Cycle 1
Health 2025-07-03 · Fire 2025-07-03
3 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Meadville, PA
Wesbury United Methodist Commu
5-star overall rating with 4-star inspections with 3 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
31 North Park Ave Ext, Meadville, PA
(814) 332-9000
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
210
Certified beds
Average residents
150
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1971-07-01
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
0.40
Registered nurse staffing · state 0.78 · national 0.68
LPN hours / resident day
1.08
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
2.14
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.61
All reported nurse hours · state 3.89 · national 3.89
Licensed hours
1.48
RN + LPN hours · state 1.69 · national 1.54
Weekend hours
3.31
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.25
Weekend registered nurse coverage · state 0.55 · national 0.47
Physical therapist
0.04
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.46
CMS adjusted RN staffing hours
Adjusted total hours
4.19
CMS adjusted total nurse staffing hours
Case-mix index
1.18
Higher values indicate more complex resident acuity
RN turnover
29%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
52%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
8,795
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
25.68
Composite VBP score used to determine payment impact.
Payment multiplier
0.9839
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.99
Baseline 18.79% · Performance 20.05% · Measure score 2.99 · Achievement 2.99 · Improvement 0
Healthcare-associated infections
0
Baseline 7.02% · Performance 7.81% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
2.53
Baseline 47.68% · Performance 53.33% · Measure score 2.53 · Achievement 2.53 · Improvement 0
Adjusted total nurse staffing
4.76
Baseline 3.73 hours · Performance 4.43 hours · Measure score 4.76 · Achievement 4.76 · Improvement 2.93
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.2% |
10.72%
0.5 pts better
|
No Different than the National Rate · Eligible stays 170 · Observed rate 8.82% · Lower 95% interval 7.07% |
| Discharge to community | 59.15% |
50.57%
8.6 pts better
|
Better than the National Rate · Eligible stays 164 · Observed rate 54.27% · Lower 95% interval 51.99% |
| Medicare spending per beneficiary | 0.88 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 27.42% |
95.27%
67.8 pts worse
|
Numerator 17 · Denominator 62 |
| Falls with major injury | 1.61% |
0.77%
0.8 pts worse
|
Numerator 1 · Denominator 62 |
| Discharge self-care score | 56.86% |
53.69%
3.2 pts better
|
Numerator 29 · Denominator 51 |
| Discharge mobility score | 60.78% |
50.94%
9.8 pts better
|
Numerator 31 · Denominator 51 |
| Pressure ulcers or injuries, new or worsened | 1.61% |
2.29%
0.7 pts better
|
Numerator 1 · Denominator 62 · Adjusted rate 2.06% |
| Healthcare-associated infections requiring hospitalization | 7.81% |
7.12%
0.7 pts worse
|
No Different than the National Rate · Eligible stays 93 · Observed rate 7.53% · Lower 95% interval 5.24% |
| Staff COVID-19 vaccination coverage | 2.12% |
8.2%
6.1 pts worse
|
Numerator 5 · Denominator 236 |
| Staff flu vaccination coverage | 24.23% |
42%
17.8 pts worse
|
Numerator 95 · Denominator 392 |
| Discharge function score | 56.86% |
56.45%
0.4 pts better
|
Numerator 29 · Denominator 51 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 45 · Denominator 45 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 24% |
25.2%
1.2 pts worse
|
Numerator 6 · Denominator 25 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.3 |
1.7
1.4 pts better
|
1.9
1.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.3 · Observed 0.2 · Expected 1.1 · 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 0.3 · Expected 1.2 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 86.0% |
86.9%
0.9 pts worse
|
93.4%
7.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 84.3% · Q2 84.3% · Q3 85.8% · Q4 89.8% · 4Q avg 86.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.8% |
93.5%
4.3 pts better
|
95.5%
2.3 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.8% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.9% |
3.2%
0.7 pts worse
|
3.3%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 3.9% · Q3 3.9% · Q4 5.5% · 4Q avg 3.9% · 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 | 11.0% |
6.5%
4.5 pts worse
|
5.4%
5.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 11.0% · Q2 15.4% · Q3 9.2% · Q4 8.2% · 4Q avg 11.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 21.9% |
19.9%
2 pts worse
|
19.6%
2.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.3% · Q2 20.9% · Q3 23.4% · Q4 24.6% · 4Q avg 21.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 25.2% |
18.7%
6.5 pts worse
|
16.7%
8.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.8% · Q2 25.3% · Q3 24.7% · Q4 25.0% · 4Q avg 25.2% · 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 | 36.9% |
19.6%
17.3 pts worse
|
16.3%
20.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 32.6% · Q2 52.3% · Q3 29.5% · Q4 33.0% · 4Q avg 36.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 26.6% |
18.3%
8.3 pts worse
|
14.9%
11.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.8% · Q2 29.6% · Q3 24.3% · Q4 31.2% · 4Q avg 26.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.9%
0.9 pts better
|
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% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.0% |
1.7%
0.7 pts better
|
1.7%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.8% · Q3 0.8% · Q4 2.4% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 29.3% |
26.4%
2.9 pts worse
|
19.8%
9.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.4% · Q2 31.5% · Q3 23.8% · Q4 36.3% · 4Q avg 29.3% |
| Percentage of long-stay residents with pressure ulcers | 3.7% |
5.3%
1.6 pts better
|
5.1%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 2.7% · Q3 5.6% · Q4 3.3% · 4Q avg 3.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 73.1% |
68.9%
4.2 pts better
|
81.7%
8.6 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 66.7% · Q2 68.2% · Q3 73.5% · Q4 78.6% · 4Q avg 73.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 4.3% |
9.8%
5.5 pts better
|
12.0%
7.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 4.3% · Observed 3.9% · Expected 10.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.5%
1.5 pts better
|
1.6%
1.6 pts better
|
Short 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 short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 65.9% |
68.7%
2.8 pts worse
|
79.7%
13.8 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 65.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 19.2% |
23.1%
3.9 pts better
|
23.9%
4.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 19.2% · Observed 17.6% · Expected 21.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-08-16 · Fire 2024-08-16
5 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
17 fire-safety deficiencies
Top issue: Egress (7 deficiencies)
Cycle 3
Health 2023-10-27 · Fire 2023-10-27
6 health deficiencies
Top issue: Resident Rights (3 deficiencies)
10 fire-safety deficiencies
Top issue: Egress (4 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-07-03
K133 · Construction Deficiencies
Fire Safety
Install a two-hour-resistant firewall separation.
Corrected 2025-07-25
F · Potential for more than minimal harm
2025-07-03
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-07-25
F · Potential for more than minimal harm
2025-07-03
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-07-25
D · Potential for more than minimal harm
2025-07-03
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2025-07-25
D · Potential for more than minimal harm
2025-07-03
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-07-25
D · Potential for more than minimal harm
2025-07-03
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-07-25
F · Potential for more than minimal harm
2024-08-16
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-10-17
F · Potential for more than minimal harm
2024-08-16
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-10-17
E · Potential for more than minimal harm
2024-08-16
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-10-17
E · Potential for more than minimal harm
2024-08-16
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-10-17
D · Potential for more than minimal harm
2024-08-16
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2024-10-17
D · Potential for more than minimal harm
2024-08-16
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-10-17
D · Potential for more than minimal harm
2024-08-16
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-10-17
D · Potential for more than minimal harm
2024-08-16
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-10-17
D · Potential for more than minimal harm
2024-08-16
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-10-17
C · Minimal harm
2024-08-16
K200 · Egress Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2024-10-17
C · Minimal harm
2024-08-16
K912 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2024-10-17
B · Minimal harm
2024-08-16
K111 · Construction Deficiencies
Fire Safety
Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy.
Corrected 2024-10-17
B · Minimal harm
2024-08-16
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2024-10-17
B · Minimal harm
2024-08-16
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 2024-10-17
B · Minimal harm
2024-08-16
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-10-17
B · Minimal harm
2024-08-16
K325 · Smoke Deficiencies
Fire Safety
Have properly installed hallway dispensers for alcohol-based hand rub.
Corrected 2024-10-17
B · Minimal harm
2024-08-16
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-10-17
F · Potential for more than minimal harm
2023-10-27
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-11-24
E · Potential for more than minimal harm
2023-10-27
K200 · Egress Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2023-11-24
E · Potential for more than minimal harm
2023-10-27
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-11-24
D · Potential for more than minimal harm
2023-10-27
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2023-11-24
D · Potential for more than minimal harm
2023-10-27
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-11-24
D · Potential for more than minimal harm
2023-10-27
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-11-24
D · Potential for more than minimal harm
2023-10-27
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-11-24
C · Minimal harm
2023-10-27
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 2023-11-24
B · Minimal harm
2023-10-27
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-11-24
B · Minimal harm
2023-10-27
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-11-24
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-07-03
F575 · Resident Rights Deficiencies
Health
Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency.
Corrected 2025-07-25
D · Potential for more than minimal harm
2025-07-03
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-07-25
D · Potential for more than minimal harm
2025-07-03
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 2025-07-25
D · Potential for more than minimal harm
2024-08-16
F657 · Resident Assessment and Care Planning Deficiencies
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 2024-09-20
D · Potential for more than minimal harm
2024-08-16
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-09-20
D · Potential for more than minimal harm
2024-08-16
F758 · Pharmacy Service Deficiencies
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 2024-09-20
D · Potential for more than minimal harm
2024-08-16
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 2024-09-20
D · Potential for more than minimal harm
2024-08-16
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-09-20
D · Potential for more than minimal harm
2023-10-27
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-11-24
D · Potential for more than minimal harm
2023-10-27
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2023-11-24
D · Potential for more than minimal harm
2023-10-27
F584 · Resident Rights Deficiencies
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 2023-11-24
D · Potential for more than minimal harm
2023-10-27
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-11-24
D · Potential for more than minimal harm
2023-10-27
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-11-24
D · Potential for more than minimal harm
2023-10-27
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 2023-11-24
Penalties and ownership
What sits behind the stars
Ownership
Becker, James
Corporate Director · Individual
Bish, Tanya
Operational/Managerial Control · Individual
Maddy, Lisa
Operational/Managerial Control · Individual
Maddy, Lisa
Corporate Officer · Individual
Mook, Lyle
Corporate Director · Individual
Nageotte, Brian
Corporate Officer · Individual
Reyer, Ron
Corporate Director · Individual
Spence, Debora
Corporate Director · Individual
Stevenson, Alishia
Operational/Managerial Control · Individual
Swick, John
Corporate Director · Individual
Thomas, Susan
Corporate Director · Individual
Waid, Robert
Corporate Director · Individual
Weindorf, Mark
Corporate Director · Individual
Zerbe, Christopher
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Meadville Medical Ctr Tcu
Meadville, PA
5-star overall rating with 4-star inspections with $7,172 in total fines with 4 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
Embassy Of Park Avenue
Meadville, PA
5-star overall rating with 4-star inspections with 4 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Crawford Care Center
Saegertown, PA
1-star overall rating with 2-star inspections with $158,696 in total fines with 10 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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