Cycle 1
Health 2025-03-28 · Fire 2025-03-28
3 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Hermitage, PA
Saint John Xxiii Home
5-star overall rating with 4-star inspections with 3 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
2250 Shenango Freeway, Hermitage, PA
(724) 981-3200
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
90
Certified beds
Average residents
49
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1989-07-01
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
Staffing
Hours and turnover
RN hours / resident day
1.06
Registered nurse staffing · state 0.78 · national 0.68
LPN hours / resident day
0.76
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
1.69
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.52
All reported nurse hours · state 3.89 · national 3.89
Licensed hours
1.82
RN + LPN hours · state 1.69 · national 1.54
Weekend hours
3.25
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.76
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
1.20
CMS adjusted RN staffing hours
Adjusted total hours
3.96
CMS adjusted total nurse staffing hours
Case-mix index
1.21
Higher values indicate more complex resident acuity
RN turnover
8%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
21%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,423
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
56.79
Composite VBP score used to determine payment impact.
Payment multiplier
1.0119
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.53
Baseline 19.36% · Performance 18.87% · Measure score 5.53 · Achievement 5.53 · Improvement 1.62
Healthcare-associated infections
3.48
Baseline 6.30% · Performance 6.79% · Measure score 3.48 · Achievement 3.48 · Improvement 0
Total nurse turnover
10
Baseline 34.09% · Performance 24.44% · Measure score 10 · Achievement 10 · Improvement 9
Adjusted total nurse staffing
3.71
Baseline 3.48 hours · Performance 4.13 hours · Measure score 3.71 · Achievement 3.71 · Improvement 2.33
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.12% |
10.72%
0.6 pts better
|
No Different than the National Rate · Eligible stays 113 · Observed rate 7.08% · Lower 95% interval 6.94% |
| Discharge to community | 54.09% |
50.57%
3.5 pts better
|
No Different than the National Rate · Eligible stays 102 · Observed rate 51.96% · Lower 95% interval 46.4% |
| Medicare spending per beneficiary | 1.1 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 97.01% |
95.27%
1.7 pts better
|
Numerator 65 · Denominator 67 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 67 |
| Discharge self-care score | 68.42% |
53.69%
14.7 pts better
|
Numerator 39 · Denominator 57 |
| Discharge mobility score | 66.67% |
50.94%
15.7 pts better
|
Numerator 38 · Denominator 57 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 67 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.79% |
7.12%
0.3 pts better
|
No Different than the National Rate · Eligible stays 71 · Observed rate 4.23% · Lower 95% interval 3.72% |
| Staff COVID-19 vaccination coverage | 43.3% |
8.2%
35.1 pts better
|
Numerator 42 · Denominator 97 |
| Staff flu vaccination coverage | 53.97% |
42%
12 pts better
|
Numerator 68 · Denominator 126 |
| Discharge function score | 75.44% |
56.45%
19 pts better
|
Numerator 43 · Denominator 57 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 38 · Denominator 38 |
| Resident COVID-19 vaccinations up to date | 52.94% |
25.2%
27.7 pts better
|
Numerator 18 · Denominator 34 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.2 |
1.7
0.5 pts better
|
1.9
0.7 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.1 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.7 |
1.2
0.5 pts worse
|
1.8
0.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 1.5 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 74.0% |
86.9%
12.9 pts worse
|
93.4%
19.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 80.5% · Q2 70.7% · Q3 71.4% · Q4 73.3% · 4Q avg 74.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 91.3% |
93.5%
2.2 pts worse
|
95.5%
4.2 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 91.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.7% |
3.2%
1.5 pts worse
|
3.3%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.9% · Q2 4.9% · Q3 2.4% · Q4 6.7% · 4Q avg 4.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 19.0% |
6.5%
12.5 pts worse
|
11.4%
7.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.2% · Q2 22.0% · Q3 22.5% · Q4 15.6% · 4Q avg 19.0% |
| Percentage of long-stay residents who lose too much weight | 8.1% |
6.5%
1.6 pts worse
|
5.4%
2.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 7.9% · Q3 12.2% · Q4 9.5% · 4Q avg 8.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 10.7% |
19.9%
9.2 pts better
|
19.6%
8.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.6% · Q2 10.0% · Q3 9.5% · Q4 8.9% · 4Q avg 10.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 20.6% |
18.7%
1.9 pts worse
|
16.7%
3.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 15.2% · Q2 21.2% · Q3 25.0% · Q4 20.5% · 4Q avg 20.6% · 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 | 35.2% |
19.6%
15.6 pts worse
|
16.3%
18.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 41.2% · Q2 22.5% · Q3 29.1% · Q4 47.7% · 4Q avg 35.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 37.7% |
18.3%
19.4 pts worse
|
14.9%
22.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 40.0% · Q2 29.7% · Q3 22.0% · Q4 56.8% · 4Q avg 37.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 3.7% |
0.9%
2.8 pts worse
|
1.0%
2.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 2.8% · Q3 4.8% · Q4 4.1% · 4Q avg 3.7% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 4.3% |
1.7%
2.6 pts worse
|
1.7%
2.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 5.1% · Q3 2.4% · Q4 7.1% · 4Q avg 4.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 22.6% |
26.4%
3.8 pts better
|
19.8%
2.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.9% · Q2 26.3% · Q3 20.5% · Q4 15.7% · 4Q avg 22.6% |
| Percentage of long-stay residents with pressure ulcers | 2.0% |
5.3%
3.3 pts better
|
5.1%
3.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.5% · Q4 5.1% · 4Q avg 2.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 50.0% |
68.9%
18.9 pts worse
|
81.7%
31.7 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 38.6% · Q2 60.5% · Q3 57.5% · Q4 42.3% · 4Q avg 50.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 19.9% |
9.8%
10.1 pts worse
|
12.0%
7.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 19.9% · Observed 18.6% · Expected 10.4% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 3.7% · Q3 3.4% · 4Q avg 2.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 76.9% |
68.7%
8.2 pts better
|
79.7%
2.8 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 76.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 10.3% |
23.1%
12.8 pts better
|
23.9%
13.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.3% · Observed 8.5% · Expected 19.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-04-25 · Fire 2024-04-25
1 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
9 fire-safety deficiencies
Top issue: Egress (3 deficiencies)
Cycle 3
Health 2023-05-04 · Fire 2023-05-04
1 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Fire safety
Fire-safety citations
C · Minimal harm
2025-03-28
K200 · Egress Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2025-04-28
C · Minimal harm
2025-03-28
K912 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2025-04-28
F · Potential for more than minimal harm
2024-04-25
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-06-01
F · Potential for more than minimal harm
2024-04-25
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-06-01
F · Potential for more than minimal harm
2024-04-25
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-06-01
D · Potential for more than minimal harm
2024-04-25
K912 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2024-06-01
C · Minimal harm
2024-04-25
K100 · Construction Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2024-06-01
C · Minimal harm
2024-04-25
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-06-01
B · Minimal harm
2024-04-25
K200 · Egress Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2024-06-01
B · Minimal harm
2024-04-25
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 2024-06-01
B · Minimal harm
2024-04-25
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-06-01
D · Potential for more than minimal harm
2023-05-04
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-05-22
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-03-28
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-05-05
D · Potential for more than minimal harm
2025-03-28
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-05-05
D · Potential for more than minimal harm
2025-03-28
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 2025-05-05
F · Potential for more than minimal harm
2024-04-25
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 2024-05-23
D · Potential for more than minimal harm
2023-05-04
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 2023-05-22
Penalties and ownership
What sits behind the stars
Ownership
Abbott, Michael
Operational/Managerial Control · Individual
Abbott, Michael
Corporate Officer · Individual
Abbott, Michael
W-2 Managing Employee · Individual
Dunn, Dana
Corporate Director · Individual
Hawthorne, Kirk
Corporate Officer · Individual
Hawthorne, Kirk
W-2 Managing Employee · Individual
John Xxiii Home
5% Or Greater Direct Ownership Interest · Organization
Lackey, Gary
Corporate Director · Individual
Linn, Jeff
Corporate Director · Individual
Mclaughlin, Joseph
Corporate Officer · Individual
Roman Catholic Diocese Of Erie
5% Or Greater Direct Ownership Interest · Organization
Nearby options
Other facilities in reach
#1
Hermitage Nursing And Rehabilitation
Hermitage, PA
4-star overall rating with 4-star inspections with 3 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
Clepper Manor
Sharon, PA
2-star overall rating with 2-star inspections with $169,599 in total fines with 2 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#3
O'brien Memorial Health Care C
Masury, OH
2-star overall rating with 2-star inspections with abuse icon flag with $68,952 in total fines with 11 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
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