Cycle 1
Health 2025-09-12 · Fire 2025-09-12
6 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Moscow, PA
Saint Mary's Villa Nursing Hom
4-star overall rating with 4-star inspections with 6 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
516 St. Mary's Villa Road, Moscow, PA
(570) 842-7621
Overall
4 / 5
CMS overall stars
Health inspections
4 / 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
112
Certified beds
Average residents
92
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Covenant Health
Operator or chain grouping
Approved since
1977-01-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
11 facilities
Chain averages 3 overall / 3 health / 5 staffing / 3 quality stars
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
0.81
Registered nurse staffing · state 0.78 · national 0.68
LPN hours / resident day
0.98
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
2.38
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
4.17
All reported nurse hours · state 3.89 · national 3.89
Licensed hours
1.79
RN + LPN hours · state 1.69 · national 1.54
Weekend hours
3.61
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.35
Weekend registered nurse coverage · state 0.55 · national 0.47
Physical therapist
0.06
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.83
CMS adjusted RN staffing hours
Adjusted total hours
4.30
CMS adjusted total nurse staffing hours
Case-mix index
1.33
Higher values indicate more complex resident acuity
RN turnover
33%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
41%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
7,636
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
29.18
Composite VBP score used to determine payment impact.
Payment multiplier
0.9853
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 20.23% · Performance 21.41% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 6.62% · Performance 9.23% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
5.93
Baseline 34.12% · Performance 39.42% · Measure score 5.93 · Achievement 5.93 · Improvement 0
Adjusted total nurse staffing
5.74
Baseline 3.96 hours · Performance 4.71 hours · Measure score 5.74 · Achievement 5.74 · Improvement 3.63
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.68% |
10.72%
1 pts worse
|
No Different than the National Rate · Eligible stays 142 · Observed rate 13.38% · Lower 95% interval 8.82% |
| Discharge to community | 33.25% |
50.57%
17.3 pts worse
|
Worse than the National Rate · Eligible stays 130 · Observed rate 23.85% · Lower 95% interval 26.58% |
| Medicare spending per beneficiary | 0.86 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 106 · Denominator 106 |
| Falls with major injury | 0.94% |
0.77%
0.2 pts worse
|
Numerator 1 · Denominator 106 |
| Discharge self-care score | 22.99% |
53.69%
30.7 pts worse
|
Numerator 20 · Denominator 87 |
| Discharge mobility score | 32.18% |
50.94%
18.8 pts worse
|
Numerator 28 · Denominator 87 |
| Pressure ulcers or injuries, new or worsened | 4.72% |
2.29%
2.4 pts worse
|
Numerator 5 · Denominator 106 · Adjusted rate 3.96% |
| Healthcare-associated infections requiring hospitalization | 9.23% |
7.12%
2.1 pts worse
|
No Different than the National Rate · Eligible stays 97 · Observed rate 13.4% · Lower 95% interval 6.32% |
| Staff COVID-19 vaccination coverage | 4.76% |
8.2%
3.4 pts worse
|
Numerator 8 · Denominator 168 |
| Staff flu vaccination coverage | 64.47% |
42%
22.5 pts better
|
Numerator 98 · Denominator 152 |
| Discharge function score | 37.93% |
56.45%
18.5 pts worse
|
Numerator 33 · Denominator 87 |
| Transfer of health information to provider | 95.35% |
95.95%
0.6 pts worse
|
Numerator 41 · Denominator 43 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 22.41% |
25.2%
2.8 pts worse
|
Numerator 13 · Denominator 58 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.2 |
1.7
0.5 pts worse
|
1.9
0.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.2 · Observed 2.5 · Expected 2.1 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.7 |
1.2
0.5 pts better
|
1.8
1.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.7 · Observed 0.7 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.7% |
86.9%
11.8 pts better
|
93.4%
5.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.6% · Q2 98.7% · Q3 98.7% · Q4 98.8% · 4Q avg 98.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
93.5%
6.5 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.8% |
3.2%
2.6 pts worse
|
3.3%
2.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.6% · Q2 6.6% · Q3 6.6% · Q4 4.8% · 4Q avg 5.8% · 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 | 5.2% |
6.5%
1.3 pts better
|
5.4%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 8.6% · Q3 4.2% · Q4 3.8% · 4Q avg 5.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 21.2% |
19.9%
1.3 pts worse
|
19.6%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.9% · Q2 21.6% · Q3 21.3% · Q4 18.3% · 4Q avg 21.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 10.1% |
18.7%
8.6 pts better
|
16.7%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.7% · Q2 8.9% · Q3 10.0% · Q4 10.6% · 4Q avg 10.1% · 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 | 18.2% |
19.6%
1.4 pts better
|
16.3%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.2% · Q2 18.6% · Q3 21.1% · Q4 7.4% · 4Q avg 18.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 11.7% |
18.3%
6.6 pts better
|
14.9%
3.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.2% · Q2 11.8% · Q3 15.7% · Q4 6.7% · 4Q avg 11.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.7% |
0.9%
0.8 pts worse
|
1.0%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 3.0% · Q3 1.2% · Q4 0.0% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.4% |
1.7%
1.7 pts worse
|
1.7%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 4.2% · Q3 2.7% · Q4 3.7% · 4Q avg 3.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 33.4% |
26.4%
7 pts worse
|
19.8%
13.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.5% · Q2 40.6% · Q3 30.9% · Q4 33.1% · 4Q avg 33.4% |
| Percentage of long-stay residents with pressure ulcers | 2.5% |
5.3%
2.8 pts better
|
5.1%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 1.4% · Q3 2.5% · Q4 3.0% · 4Q avg 2.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.0% |
68.9%
28.1 pts better
|
81.7%
15.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 96.8% · Q2 95.8% · Q3 97.0% · Q4 98.5% · 4Q avg 97.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.3% |
9.8%
1.5 pts worse
|
12.0%
0.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.3% · Observed 10.6% · Expected 10.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.6% |
1.5%
0.9 pts better
|
1.6%
1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.4% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 88.0% |
68.7%
19.3 pts better
|
79.7%
8.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 88.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 20.2% |
23.1%
2.9 pts better
|
23.9%
3.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 20.2% · Observed 21.2% · Expected 25.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-11-15 · Fire 2024-11-15
4 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
8 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cycle 3
Health 2023-11-30 · Fire 2023-11-30
8 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-09-12
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2025-10-16
E · Potential for more than minimal harm
2025-09-12
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2025-10-16
E · Potential for more than minimal harm
2025-09-12
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 2025-10-16
E · Potential for more than minimal harm
2025-09-12
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-10-16
E · Potential for more than minimal harm
2025-09-12
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-10-16
E · Potential for more than minimal harm
2025-09-12
K541 · Services Deficiencies
Fire Safety
Install properly constructed and protected linen or trash chutes.
Corrected 2025-10-16
E · Potential for more than minimal harm
2024-11-15
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-01-10
E · Potential for more than minimal harm
2024-11-15
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2025-01-10
E · Potential for more than minimal harm
2024-11-15
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2025-01-10
E · Potential for more than minimal harm
2024-11-15
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 2025-01-10
E · Potential for more than minimal harm
2024-11-15
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-01-10
E · Potential for more than minimal harm
2024-11-15
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-01-10
E · Potential for more than minimal harm
2024-11-15
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2025-01-10
E · Potential for more than minimal harm
2024-11-15
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-01-10
E · Potential for more than minimal harm
2023-11-30
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 2024-01-06
E · Potential for more than minimal harm
2023-11-30
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-01-06
E · Potential for more than minimal harm
2023-11-30
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-01-06
E · Potential for more than minimal harm
2023-11-30
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-01-06
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-09-12
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 2025-10-24
D · Potential for more than minimal harm
2025-09-12
F553 · Resident Rights Deficiencies
Health
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Corrected 2025-10-24
D · Potential for more than minimal harm
2025-09-12
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2025-10-24
D · 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 2025-10-24
D · Potential for more than minimal harm
2025-09-12
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 2025-10-24
D · Potential for more than minimal harm
2025-09-12
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2025-10-24
D · Potential for more than minimal harm
2024-11-15
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2025-01-06
D · Potential for more than minimal harm
2024-11-15
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 2025-01-06
D · Potential for more than minimal harm
2024-11-15
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 2025-01-06
D · Potential for more than minimal harm
2024-07-02
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 2024-08-27
E · Potential for more than minimal harm
2023-11-30
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-01-30
E · Potential for more than minimal harm
2023-11-30
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-01-30
D · Potential for more than minimal harm
2023-11-30
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-01-30
D · Potential for more than minimal harm
2023-11-30
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 2024-02-19
D · Potential for more than minimal harm
2023-11-30
F740 · Quality of Life and Care Deficiencies
Health
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected 2024-01-30
D · Potential for more than minimal harm
2023-11-30
F790 · Quality of Life and Care Deficiencies
Health
Provide routine and 24-hour emergency dental care for each resident.
Corrected 2024-01-30
D · Potential for more than minimal harm
2023-11-30
F791 · Quality of Life and Care Deficiencies
Health
Provide or obtain dental services for each resident.
Corrected 2024-01-30
B · Minimal harm
2023-11-30
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-01-30
Penalties and ownership
What sits behind the stars
Ownership
Covenant Health
5% Or Greater Mortgage Interest · Organization
Morgan Chopick, Tracey
Corporate Director · Individual
Newcomb, Nancy
Operational/Managerial Control · Individual
Newcomb, Nancy
Corporate Director · Individual
Scanlon, Catherine
Corporate Director · Individual
Valenti, Samuel
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
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Dunmore Health Care Center
Dunmore, PA
3-star overall rating with 3-star inspections with $12,048 in total fines with 6 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#2
Linwood Nursing And Rehabilitation Center
Scranton, PA
1-star overall rating with 1-star inspections with $113,348 in total fines with 8 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#3
Elan Skilled Nursing And Rehab, A Jewish Senior Li
Scranton, PA
2-star overall rating with 2-star inspections with 13 recent health deficiencies
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