Cycle 1
Health 2025-05-16 · Fire 2025-05-16
6 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Pittsburgh, PA
Whitehall Borough Post Acute
3-star overall rating with 3-star inspections with 6 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
505 Weyman Road, Pittsburgh, PA
(412) 884-3500
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
166
Certified beds
Average residents
136
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Pacs Group
Operator or chain grouping
Approved since
1999-09-23
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
264 facilities
Chain averages 3 overall / 3 health / 2 staffing / 4 quality stars
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
0.94
Registered nurse staffing · state 0.78 · national 0.68
LPN hours / resident day
0.58
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
1.94
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.45
All reported nurse hours · state 3.89 · national 3.89
Licensed hours
1.52
RN + LPN hours · state 1.69 · national 1.54
Weekend hours
3.27
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.76
Weekend registered nurse coverage · state 0.55 · national 0.47
Physical therapist
0.15
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.80
CMS adjusted RN staffing hours
Adjusted total hours
2.94
CMS adjusted total nurse staffing hours
Case-mix index
1.61
Higher values indicate more complex resident acuity
RN turnover
42%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
58%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
13,005
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
9.06
Composite VBP score used to determine payment impact.
Payment multiplier
0.9808
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 21.00% · Performance 22.87% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 4.36% · Performance 8.26% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
2.73
Baseline 44.76% · Performance 52.53% · Measure score 2.73 · Achievement 2.73 · Improvement 0
Adjusted total nurse staffing
0.90
Baseline 3.59 hours · Performance 3.33 hours · Measure score 0.90 · Achievement 0.90 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.38% |
10.72%
0.7 pts worse
|
No Different than the National Rate · Eligible stays 267 · Observed rate 11.61% · Lower 95% interval 8.14% |
| Discharge to community | 48.34% |
50.57%
2.2 pts worse
|
No Different than the National Rate · Eligible stays 274 · Observed rate 43.43% · Lower 95% interval 43.09% |
| Medicare spending per beneficiary | 0.88 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 93.25% |
95.27%
2 pts worse
|
Numerator 152 · Denominator 163 |
| Falls with major injury | 1.23% |
0.77%
0.5 pts worse
|
Numerator 2 · Denominator 162 |
| Discharge self-care score | 41.53% |
53.69%
12.2 pts worse
|
Numerator 49 · Denominator 118 |
| Discharge mobility score | 52.54% |
50.94%
1.6 pts better
|
Numerator 62 · Denominator 118 |
| Pressure ulcers or injuries, new or worsened | 1.88% |
2.29%
0.4 pts better
|
Numerator 3 · Denominator 160 · Adjusted rate 2.24% |
| Healthcare-associated infections requiring hospitalization | 8.26% |
7.12%
1.1 pts worse
|
No Different than the National Rate · Eligible stays 177 · Observed rate 9.04% · Lower 95% interval 4.57% |
| Staff COVID-19 vaccination coverage | 1.3% |
8.2%
6.9 pts worse
|
Numerator 3 · Denominator 231 |
| Staff flu vaccination coverage | 46.06% |
42%
4.1 pts better
|
Numerator 111 · Denominator 241 |
| Discharge function score | 44.07% |
56.45%
12.4 pts worse
|
Numerator 52 · Denominator 118 |
| Transfer of health information to provider | 98.39% |
95.95%
2.4 pts better
|
Numerator 61 · Denominator 62 |
| Transfer of health information to patient | 98.9% |
96.28%
2.6 pts better
|
Numerator 90 · Denominator 91 |
| Resident COVID-19 vaccinations up to date | 22.37% |
25.2%
2.8 pts worse
|
Numerator 17 · Denominator 76 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 90.3% |
86.9%
3.4 pts better
|
93.4%
3.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 80.4% · Q2 91.8% · Q3 94.7% · Q4 94.8% · 4Q avg 90.3% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 94.4% |
93.5%
0.9 pts better
|
95.5%
1.1 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 94.4% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.6% |
3.2%
0.6 pts better
|
3.3%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.9% · Q2 2.0% · Q3 2.1% · Q4 1.0% · 4Q avg 2.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 22.2% |
6.5%
15.7 pts worse
|
11.4%
10.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 13.1% · Q3 16.5% · Q4 59.3% · 4Q avg 22.2% |
| Percentage of long-stay residents who lose too much weight | 1.2% |
6.5%
5.3 pts better
|
5.4%
4.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 2.6% · Q3 0.0% · Q4 0.0% · 4Q avg 1.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 16.2% |
19.9%
3.7 pts better
|
19.6%
3.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.3% · Q2 16.7% · Q3 16.9% · Q4 12.7% · 4Q avg 16.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 10.5% |
18.7%
8.2 pts better
|
16.7%
6.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.5% · Q2 8.9% · Q3 10.9% · Q4 11.4% · 4Q avg 10.5% · 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 | 30.7% |
19.6%
11.1 pts worse
|
16.3%
14.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 47.4% · Q2 35.9% · Q3 15.7% · Q4 18.4% · 4Q avg 30.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 22.7% |
18.3%
4.4 pts worse
|
14.9%
7.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 33.0% · Q2 15.3% · Q3 13.9% · Q4 25.7% · 4Q avg 22.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.5% |
0.9%
0.4 pts better
|
1.0%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.9% · Q2 1.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% · 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 2.0% · Q2 0.0% · Q3 1.1% · Q4 1.0% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 20.3% |
26.4%
6.1 pts better
|
19.8%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.9% · Q2 31.1% · Q3 9.9% · Q4 12.2% · 4Q avg 20.3% |
| Percentage of long-stay residents with pressure ulcers | 3.6% |
5.3%
1.7 pts better
|
5.1%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.1% · Q2 4.4% · Q3 4.3% · Q4 1.7% · 4Q avg 3.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 73.5% |
68.9%
4.6 pts better
|
81.7%
8.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 46.6% · Q2 69.0% · Q3 89.5% · Q4 96.6% · 4Q avg 73.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.4% |
9.8%
0.4 pts better
|
12.0%
2.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.4% · Observed 9.0% · Expected 10.7% · 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 2.4% · Q2 1.5% · Q3 0.4% · Q4 0.0% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 69.3% |
68.7%
0.6 pts better
|
79.7%
10.4 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 69.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 28.5% |
23.1%
5.4 pts worse
|
23.9%
4.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 28.5% · Observed 26.9% · Expected 22.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-05-09 · Fire 2024-05-09
18 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (4 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2023-05-05 · Fire 2023-05-05
8 health deficiencies
Top issue: Resident Rights (3 deficiencies)
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
2025-05-16
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2025-06-03
D · Potential for more than minimal harm
2024-05-09
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-05-28
D · Potential for more than minimal harm
2024-05-09
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-05-28
E · Potential for more than minimal harm
2023-05-05
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-06-12
D · Potential for more than minimal harm
2023-05-05
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-06-12
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-09-05
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-10-20
E · Potential for more than minimal harm
2025-05-16
F628 · Resident Rights Deficiencies
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2025-06-10
E · Potential for more than minimal harm
2025-05-16
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-06-10
E · Potential for more than minimal harm
2025-05-16
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 2025-06-10
D · Potential for more than minimal harm
2025-05-16
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2025-06-10
D · Potential for more than minimal harm
2025-05-16
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-06-10
D · Potential for more than minimal harm
2025-02-20
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 2025-04-01
E · Potential for more than minimal harm
2024-12-12
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 2025-01-08
D · Potential for more than minimal harm
2024-12-12
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2025-01-08
D · Potential for more than minimal harm
2024-12-12
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-01-08
F · Potential for more than minimal harm
2024-09-09
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 2024-10-08
E · Potential for more than minimal harm
2024-09-09
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2024-10-08
D · Potential for more than minimal harm
2024-06-13
F603 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).
Corrected 2024-07-01
D · Potential for more than minimal harm
2024-06-13
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2024-07-01
E · Potential for more than minimal harm
2024-05-09
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-06-18
E · Potential for more than minimal harm
2024-05-09
F636 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2024-06-18
E · Potential for more than minimal harm
2024-05-09
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2024-06-18
E · Potential for more than minimal harm
2024-05-09
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-06-18
E · Potential for more than minimal harm
2024-05-09
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2024-06-18
D · Potential for more than minimal harm
2024-05-09
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2024-06-18
D · Potential for more than minimal harm
2024-05-09
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-06-18
B · Minimal harm
2024-05-09
F944 · Administration Deficiencies
Health
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
Corrected 2024-06-18
B · Minimal harm
2024-05-09
F947 · Nursing and Physician Services Deficiencies
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 2024-06-18
E · Potential for more than minimal harm
2024-04-08
F836 · Administration Deficiencies
Health
Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards.
Corrected 2024-05-16
D · Potential for more than minimal harm
2023-12-19
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-02-01
D · Potential for more than minimal harm
2023-12-19
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2024-02-01
E · Potential for more than minimal harm
2023-10-05
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2023-11-10
D · Potential for more than minimal harm
2023-05-05
F557 · Resident Rights Deficiencies
Health
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Corrected 2023-06-12
D · Potential for more than minimal harm
2023-05-05
F676 · Quality of Life and Care Deficiencies
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2023-06-12
D · Potential for more than minimal harm
2023-05-05
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 2023-06-12
D · Potential for more than minimal harm
2023-05-05
F825 · Quality of Life and Care Deficiencies
Health
Provide or get specialized rehabilitative services as required for a resident.
Corrected 2023-06-12
D · Potential for more than minimal harm
2023-05-05
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-06-12
Penalties and ownership
What sits behind the stars
Ownership
Providence Group Nh, LLC
5% Or Greater Direct Ownership Interest · Organization
Apt, Frederick
Operational/Managerial Control · Individual
Apt, Frederick
Corporate Officer · Individual
Hancock, Mark
5% Or Greater Indirect Ownership Interest · Individual
Jergensen, Joshua
Operational/Managerial Control · Individual
Jergensen, Joshua
Corporate Officer · Individual
Mitchell, John
Operational/Managerial Control · Individual
Mitchell, John
Corporate Officer · Individual
Murray, Jason
5% Or Greater Indirect Ownership Interest · Individual
Pacs Group, Inc.
5% Or Greater Indirect Ownership Interest · Organization
Pacs Group, Inc.
Operational/Managerial Control · Organization
Pacs Holdings, LLC
5% Or Greater Indirect Ownership Interest · Organization
Pacs Holdings, LLC
Operational/Managerial Control · Organization
Providence Group Nh, LLC
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
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2-star overall rating with 1-star inspections with abuse icon flag with $283,966 in total fines with 8 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
South Hills Post Acute
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3-star overall rating with 3-star inspections with 10 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#3
Wecare At Mt Lebanon Rehabilitation And Nrsg Ctr
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2-star overall rating with 1-star inspections with 26 recent health deficiencies
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