Cycle 1
Health 2025-12-24 · Fire 2024-11-06
3 health deficiencies
Top issue: Infection Control (1 deficiency)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Columbia, PA
St Anne's Retirement Community
4-star overall rating with 4-star inspections with 3 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
3952 Columbia Avenue, Columbia, PA
(717) 285-5443
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
119
Certified beds
Average residents
74
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1990-03-31
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
0.92
Registered nurse staffing · state 0.78 · national 0.68
LPN hours / resident day
1.22
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
2.77
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
4.92
All reported nurse hours · state 3.89 · national 3.89
Licensed hours
2.14
RN + LPN hours · state 1.69 · national 1.54
Weekend hours
4.11
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.43
Weekend registered nurse coverage · state 0.55 · national 0.47
Physical therapist
0.08
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.92
CMS adjusted RN staffing hours
Adjusted total hours
4.91
CMS adjusted total nurse staffing hours
Case-mix index
1.37
Higher values indicate more complex resident acuity
RN turnover
17%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
26%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
787
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
63.82
Composite VBP score used to determine payment impact.
Payment multiplier
1.0185
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
7.91
Baseline 17.09% · Performance 17.76% · Measure score 7.91 · Achievement 7.91 · Improvement 0
Healthcare-associated infections
3.20
Baseline 5.48% · Performance 6.88% · Measure score 3.20 · Achievement 3.20 · Improvement 0
Total nurse turnover
10
Baseline 29.27% · Performance 23.23% · Measure score 10 · Achievement 10 · Improvement 9
Adjusted total nurse staffing
4.42
Baseline 4.68 hours · Performance 4.33 hours · Measure score 4.42 · Achievement 4.42 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.22% |
10.72%
1.5 pts better
|
No Different than the National Rate · Eligible stays 131 · Observed rate 6.11% · Lower 95% interval 6.11% |
| Discharge to community | 45.82% |
50.57%
4.8 pts worse
|
No Different than the National Rate · Eligible stays 117 · Observed rate 37.61% · Lower 95% interval 39.02% |
| Medicare spending per beneficiary | 0.93 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 98.91% |
95.27%
3.6 pts better
|
Numerator 91 · Denominator 92 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 92 |
| Discharge self-care score | 45.71% |
53.69%
8 pts worse
|
Numerator 32 · Denominator 70 |
| Discharge mobility score | 60% |
50.94%
9.1 pts better
|
Numerator 42 · Denominator 70 |
| Pressure ulcers or injuries, new or worsened | 1.09% |
2.29%
1.2 pts better
|
Numerator 1 · Denominator 92 · Adjusted rate 0.83% |
| Healthcare-associated infections requiring hospitalization | 6.88% |
7.12%
0.2 pts better
|
No Different than the National Rate · Eligible stays 95 · Observed rate 6.32% · Lower 95% interval 4.05% |
| Staff COVID-19 vaccination coverage | 14.76% |
8.2%
6.6 pts better
|
Numerator 40 · Denominator 271 |
| Staff flu vaccination coverage | 70.69% |
42%
28.7 pts better
|
Numerator 205 · Denominator 290 |
| Discharge function score | 58.57% |
56.45%
2.1 pts better
|
Numerator 41 · Denominator 70 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 27 · Denominator 27 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 40% |
25.2%
14.8 pts better
|
Numerator 16 · Denominator 40 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.8 |
1.7
0.1 pts worse
|
1.9
0.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 1.8 · Expected 1.9 · 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 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.9% |
86.9%
12 pts better
|
93.4%
5.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 97.0% · Q2 98.5% · Q3 100.0% · Q4 100.0% · 4Q avg 98.9% |
| 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 | 5.5% |
3.2%
2.3 pts worse
|
3.3%
2.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.0% · Q2 4.6% · Q3 7.1% · Q4 4.2% · 4Q avg 5.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 6.4% |
6.5%
0.1 pts better
|
11.4%
5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 4.9% · Q3 11.1% · Q4 6.3% · 4Q avg 6.4% |
| Percentage of long-stay residents who lose too much weight | 8.3% |
6.5%
1.8 pts worse
|
5.4%
2.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.2% · Q2 5.8% · Q3 6.9% · Q4 10.2% · 4Q avg 8.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 21.4% |
19.9%
1.5 pts worse
|
19.6%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.6% · Q2 18.2% · Q3 21.3% · Q4 21.3% · 4Q avg 21.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 18.8% |
18.7%
0.1 pts worse
|
16.7%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.9% · Q2 18.8% · Q3 21.1% · Q4 16.4% · 4Q avg 18.8% · 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 | 18.8% |
19.6%
0.8 pts better
|
16.3%
2.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q3 9.6% · Q4 21.5% · 4Q avg 18.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 14.4% |
18.3%
3.9 pts better
|
14.9%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 19.6% · Q2 9.1% · Q3 11.8% · Q4 16.3% · 4Q avg 14.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.7% |
0.9%
0.2 pts better
|
1.0%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.5% · Q3 1.5% · Q4 0.0% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.0% |
1.7%
1.3 pts worse
|
1.7%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 1.6% · Q3 4.5% · Q4 4.3% · 4Q avg 3.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 30.9% |
26.4%
4.5 pts worse
|
19.8%
11.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 33.9% · Q2 39.2% · Q3 24.0% · Q4 26.8% · 4Q avg 30.9% |
| Percentage of long-stay residents with pressure ulcers | 2.6% |
5.3%
2.7 pts better
|
5.1%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 2.3% · Q3 2.7% · Q4 3.7% · 4Q avg 2.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 96.5% |
68.9%
27.6 pts better
|
81.7%
14.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 94.5% · Q2 96.6% · Q3 98.0% · Q4 97.2% · 4Q avg 96.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 3.0% |
9.8%
6.8 pts better
|
12.0%
9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 3.0% · Observed 2.9% · Expected 10.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.8% |
1.5%
1.3 pts worse
|
1.6%
1.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 3.8% · Q3 0.0% · Q4 4.5% · 4Q avg 2.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 98.3% |
68.7%
29.6 pts better
|
79.7%
18.6 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 98.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 15.0% |
23.1%
8.1 pts better
|
23.9%
8.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 15.0% · Observed 14.3% · Expected 22.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-11-06 · Fire 2023-12-07
0 health deficiencies
No concentrated health issue counts in this cycle.
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2023-12-07 · Fire 2023-02-10
2 health deficiencies
Top issue: Infection Control (1 deficiency)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-11-06
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 2025-01-13
E · Potential for more than minimal harm
2024-11-06
K541 · Services Deficiencies
Fire Safety
Install properly constructed and protected linen or trash chutes.
Corrected 2025-01-13
F · Potential for more than minimal harm
2023-02-10
K932 · Smoke Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2023-01-18
E · Potential for more than minimal harm
2023-02-10
K912 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2023-01-18
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-12-24
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2026-02-09
D · Potential for more than minimal harm
2025-12-24
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2026-02-09
D · Potential for more than minimal harm
2025-12-24
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2026-02-09
E · Potential for more than minimal harm
2023-12-07
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-01-26
D · Potential for more than minimal harm
2023-12-07
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2024-01-26
Penalties and ownership
What sits behind the stars
Ownership
Bachman, Theresa
Corporate Director · Individual
Bard, Michele
W-2 Managing Employee · Individual
Grab, Michael
Corporate Director · Individual
Hollywood, Lisa
W-2 Managing Employee · Individual
Hornick, Joan
Corporate Director · Individual
Kendig, James
Corporate Director · Individual
Kiely, William
Corporate Director · Individual
Love, Cheryl
Corporate Director · Individual
Martin, Donald
Corporate Director · Individual
Patterson, Matthew
Corporate Director · Individual
Riley, Sheri
Corporate Director · Individual
Schumer, Mary
Corporate Director · Individual
Sosa, Eileen
Corporate Director · Individual
Spicher, James
Contracted Managing Employee · Individual
Turnbaugh, Mary
W-2 Managing Employee · Individual
Woodruff, Michelle
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Susquehanna Health And Wellness Center
Columbia, PA
3-star overall rating with 3-star inspections with $132,901 in total fines with 8 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
Homestead Village, Inc
Lancaster, PA
5-star overall rating with 4-star inspections with 2 recent health deficiencies
#3
Trillium Place
Lancaster, PA
5-star overall rating with 5-star inspections with 1 fire-safety deficiencies in the latest cycle
Jump out