South Mountain, PA

South Mountain Restoration Cen

5-star overall rating with 5-star inspections with 1 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle

Building #1, South Mountain, PA

(717) 749-3121

Compare this facility

Overall

5 / 5

CMS overall stars

Health inspections

5 / 5

Survey and complaint cycles

Staffing

5 / 5

RN + nurse staffing

Quality measures

4 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

159

Certified beds

Average residents

95

Average occupied residents

Ownership

Government

Publicly displayed owner type

Chain

No chain reported

Operator or chain grouping

Approved since

1985-07-01

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Staffing

Hours and turnover

RN hours / resident day

1.22

Registered nurse staffing

LPN hours / resident day

1.38

Licensed practical nurse staffing

Aide hours / resident day

2.52

Nurse aide staffing

Weekend hours

3.87

Weekend nurse staffing

RN turnover

51%

Annual RN turnover

Total nurse turnover

51%

Annual nurse turnover

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	2.3	1.7 0.6 pts worse	1.9 0.4 pts worse	Long Stay · 20240701-20250630
Number of outpatient emergency department visits per 1000 long-stay resident days	0.4	1.2 0.8 pts better	1.8 1.4 pts better	Long Stay · 20240701-20250630
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	98.3%	86.9% 11.4 pts better	93.4% 4.9 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	98.9%	93.5% 5.4 pts better	95.5% 3.4 pts better	Long Stay · 2024Q3-2025Q2
Percentage of long-stay residents experiencing one or more falls with major injury	3.3%	3.2% 0.1 pts worse	3.3% About the same	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who have depressive symptoms	0.3%	6.5% 6.2 pts better	11.4% 11.1 pts better	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	36.6%	19.9% 16.7 pts worse	19.6% 17 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	12.3%	19.6% 7.3 pts better	16.3% 4 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents whose need for help with daily activities has increased	14.1%	18.3% 4.2 pts better	14.9% 0.8 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with a catheter inserted and left in their bladder	2.2%	0.9% 1.3 pts worse	1.0% 1.2 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with a urinary tract infection	1.7%	1.7% About the same	1.7% About the same	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	13.2%	26.4% 13.2 pts better	19.8% 6.6 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with pressure ulcers	3.2%	5.3% 2.1 pts better	5.1% 1.9 pts better	Long Stay · 2024Q4-2025Q3
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	90.0%	68.9% 21.1 pts better	81.7% 8.3 pts better	Short Stay · 2024Q4-2025Q3

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-09-18 · Fire 2024-10-03

1 health deficiencies

Top issue: Nutrition and Dietary (1 deficiency)

5 fire-safety deficiencies

Top issue: Smoke (3 deficiencies)

Cycle 2 Health 2024-10-03 · Fire 2023-12-07

1 health deficiencies

Top issue: Nutrition and Dietary (1 deficiency)

4 fire-safety deficiencies

Top issue: Egress (2 deficiencies)

Cycle 3 Health 2023-12-07 · Fire 2022-12-14

4 health deficiencies

Top issue: Administration (1 deficiency)

5 fire-safety deficiencies

Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)

Fire safety

Fire-safety citations

E · Potential for more than minimal harm 2024-10-03

K372 · Smoke Deficiencies

Fire Safety

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Corrected 2024-12-20

D · Potential for more than minimal harm 2024-10-03

K225 · Egress Deficiencies

Fire Safety

Have stairways and smokeproof enclosures used as exits that meet safety requirements.

Corrected 2024-12-20

D · Potential for more than minimal harm 2024-10-03

K351 · Smoke Deficiencies

Fire Safety

Install an approved automatic sprinkler system.

Corrected 2024-12-20

D · Potential for more than minimal harm 2024-10-03

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2024-12-20

C · Minimal harm 2024-10-03

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2024-12-20

E · Potential for more than minimal harm 2023-12-07

K291 · Egress Deficiencies

Fire Safety

Install emergency lighting that can last at least 1 1/2 hours.

Corrected 2024-02-07

D · Potential for more than minimal harm 2023-12-07

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 2024-02-07

D · Potential for more than minimal harm 2023-12-07

K374 · Smoke Deficiencies

Fire Safety

Install smoke barrier doors that can resist smoke for at least 20 minutes.

Corrected 2024-02-07

C · Minimal harm 2023-12-07

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2024-02-07

D · Potential for more than minimal harm 2022-12-14

K225 · Egress Deficiencies

Fire Safety

Have stairways and smokeproof enclosures used as exits that meet safety requirements.

Corrected 2023-02-17

D · Potential for more than minimal harm 2022-12-14

K364 · Smoke Deficiencies

Fire Safety

Install properly constructed windows in hallway walls or doors.

Corrected 2023-02-17

D · Potential for more than minimal harm 2022-12-14

K372 · Smoke Deficiencies

Fire Safety

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Corrected 2023-02-17

D · Potential for more than minimal harm 2022-12-14

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2023-02-17

C · Minimal harm 2022-12-14

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2023-02-17

Inspection history

Recent health citations

E · Potential for more than minimal harm 2025-09-18

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 2025-11-06

E · Potential for more than minimal harm 2024-10-03

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 2024-11-18

E · Potential for more than minimal harm 2023-12-07

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 2024-01-30

E · Potential for more than minimal harm 2023-12-07

F868 · Administration Deficiencies

Health

Have the Quality Assessment and Assurance group have the required members and meet at least quarterly

Corrected 2024-01-30

D · Potential for more than minimal harm 2023-12-07

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 2024-01-30

D · Potential for more than minimal harm 2023-12-07

F686 · Quality of Life and Care Deficiencies

Health

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

Corrected 2024-01-30

Penalties and ownership