Cycle 1
Health 2025-06-18 · Fire 2025-06-18
16 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Pittsburgh, PA
Reformed Presbyterian Home
3-star overall rating with 2-star inspections with abuse icon flag with $7,446 in total fines with 16 recent health deficiencies
2344 Perrysville Avenue, Pittsburgh, PA
(412) 321-4139
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
58
Certified beds
Average residents
55
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1983-02-16
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
Hours and turnover
RN hours / resident day
1.06
Registered nurse staffing · state 0.78 · national 0.68
LPN hours / resident day
0.50
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
2.30
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.86
All reported nurse hours · state 3.89 · national 3.89
Licensed hours
1.56
RN + LPN hours · state 1.69 · national 1.54
Weekend hours
3.65
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.97
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
1.22
CMS adjusted RN staffing hours
Adjusted total hours
4.43
CMS adjusted total nurse staffing hours
Case-mix index
1.19
Higher values indicate more complex resident acuity
RN turnover
31%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
31%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,037
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
41.60
Composite VBP score used to determine payment impact.
Payment multiplier
0.9945
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Performance 23.30% · Measure score 0 · Achievement 0 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
4.76
Performance 6.41% · Measure score 4.76 · Achievement 4.76 · This facility did not have sufficient data to calculate a baseline period measure result.
Total nurse turnover
6.97
Baseline 36.73% · Performance 35.19% · Measure score 6.97 · Achievement 6.97 · Improvement 0.80
Adjusted total nurse staffing
4.91
Baseline 4.01 hours · Performance 4.48 hours · Measure score 4.91 · Achievement 4.91 · Improvement 2.12
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.66% |
10.72%
1.1 pts better
|
No Different than the National Rate · Eligible stays 33 · Observed rate 6.06% · Lower 95% interval 6.12% |
| Discharge to community | 46.93% |
50.57%
3.6 pts worse
|
No Different than the National Rate · Eligible stays 30 · Observed rate 33.33% · Lower 95% interval 28.98% |
| Medicare spending per beneficiary | 1.02 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 31 · Denominator 31 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 31 |
| Discharge self-care score | 65% |
53.69%
11.3 pts better
|
Numerator 13 · Denominator 20 |
| Discharge mobility score | 45% |
50.94%
5.9 pts worse
|
Numerator 9 · Denominator 20 |
| Pressure ulcers or injuries, new or worsened | 3.23% |
2.29%
0.9 pts worse
|
Numerator 1 · Denominator 31 · Adjusted rate 3.09% |
| Healthcare-associated infections requiring hospitalization | 6.41% |
7.12%
0.7 pts better
|
No Different than the National Rate · Eligible stays 29 · Observed rate 3.45% · Lower 95% interval 3.56% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 125 |
| Staff flu vaccination coverage | 41.45% |
42%
0.5 pts worse
|
Numerator 63 · Denominator 152 |
| Discharge function score | 75% |
56.45%
18.5 pts better
|
Numerator 15 · Denominator 20 |
| 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 | Not Available |
96.28%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 74.2% |
86.9%
12.7 pts worse
|
93.4%
19.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 88.0% · Q2 77.6% · Q3 69.0% · Q4 58.5% · 4Q avg 74.2% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 88.9% |
93.5%
4.6 pts worse
|
95.5%
6.6 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 88.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 7.1% |
3.2%
3.9 pts worse
|
3.3%
3.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.0% · Q2 6.1% · Q3 4.8% · Q4 7.3% · 4Q avg 7.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.8% |
6.5%
2.7 pts better
|
11.4%
7.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 4.8% · Q3 0.0% · Q4 5.4% · 4Q avg 3.8% |
| 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 7.0% · Q2 9.3% · Q3 5.3% · Q4 7.9% · 4Q avg 7.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 9.0% |
19.9%
10.9 pts better
|
19.6%
10.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.1% · Q2 6.8% · Q3 12.8% · Q4 7.7% · 4Q avg 9.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 25.0% |
18.7%
6.3 pts worse
|
16.7%
8.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.2% · Q2 25.8% · Q3 25.9% · Q4 24.1% · 4Q avg 25.0% · 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 | 23.6% |
19.6%
4 pts worse
|
16.3%
7.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q3 48.8% · 4Q avg 23.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 22.1% |
18.3%
3.8 pts worse
|
14.9%
7.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.8% · Q2 22.7% · Q3 20.5% · Q4 21.1% · 4Q avg 22.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.2% |
0.9%
0.3 pts worse
|
1.0%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.7% · Q3 0.0% · Q4 3.2% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.8% |
1.7%
1.1 pts worse
|
1.7%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.1% · Q2 4.2% · Q3 2.4% · Q4 0.0% · 4Q avg 2.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 23.8% |
26.4%
2.6 pts better
|
19.8%
4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 15.9% · Q2 25.2% · Q3 28.9% · Q4 26.6% · 4Q avg 23.8% |
| Percentage of long-stay residents with pressure ulcers | 5.0% |
5.3%
0.3 pts better
|
5.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.9% · Q2 5.8% · Q3 3.6% · Q4 4.3% · 4Q avg 5.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 44.6% |
68.9%
24.3 pts worse
|
81.7%
37.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 48.3% · Q2 56.8% · Q3 42.7% · Q4 33.3% · 4Q avg 44.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 21.3% |
9.8%
11.5 pts worse
|
12.0%
9.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 21.3% · Observed 20.0% · Expected 10.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.6% |
1.5%
0.1 pts worse
|
1.6%
About the same
|
Short Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 2.0% · Q3 0.0% · Q4 2.2% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 55.6% |
68.7%
13.1 pts worse
|
79.7%
24.1 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 55.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 41.7% |
23.1%
18.6 pts worse
|
23.9%
17.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 41.7% · Observed 35.0% · Expected 20.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-08-14 · Fire 2024-08-14
14 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2023-09-29 · Fire 2023-09-29
10 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Inspection history
Recent health citations
D · Potential for more than minimal harm
2026-01-22
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Not marked corrected
D · Potential for more than minimal harm
2026-01-22
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.
Not marked corrected
D · Potential for more than minimal harm
2025-11-24
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 2026-01-06
D · Potential for more than minimal harm
2025-11-24
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 2026-01-06
F · Potential for more than minimal harm
2025-06-18
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 2025-07-31
D · Potential for more than minimal harm
2025-06-18
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2025-07-31
D · Potential for more than minimal harm
2025-06-18
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 2025-07-31
D · Potential for more than minimal harm
2025-06-18
F628 · Resident Rights Deficiencies
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2025-07-31
D · Potential for more than minimal harm
2025-06-18
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 2025-07-31
D · Potential for more than minimal harm
2025-06-18
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 2025-07-31
D · Potential for more than minimal harm
2025-06-18
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-07-31
D · Potential for more than minimal harm
2025-06-18
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 2025-07-31
D · Potential for more than minimal harm
2025-06-18
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-07-31
D · Potential for more than minimal harm
2025-06-18
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 2025-07-31
D · Potential for more than minimal harm
2025-06-18
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 2025-07-31
D · Potential for more than minimal harm
2025-06-18
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 2025-07-31
D · Potential for more than minimal harm
2025-02-27
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 2025-04-10
D · Potential for more than minimal harm
2024-11-22
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 2025-01-10
D · Potential for more than minimal harm
2024-08-14
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 2024-09-27
D · Potential for more than minimal harm
2024-08-14
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 2024-09-27
D · Potential for more than minimal harm
2024-08-14
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 2024-09-27
D · Potential for more than minimal harm
2024-08-14
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-09-27
D · Potential for more than minimal harm
2024-08-14
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-09-27
D · Potential for more than minimal harm
2024-08-14
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-09-27
D · Potential for more than minimal harm
2024-08-14
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 2024-09-27
D · Potential for more than minimal harm
2024-08-14
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2024-09-27
D · Potential for more than minimal harm
2024-08-14
F742 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
Corrected 2024-09-27
D · Potential for more than minimal harm
2024-08-14
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 2024-09-27
D · Potential for more than minimal harm
2024-08-14
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-09-27
D · Potential for more than minimal harm
2024-03-09
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-04-20
D · Potential for more than minimal harm
2023-09-29
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 2023-11-15
D · Potential for more than minimal harm
2023-09-29
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 2023-11-15
D · Potential for more than minimal harm
2023-09-29
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-11-15
D · Potential for more than minimal harm
2023-09-29
F685 · Quality of Life and Care Deficiencies
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2023-11-15
D · Potential for more than minimal harm
2023-09-29
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-11-15
D · Potential for more than minimal harm
2023-09-29
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-11-15
B · Minimal harm
2023-09-29
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2023-11-15
J · Immediate jeopardy
2023-04-28
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 2023-05-30
D · Potential for more than minimal harm
2023-04-28
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 2023-05-30
D · Potential for more than minimal harm
2023-04-28
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-05-30
Penalties and ownership
What sits behind the stars
$7,446
2023-04-28
Fine
Fine · fine $7,446
Fine
Ownership
Meneely, Lorrie
Corporate Officer · Individual
Meneely, Lorrie
W-2 Managing Employee · Individual
Todhunter, Cara
Corporate Officer · Individual
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#3
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