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

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

1.22

Registered nurse staffing · state 0.78 · national 0.68

LPN hours / resident day

1.38

Licensed practical nurse staffing · state 0.91 · national 0.87

Aide hours / resident day

2.52

Nurse aide staffing · state 2.20 · national 2.35

Total nurse hours

5.11

All reported nurse hours · state 3.89 · national 3.89

Licensed hours

2.59

RN + LPN hours · state 1.69 · national 1.54

Weekend hours

3.87

Weekend nurse staffing · state 3.51 · national 3.43

Weekend RN hours

0.72

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

1.43

CMS adjusted RN staffing hours

Adjusted total hours

6.01

CMS adjusted total nurse staffing hours

Case-mix index

1.16

Higher values indicate more complex resident acuity

RN turnover

51%

Annual RN turnover · state 43% · national 45%

Total nurse turnover

51%

Annual nurse turnover · state 47% · national 46%

SNF VBP

Value-based purchasing

Program rank

559

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

67.52

Composite VBP score used to determine payment impact.

Payment multiplier

1.0210

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

Not reported

This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.

Healthcare-associated infections

Not reported

This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.

Total nurse turnover

3.50

Baseline 32.26% · Performance 49.36% · Measure score 3.50 · Achievement 3.50 · Improvement 0

Adjusted total nurse staffing

10

Baseline 5.37 hours · Performance 6.99 hours · Measure score 10 · Achievement 10 · Improvement 9

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	Not Available	10.72%	Not Available · Eligible stays 3 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly.
Discharge to community	Not Available	50.57%	Not Available · Eligible stays Not Available · Observed rate Not Available · Lower 95% interval Not Available · No data were submitted for this measure.
Medicare spending per beneficiary	Not Available	1.02	Too few residents or stays to report publicly.
Drug regimen review with follow-up	Not Available	95.27%	Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly.
Falls with major injury	Not Available	0.77%	Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly.
Discharge self-care score	Not Available	53.69%	Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly.
Discharge mobility score	Not Available	50.94%	Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly.
Pressure ulcers or injuries, new or worsened	Not Available	2.29%	Numerator Not Available · Denominator 2 · Adjusted rate Not Available · Too few residents or stays to report publicly.
Healthcare-associated infections requiring hospitalization	Not Available	7.12%	Not Available · Eligible stays 2 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly.
Staff COVID-19 vaccination coverage	3.29%	8.2% 4.9 pts worse	Numerator 7 · Denominator 213
Staff flu vaccination coverage	33.2%	42% 8.8 pts worse	Numerator 84 · Denominator 253
Discharge function score	Not Available	56.45%	Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly.
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report.
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report.
Resident COVID-19 vaccinations up to date	Not Available	25.2%	Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly.

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 · Adjusted 2.3 · Observed 1.7 · Expected 1.5 · Used in QM five-star
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 · Adjusted 0.4 · Observed 0.4 · Expected 1.5 · Used in QM five-star
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 · Q1 96.6% · Q2 98.9% · Q3 98.9% · Q4 98.9% · 4Q avg 98.3%
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 · 4Q avg 98.9%
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 · Q1 4.5% · Q2 4.4% · Q3 3.4% · Q4 1.1% · 4Q avg 3.3% · Used in QM five-star
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 · Q1 0.0% · Q2 0.0% · Q3 1.4% · Q4 0.0% · 4Q avg 0.3%
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 5.7% · Q2 9.0% · Q3 9.1% · Q4 8.7% · 4Q avg 8.1%
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 · Q1 34.5% · Q2 35.6% · Q3 39.8% · Q4 36.6% · 4Q avg 36.6%
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	12.3%	19.6% 7.3 pts better	16.3% 4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 17.6% · Q2 13.3% · Q3 10.8% · Q4 8.8% · 4Q avg 12.3% · Used in QM five-star
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 · Q1 13.2% · Q2 15.9% · Q3 9.4% · Q4 17.1% · 4Q avg 14.1% · Used in QM five-star
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 · Q1 2.5% · Q2 2.1% · Q3 2.7% · Q4 1.6% · 4Q avg 2.2% · Used in QM five-star
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 · Q1 3.4% · Q2 2.2% · Q3 0.0% · Q4 1.1% · 4Q avg 1.7% · Used in QM five-star
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 · Q1 17.8% · Q2 12.0% · Q3 14.5% · Q4 8.7% · 4Q avg 13.2%
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 · Q1 1.4% · Q2 2.8% · Q3 7.4% · Q4 1.4% · 4Q avg 3.2% · Used in QM five-star
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 · 4Q avg 90.0%

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