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
Staffing
Hours and turnover
RN hours / resident day
1.06
Registered nurse staffing
LPN hours / resident day
0.76
Licensed practical nurse staffing
Aide hours / resident day
1.69
Nurse aide staffing
Weekend hours
3.25
Weekend nurse staffing
RN turnover
8%
Annual RN turnover
Total nurse turnover
21%
Annual nurse turnover
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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 | 35.2% |
19.6%
15.6 pts worse
|
16.3%
18.9 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 | 76.9% |
68.7%
8.2 pts better
|
79.7%
2.8 pts worse
|
Short Stay · 2024Q3-2025Q2 |
| 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 |
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
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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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