9 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
2 fire-safety deficiencies
Top issue: Construction (1 deficiency)
Montoursville, PA
4-star overall rating with 3-star inspections with $11,788 in total fines with 9 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
2140 Warrensville Road, Montoursville, PA
(570) 433-3161
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Beds
163
Certified beds
Average residents
130
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1993-04-21
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
0.66
Registered nurse staffing · state 0.78 · national 0.68
LPN hours / resident day
1.20
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
2.67
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
4.53
All reported nurse hours · state 3.89 · national 3.89
Licensed hours
1.86
RN + LPN hours · state 1.69 · national 1.54
Weekend hours
4.12
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.48
Weekend registered nurse coverage · state 0.55 · national 0.47
Physical therapist
0.09
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.73
CMS adjusted RN staffing hours
Adjusted total hours
5.00
CMS adjusted total nurse staffing hours
Case-mix index
1.24
Higher values indicate more complex resident acuity
RN turnover
17%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
17%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Program rank
2,241
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
50.75
Composite VBP score used to determine payment impact.
Payment multiplier
1.0050
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
0
Baseline 19.33% · Performance 23.43% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
5.28
Baseline 4.90% · Performance 6.26% · Measure score 5.28 · Achievement 5.28 · Improvement 0
Total nurse turnover
10
Baseline 28.23% · Performance 22.73% · Measure score 10 · Achievement 10 · Improvement 9
Adjusted total nurse staffing
5.02
Baseline 4.14 hours · Performance 4.51 hours · Measure score 5.02 · Achievement 5.02 · Improvement 1.73
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.13% |
10.72%
1.4 pts worse
|
No Different than the National Rate · Eligible stays 220 · Observed rate 12.27% · Lower 95% interval 9.23% |
| Discharge to community | 38.16% |
50.57%
12.4 pts worse
|
Worse than the National Rate · Eligible stays 211 · Observed rate 31.75% · Lower 95% interval 29.74% |
| Medicare spending per beneficiary | 0.82 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 99.17% |
95.27%
3.9 pts better
|
Numerator 120 · Denominator 121 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 121 |
| Discharge self-care score | 62.86% |
53.69%
9.2 pts better
|
Numerator 66 · Denominator 105 |
| Discharge mobility score | 59.05% |
50.94%
8.1 pts better
|
Numerator 62 · Denominator 105 |
| Pressure ulcers or injuries, new or worsened | 1.65% |
2.29%
0.6 pts better
|
Numerator 2 · Denominator 121 · Adjusted rate 1.67% |
| Healthcare-associated infections requiring hospitalization | 6.26% |
7.12%
0.9 pts better
|
No Different than the National Rate · Eligible stays 123 · Observed rate 4.88% · Lower 95% interval 3.93% |
| Staff COVID-19 vaccination coverage | 2.55% |
8.2%
5.6 pts worse
|
Numerator 5 · Denominator 196 |
| Staff flu vaccination coverage | 87.5% |
42%
45.5 pts better
|
Numerator 189 · Denominator 216 |
| Discharge function score | 65.71% |
56.45%
9.3 pts better
|
Numerator 69 · Denominator 105 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 59 · Denominator 59 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 22 · Denominator 22 |
| Resident COVID-19 vaccinations up to date | 18.57% |
25.2%
6.6 pts worse
|
Numerator 13 · Denominator 70 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.7 |
1.7
About the same
|
1.9
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 1.3 · Expected 1.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.8 |
1.2
0.4 pts better
|
1.8
1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.8 · Observed 0.6 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.1% |
86.9%
12.2 pts better
|
93.4%
5.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 99.2% · Q2 97.3% · Q3 100.0% · Q4 100.0% · 4Q avg 99.1% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 99.2% |
93.5%
5.7 pts better
|
95.5%
3.7 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 99.2% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.8% |
3.2%
0.6 pts worse
|
3.3%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.8% · Q2 3.6% · Q3 3.3% · Q4 2.6% · 4Q avg 3.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.4% |
6.5%
5.1 pts better
|
11.4%
10 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 0.0% · Q3 3.6% · Q4 0.0% · 4Q avg 1.4% |
| Percentage of long-stay residents who lose too much weight | 6.4% |
6.5%
0.1 pts better
|
5.4%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 11.3% · Q3 7.0% · Q4 2.9% · 4Q avg 6.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 21.5% |
19.9%
1.6 pts worse
|
19.6%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.1% · Q2 21.1% · Q3 19.3% · Q4 21.3% · 4Q avg 21.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 30.4% |
18.7%
11.7 pts worse
|
16.7%
13.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.7% · Q2 30.8% · Q3 32.6% · Q4 33.7% · 4Q avg 30.4% · 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 | 18.0% |
19.6%
1.6 pts better
|
16.3%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.7% · Q2 13.0% · Q3 17.8% · Q4 21.9% · 4Q avg 18.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 29.5% |
18.3%
11.2 pts worse
|
14.9%
14.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.2% · Q2 18.6% · Q3 30.7% · Q4 38.7% · 4Q avg 29.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.4% |
0.9%
1.5 pts worse
|
1.0%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 3.4% · Q3 2.2% · Q4 1.6% · 4Q avg 2.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.7% |
1.7%
1 pts better
|
1.7%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.7% · Q4 0.9% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 29.4% |
26.4%
3 pts worse
|
19.8%
9.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.9% · Q2 29.7% · Q3 28.0% · Q4 28.9% · 4Q avg 29.4% |
| Percentage of long-stay residents with pressure ulcers | 5.1% |
5.3%
0.2 pts better
|
5.1%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 5.3% · Q2 4.9% · Q3 3.2% · Q4 7.1% · 4Q avg 5.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 95.1% |
68.9%
26.2 pts better
|
81.7%
13.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 90.1% · Q2 95.6% · Q3 98.1% · Q4 96.0% · 4Q avg 95.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.3% |
9.8%
1.5 pts better
|
12.0%
3.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.3% · Observed 8.5% · Expected 11.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.8% |
1.5%
0.7 pts better
|
1.6%
0.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 1.4% · Q3 0.0% · Q4 0.0% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 75.7% |
68.7%
7 pts better
|
79.7%
4 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 75.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 14.2% |
23.1%
8.9 pts better
|
23.9%
9.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 14.2% · Observed 16.0% · Expected 27.0% · Used in QM five-star |
Survey summary
Top issue: Quality of Life and Care (4 deficiencies)
2 fire-safety deficiencies
Top issue: Construction (1 deficiency)
Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)
4 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Top issue: Quality of Life and Care (3 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire Safety
Use approved construction type or materials.
Corrected 2025-06-02
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-06-02
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-07-08
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-07-08
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 2024-07-08
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-07-08
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2023-08-04
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2023-08-04
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2023-08-04
Inspection history
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Not marked corrected
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-06-30
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 2025-06-30
Health
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Corrected 2025-06-30
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2025-06-30
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2025-06-30
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2025-06-30
Health
Provide or obtain dental services for each resident.
Corrected 2025-06-30
Health
Provide and implement an infection prevention and control program.
Corrected 2025-06-30
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-08-09
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-08-09
Health
Have policies and procedures ensuring the administrator's responsibilities for facility closure are completed successfully.
Corrected 2024-08-09
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 2024-08-09
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-08-09
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2024-08-09
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-08-09
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2024-08-09
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-08-09
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-08-09
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2024-08-09
Health
Provide and implement an infection prevention and control program.
Corrected 2024-08-09
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2024-07-12
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2023-12-15
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-08-25
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2023-08-25
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-08-25
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 2023-08-25
Penalties and ownership
Fine · fine $11,788
Fine
Operational/Managerial Control · Individual
Corporate Director · Individual
Operational/Managerial Control · Individual
Corporate Director · Individual
Operational/Managerial Control · Individual
Corporate Director · Individual
Operational/Managerial Control · Individual
Corporate Officer · Individual
Operational/Managerial Control · Individual
Corporate Officer · Individual
Operational/Managerial Control · Individual
Corporate Officer · Individual
Corporate Director · Individual
Operational/Managerial Control · Individual
Corporate Director · Individual
Operational/Managerial Control · Individual
Corporate Director · Individual
Operational/Managerial Control · Individual
Corporate Officer · Individual
Operational/Managerial Control · Individual
Corporate Director · Individual
Operational/Managerial Control · Individual
Corporate Director · Individual
Nearby options
Montoursville, PA
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Williamsport, PA
2-star overall rating with 2-star inspections with $305,250 in total fines with 15 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
Williamsport, PA
1-star overall rating with 1-star inspections with $10,824 in total fines with 18 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
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