11 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Gibsonia, PA
3-star overall rating with 3-star inspections with 11 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
5827 Meridian Road, Gibsonia, PA
(724) 443-0700
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Beds
119
Certified beds
Average residents
63
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1984-01-01
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
RN hours / resident day
0.85
Registered nurse staffing · state 0.78 · national 0.68
LPN hours / resident day
0.55
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
2.47
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.87
All reported nurse hours · state 3.89 · national 3.89
Licensed hours
1.40
RN + LPN hours · state 1.69 · national 1.54
Weekend hours
3.78
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.88
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
0.86
CMS adjusted RN staffing hours
Adjusted total hours
3.92
CMS adjusted total nurse staffing hours
Case-mix index
1.35
Higher values indicate more complex resident acuity
RN turnover
40%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
52%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Program rank
8,713
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
25.89
Composite VBP score used to determine payment impact.
Payment multiplier
0.9840
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
2.80
Baseline 17.99% · Performance 20.14% · Measure score 2.80 · Achievement 2.80 · Improvement 0
Healthcare-associated infections
0
Baseline 5.83% · Performance 7.79% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
4.32
Baseline 20.00% · Performance 46.03% · Measure score 4.32 · Achievement 4.32 · Improvement 0
Adjusted total nurse staffing
3.24
Baseline 3.30 hours · Performance 4 hours · Measure score 3.24 · Achievement 3.24 · Improvement 2.31
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.86% |
10.72%
2.1 pts worse
|
No Different than the National Rate · Eligible stays 109 · Observed rate 13.76% · Lower 95% interval 9.33% |
| Discharge to community | 66.26% |
50.57%
15.7 pts better
|
Better than the National Rate · Eligible stays 93 · Observed rate 67.74% · Lower 95% interval 57.59% |
| Medicare spending per beneficiary | 0.71 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 96.97% |
95.27%
1.7 pts better
|
Numerator 64 · Denominator 66 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 66 |
| Discharge self-care score | 35.29% |
53.69%
18.4 pts worse
|
Numerator 18 · Denominator 51 |
| Discharge mobility score | 50.98% |
50.94%
About the same
|
Numerator 26 · Denominator 51 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 66 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 7.79% |
7.12%
0.7 pts worse
|
No Different than the National Rate · Eligible stays 65 · Observed rate 7.69% · Lower 95% interval 4.1% |
| Staff COVID-19 vaccination coverage | 4.11% |
8.2%
4.1 pts worse
|
Numerator 3 · Denominator 73 |
| Staff flu vaccination coverage | 33.08% |
42%
8.9 pts worse
|
Numerator 43 · Denominator 130 |
| Discharge function score | 39.22% |
56.45%
17.2 pts worse
|
Numerator 20 · Denominator 51 |
| Transfer of health information to provider | 93.75% |
95.95%
2.2 pts worse
|
Numerator 45 · Denominator 48 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 18.42% |
25.2%
6.8 pts worse
|
Numerator 7 · Denominator 38 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.4% |
86.9%
12.5 pts better
|
93.4%
6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 97.7% · 4Q avg 99.4% |
| 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 | 0.0% |
3.2%
3.2 pts better
|
3.3%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · 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 | 9.3% |
6.5%
2.8 pts worse
|
5.4%
3.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.0% · Q2 3.7% · Q3 11.1% · Q4 14.3% · 4Q avg 9.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 27.5% |
19.9%
7.6 pts worse
|
19.6%
7.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.8% · Q2 25.9% · Q3 29.6% · Q4 24.1% · 4Q avg 27.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 12.9% |
18.7%
5.8 pts better
|
16.7%
3.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.0% · Q2 8.7% · Q3 12.5% · Q4 19.2% · 4Q avg 12.9% · 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 | 30.0% |
19.6%
10.4 pts worse
|
16.3%
13.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 30.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 21.6% |
18.3%
3.3 pts worse
|
14.9%
6.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.8% · Q2 12.5% · Q3 21.7% · Q4 30.8% · 4Q avg 21.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.0% |
0.9%
1.1 pts worse
|
1.0%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 2.1% · Q3 0.0% · Q4 2.7% · 4Q avg 2.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.8% |
1.7%
0.1 pts worse
|
1.7%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.6% · Q3 2.4% · Q4 2.3% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 34.1% |
26.4%
7.7 pts worse
|
19.8%
14.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 36.0% · Q2 35.3% · Q3 41.6% · Q4 23.2% · 4Q avg 34.1% |
| Percentage of long-stay residents with pressure ulcers | 4.5% |
5.3%
0.8 pts better
|
5.1%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.4% · Q2 3.8% · Q3 4.4% · Q4 5.4% · 4Q avg 4.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 87.4% |
68.9%
18.5 pts better
|
81.7%
5.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 89.1% · Q2 96.7% · Q3 89.1% · Q4 76.4% · 4Q avg 87.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 5.7% |
9.8%
4.1 pts better
|
12.0%
6.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 5.7% · Observed 5.3% · Expected 10.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.2% |
1.5%
0.3 pts better
|
1.6%
0.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 1.3% · Q3 1.3% · Q4 1.1% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 96.8% |
68.7%
28.1 pts better
|
79.7%
17.1 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 96.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.6% |
23.1%
1.5 pts worse
|
23.9%
0.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.6% · Observed 19.3% · Expected 18.7% · Used in QM five-star |
Survey summary
Top issue: Quality of Life and Care (4 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
6 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Top issue: Pharmacy Service (1 deficiency)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Fire safety
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-03-14
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2025-03-14
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2025-03-14
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2025-03-14
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2025-03-14
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-04-09
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-04-09
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-04-09
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2024-04-09
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-04-09
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-04-09
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-03-15
Inspection history
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2025-03-07
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-03-07
Health
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
Corrected 2025-03-07
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-03-07
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2025-03-07
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-03-07
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-03-07
Health
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Corrected 2025-03-07
Health
Provide and implement an infection prevention and control program.
Corrected 2025-03-07
Health
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
Corrected 2025-03-07
Health
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Corrected 2025-03-07
Health
Respond appropriately to all alleged violations.
Corrected 2024-03-25
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2024-03-25
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-03-25
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-03-25
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2023-04-07
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-04-07
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-04-07
Penalties and ownership
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Organization
Corporate Director · Individual
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