 9.23 · Improvement 7.65

Healthcare-associated infections

7.41

Baseline 5.71% · Performance 5.62% · Measure score 7.41 · Achievement 7.41 · Improvement 0.79

Total nurse turnover

5.05

Baseline 40.26% · Performance 43.02% · Measure score 5.05 · Achievement 5.05 · Improvement 0

Adjusted total nurse staffing

1.08

Baseline 3.11 hours · Performance 3.39 hours · Measure score 1.08 · Achievement 1.08 · Improvement 0.53

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	8.38%	10.72% 2.3 pts better	No Different than the National Rate · Eligible stays 168 · Observed rate 5.36% · Lower 95% interval 5.9%
Discharge to community	40.59%	50.57% 10 pts worse	Worse than the National Rate · Eligible stays 169 · Observed rate 33.14% · Lower 95% interval 32.51%
Medicare spending per beneficiary	0.92	1.02 0.1 pts better
Drug regimen review with follow-up	99.12%	95.27% 3.9 pts better	Numerator 112 · Denominator 113
Falls with major injury	0%	0.77% 0.8 pts better	Numerator 0 · Denominator 113
Discharge self-care score	39.02%	53.69% 14.7 pts worse	Numerator 32 · Denominator 82
Discharge mobility score	26.83%	50.94% 24.1 pts worse	Numerator 22 · Denominator 82
Pressure ulcers or injuries, new or worsened	4.42%	2.29% 2.1 pts worse	Numerator 5 · Denominator 113 · Adjusted rate 3.96%
Healthcare-associated infections requiring hospitalization	5.62%	7.12% 1.5 pts better	No Different than the National Rate · Eligible stays 123 · Observed rate 3.25% · Lower 95% interval 3.49%
Staff COVID-19 vaccination coverage	0%	8.2% 8.2 pts worse	Numerator 0 · Denominator 88
Staff flu vaccination coverage	22.41%	42% 19.6 pts worse	Numerator 26 · Denominator 116
Discharge function score	25.61%	56.45% 30.8 pts worse	Numerator 21 · Denominator 82
Transfer of health information to provider	98.18%	95.95% 2.2 pts better	Numerator 54 · Denominator 55
Transfer of health information to patient	100%	96.28% 3.7 pts better	Numerator 30 · Denominator 30
Resident COVID-19 vaccinations up to date	2.04%	25.2% 23.2 pts worse	Numerator 1 · Denominator 49

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	1.7	1.7 About the same	1.9 0.2 pts better	Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 1.5 · Expected 1.7 · 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	98.6%	86.9% 11.7 pts better	93.4% 5.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 98.9% · Q2 97.8% · Q3 98.9% · Q4 98.9% · 4Q avg 98.6%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	99.0%	93.5% 5.5 pts better	95.5% 3.5 pts better	Long Stay · 2024Q3-2025Q2 · 4Q avg 99.0%
Percentage of long-stay residents experiencing one or more falls with major injury	3.1%	3.2% 0.1 pts better	3.3% 0.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 1.1% · Q3 3.3% · Q4 6.7% · 4Q avg 3.1% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	3.2%	6.5% 3.3 pts better	11.4% 8.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 5.5% · Q2 5.3% · Q3 2.5% · Q4 0.0% · 4Q avg 3.2%
Percentage of long-stay residents who lose too much weight	11.5%	6.5% 5 pts worse	5.4% 6.1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 10.2% · Q2 12.8% · Q3 14.0% · Q4 8.9% · 4Q avg 11.5%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	22.2%	19.9% 2.3 pts worse	19.6% 2.6 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 23.9% · Q2 23.3% · Q3 20.5% · Q4 20.9% · 4Q avg 22.2%
Percentage of long-stay residents who received an antipsychotic medication	15.9%	18.7% 2.8 pts better	16.7% 0.8 pts better	Long Stay · 2024Q4-2025Q3 · Q1 19.7% · Q2 17.1% · Q3 13.1% · Q4 14.1% · 4Q avg 15.9% · 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	16.6%	19.6% 3 pts better	16.3% 0.3 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 19.8% · Q2 11.3% · Q3 13.4% · Q4 21.7% · 4Q avg 16.6% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	13.5%	18.3% 4.8 pts better	14.9% 1.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 8.4% · Q2 7.0% · Q3 13.1% · Q4 26.2% · 4Q avg 13.5% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.3%	0.9% 0.6 pts better	1.0% 0.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.1% · 4Q avg 0.3% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	0.3%	1.7% 1.4 pts better	1.7% 1.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.1% · 4Q avg 0.3% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	33.6%	26.4% 7.2 pts worse	19.8% 13.8 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 37.7% · Q2 32.5% · Q3 29.5% · Q4 34.8% · 4Q avg 33.6%
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 · Q1 5.1% · Q2 3.3% · Q3 3.3% · Q4 3.8% · 4Q avg 3.9% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	93.1%	68.9% 24.2 pts better	81.7% 11.4 pts better	Short Stay · 2024Q4-2025Q3 · Q1 91.3% · Q2 90.8% · Q3 96.0% · Q4 95.4% · 4Q avg 93.1%
Percentage of short-stay residents who had an outpatient emergency department visit	11.1%	9.8% 1.3 pts worse	12.0% 0.9 pts better	Short Stay · 20240701-20250630 · Adjusted 11.1% · Observed 10.6% · Expected 10.7% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	0.5%	1.5% 1 pts better	1.6% 1.1 pts better	Short Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	86.7%	68.7% 18 pts better	79.7% 7 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 86.7%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	19.5%	23.1% 3.6 pts better	23.9% 4.4 pts better	Short Stay · 20240701-20250630 · Adjusted 19.5% · Observed 18.1% · Expected 22.1% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-09-12 · Fire 2025-09-12

10 health deficiencies

Top issue: Quality of Life and Care (4 deficiencies)

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Cycle 2 Health 2024-11-21 · Fire 2024-11-21

12 health deficiencies

Top issue: Pharmacy Service (4 deficiencies)

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Cycle 3 Health 2024-07-19 · Fire 2024-07-19

20 health deficiencies

Top issue: Quality of Life and Care (6 deficiencies)

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Inspection history

Recent health citations

E · Potential for more than minimal harm 2025-09-12

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 2025-10-14

E · Potential for more than minimal harm 2025-09-12

F565 · Resident Rights Deficiencies

Health

Honor the resident's right to organize and participate in resident/family groups in the facility.

Corrected 2025-10-14

E · Potential for more than minimal harm 2025-09-12

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 2025-09-12

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2025-10-14

E · Potential for more than minimal harm 2025-09-12

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 2025-10-14

D · Potential for more than minimal harm 2025-09-12

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 2025-09-12

F693 · Quality of Life and Care Deficiencies

Health

Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.

Corrected 2025-10-14

D · Potential for more than minimal harm 2025-09-12

F699 · Quality of Life and Care Deficiencies

Health

Provide care or services that was trauma informed and/or culturally competent.

Corrected 2025-10-14

G · Actual harm 2025-03-26

F686 · Quality of Life and Care Deficiencies

Health

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected 2025-04-22

D · Potential for more than minimal harm 2025-03-26

F895 · Administration Deficiencies

Health

Have a Compliance and Ethics Program.

Corrected 2025-04-22

F · Potential for more than minimal harm 2024-11-21

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-12-17

E · Potential for more than minimal harm 2024-11-21

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 2024-12-17

E · Potential for more than minimal harm 2024-11-21

F686 · Quality of Life and Care Deficiencies

Health

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected 2024-12-17

E · Potential for more than minimal harm 2024-11-21

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 2024-12-17

D · Potential for more than minimal harm 2024-11-21

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 2024-12-17

D · Potential for more than minimal harm 2024-11-21

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 2024-12-17

D · Potential for more than minimal harm 2024-11-21

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 2024-12-17

D · Potential for more than minimal harm 2024-10-16

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 2024-11-21

D · Potential for more than minimal harm 2024-10-16

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2024-11-21

D · Potential for more than minimal harm 2024-10-16

F757 · Pharmacy Service Deficiencies

Health

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Corrected 2024-11-21

G · Actual harm 2024-07-19

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 2024-07-19

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 2024-07-19

F694 · Quality of Life and Care Deficiencies

Health

Provide for the safe, appropriate administration of IV fluids for a resident when needed.

Corrected 2024-08-27

E · Potential for more than minimal harm 2024-07-19

F697 · Quality of Life and Care Deficiencies

Health

Provide safe, appropriate pain management for a resident who requires such services.

Corrected 2024-08-27

E · Potential for more than minimal harm 2024-07-19

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

E · Potential for more than minimal harm 2024-07-19

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 2024-08-27

E · Potential for more than minimal harm 2024-07-19

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 2024-08-27

E · Potential for more than minimal harm 2024-07-19