Cycle 1
Health 2025-11-25 · Fire 2024-12-20
5 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Pittsburgh, PA
Upmc Magee-Womens Hospital Tcu
5-star overall rating with 4-star inspections with 5 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
300 Halket Street, Pittsburgh, PA
(412) 641-3318
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
20
Certified beds
Average residents
20
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Upmc Senior Communities
Operator or chain grouping
Approved since
2005-09-16
CMS approved date
Coverage
Medicare
Participation flags
Chain footprint
8 facilities
Chain averages 3 overall / 3 health / 4 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
No
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Hospital-based
Yes
CMS reports the provider resides in a hospital
Staffing
Hours and turnover
RN hours / resident day
2.59
Registered nurse staffing · state 0.78 · national 0.68
LPN hours / resident day
1.11
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
1.67
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
5.36
All reported nurse hours · state 3.89 · national 3.89
Licensed hours
3.70
RN + LPN hours · state 1.69 · national 1.54
Weekend hours
5.13
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
1.88
Weekend registered nurse coverage · state 0.55 · national 0.47
Physical therapist
0.43
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
2.78
CMS adjusted RN staffing hours
Adjusted total hours
5.77
CMS adjusted total nurse staffing hours
Case-mix index
1.27
Higher values indicate more complex resident acuity
RN turnover
17%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
24%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
5,207
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
37.03
Composite VBP score used to determine payment impact.
Payment multiplier
0.9903
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0.67
Baseline 20.49% · Performance 21.12% · Measure score 0.67 · Achievement 0.67 · Improvement 0
Healthcare-associated infections
3.39
Baseline 4.96% · Performance 6.82% · Measure score 3.39 · Achievement 3.39 · Improvement 0
Total nurse turnover
7.11
Baseline 27.78% · Performance 34.62% · Measure score 7.11 · Achievement 7.11 · Improvement 0
Adjusted total nurse staffing
3.64
Performance 4.11 hours · Measure score 3.64 · Achievement 3.64 · This facility did not have sufficient data to calculate a baseline period measure result.
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.65% |
10.72%
1.1 pts better
|
No Different than the National Rate · Eligible stays 111 · Observed rate 6.31% · Lower 95% interval 5.84% |
| Discharge to community | 70.44% |
50.57%
19.9 pts better
|
Better than the National Rate · Eligible stays 118 · Observed rate 72.03% · Lower 95% interval 61.31% |
| Medicare spending per beneficiary | 0.69 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 61.84% |
95.27%
33.4 pts worse
|
Numerator 47 · Denominator 76 |
| Falls with major injury | 1.32% |
0.77%
0.6 pts worse
|
Numerator 1 · Denominator 76 |
| Discharge self-care score | 33.87% |
53.69%
19.8 pts worse
|
Numerator 21 · Denominator 62 |
| Discharge mobility score | 53.23% |
50.94%
2.3 pts better
|
Numerator 33 · Denominator 62 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 76 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.82% |
7.12%
0.3 pts better
|
No Different than the National Rate · Eligible stays 63 · Observed rate 4.76% · Lower 95% interval 3.63% |
| Staff COVID-19 vaccination coverage | 12.24% |
8.2%
4 pts better
|
Numerator 6 · Denominator 49 |
| Staff flu vaccination coverage | 96% |
42%
54 pts better
|
Numerator 48 · Denominator 50 |
| Discharge function score | 46.77% |
56.45%
9.7 pts worse
|
Numerator 29 · Denominator 62 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 93.33% |
96.28%
3 pts worse
|
Numerator 56 · Denominator 60 |
| Resident COVID-19 vaccinations up to date | 29.41% |
25.2%
4.2 pts better
|
Numerator 10 · Denominator 34 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.7% |
68.9%
30.8 pts better
|
81.7%
18 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 99.5% · Q3 99.5% · Q4 100.0% · 4Q avg 99.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 0.0% |
9.8%
9.8 pts better
|
12.0%
12 pts better
|
Short Stay · 20240701-20250630 · Adjusted 0.0% · Observed 0.0% · Expected 10.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.0% |
1.5%
0.5 pts better
|
1.6%
0.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.0% · Q2 0.9% · Q3 0.0% · Q4 2.0% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 90.6% |
68.7%
21.9 pts better
|
79.7%
10.9 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 90.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 31.4% |
23.1%
8.3 pts worse
|
23.9%
7.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 31.4% · Observed 25.0% · Expected 19.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-12-20 · Fire 2023-12-28
5 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cycle 3
Health 2023-12-28 · Fire 2023-02-08
0 health deficiencies
No concentrated health issue counts in this cycle.
4 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
2024-12-20
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-02-15
E · Potential for more than minimal harm
2024-12-20
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-02-15
E · Potential for more than minimal harm
2024-12-20
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-02-15
E · Potential for more than minimal harm
2024-12-20
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-02-15
D · Potential for more than minimal harm
2024-12-20
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-02-15
E · Potential for more than minimal harm
2023-12-28
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-02-16
D · Potential for more than minimal harm
2023-12-28
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-02-16
D · Potential for more than minimal harm
2023-12-28
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-02-16
D · Potential for more than minimal harm
2023-12-28
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-02-16
D · Potential for more than minimal harm
2023-12-28
K912 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2024-02-16
D · Potential for more than minimal harm
2023-12-28
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-02-16
E · Potential for more than minimal harm
2023-02-08
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2023-03-31
D · Potential for more than minimal harm
2023-02-08
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-03-31
D · Potential for more than minimal harm
2023-02-08
K912 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2023-03-31
D · Potential for more than minimal harm
2023-02-08
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-03-31
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-11-25
F887 · Infection Control Deficiencies
Health
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Corrected 2026-01-12
D · Potential for more than minimal harm
2025-11-25
F628 · Resident Rights Deficiencies
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2026-01-12
D · Potential for more than minimal harm
2025-11-25
F693 · Quality of Life and Care Deficiencies
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 2026-01-12
D · Potential for more than minimal harm
2025-11-25
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2026-01-12
C · Minimal harm
2025-11-25
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 2026-01-12
E · Potential for more than minimal harm
2024-12-20
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-01-28
D · Potential for more than minimal harm
2024-12-20
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 2025-01-28
D · Potential for more than minimal harm
2024-12-20
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2025-01-28
D · Potential for more than minimal harm
2024-12-20
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-01-28
D · Potential for more than minimal harm
2024-12-20
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2025-01-28
Penalties and ownership
What sits behind the stars
Ownership
Upmc Magee-Womens Hospital
5% Or Greater Direct Ownership Interest · Organization
Almon-Martin, Rose
Corporate Officer · Individual
Aloe, Mark
Corporate Director · Individual
Ambrose, Donetta
Corporate Director · Individual
Atkins, Michele
Corporate Director · Individual
Bajeux Besnainou, Isabelle
Corporate Director · Individual
Barbarita, Debra
Corporate Director · Individual
Beigi, Richard
Corporate Officer · Individual
Conti, Tracey
Corporate Director · Individual
Coups, Alexis
Operational/Managerial Control · Individual
Davis, Leslie
Corporate Officer · Individual
Donnellan, Nicole
Corporate Director · Individual
Edwards, Robert
Corporate Officer · Individual
Eisenbrandt, Peter
Corporate Officer · Individual
English, Dennis
Corporate Director · Individual
Gosman, Gabriella
Corporate Director · Individual
Gray, Kelly
Corporate Director · Individual
Johnson, Ronald
Corporate Officer · Individual
Joy, Margaret
Corporate Director · Individual
Lesnock, Jamie
Corporate Director · Individual
Mayle-Towns, Kathy
Corporate Director · Individual
Meehan, Sarah
Corporate Director · Individual
Petrie, Jonathan
Corporate Officer · Individual
Pietragallo, William
Corporate Director · Individual
Shekhar, Anantha
Corporate Director · Individual
Sweeney, Michael
Corporate Director · Individual
Upmc
Operational/Managerial Control · Organization
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Other facilities in reach
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2-star overall rating with 1-star inspections with Special Focus status with abuse icon flag with $184,782 in total fines with 39 recent health deficiencies with 17 fire-safety deficiencies in the latest cycle
#2
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1-star overall rating with 1-star inspections with 25 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#3
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1-star overall rating with 1-star inspections with Special Focus status with 34 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
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