Oakmont, PA

Willows Of Presbyterian Senior

1-star overall rating with 1-star inspections with abuse icon flag with $57,886 in total fines with 21 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle

1215 Hulton Road, Oakmont, PA

(412) 828-5600

Compare this facility

Overall

1 / 5

CMS overall stars

Health inspections

1 / 5

Survey and complaint cycles

Staffing

4 / 5

RN + nurse staffing

Quality measures

3 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

193

Certified beds

Average residents

169

Average occupied residents

Ownership

Non-Profit

Publicly displayed owner type

Chain

Presbyterian Seniorcare Network

Operator or chain grouping

Approved since

1986-01-07

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

5 facilities

Chain averages 4 overall / 3 health / 5 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

0.71

Registered nurse staffing · state 0.78 · national 0.68

LPN hours / resident day

0.82

Licensed practical nurse staffing · state 0.91 · national 0.87

Aide hours / resident day

2.57

Nurse aide staffing · state 2.20 · national 2.35

Total nurse hours

4.10

All reported nurse hours · state 3.89 · national 3.89

Licensed hours

1.53

RN + LPN hours · state 1.69 · national 1.54

Weekend hours

3.61

Weekend nurse staffing · state 3.51 · national 3.43

Weekend RN hours

0.50

Weekend registered nurse coverage · state 0.55 · national 0.47

Physical therapist

0.07

Reported PT staffing · state 0.10 · national 0.07

Adjusted RN hours

0.72

CMS adjusted RN staffing hours

Adjusted total hours

4.14

CMS adjusted total nurse staffing hours

Case-mix index

1.35

Higher values indicate more complex resident acuity

RN turnover

46%

Annual RN turnover · state 43% · national 45%

Total nurse turnover

47%

Annual nurse turnover · state 47% · national 46%

SNF VBP

Value-based purchasing

Program rank

2,833

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

47.46

Composite VBP score used to determine payment impact.

Payment multiplier

1.0010

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

7.89

Baseline 21.92% · Performance 17.82% · Measure score 7.89 · Achievement 7.80 · Improvement 7.89

Healthcare-associated infections

6.73

Baseline 7.27% · Performance 5.82% · Measure score 6.73 · Achievement 6.73 · Improvement 5.87

Total nurse turnover

2.49

Baseline 49.46% · Performance 53.49% · Measure score 2.49 · Achievement 2.49 · Improvement 0

Adjusted total nurse staffing

1.87

Baseline 3.62 hours · Performance 3.61 hours · Measure score 1.87 · Achievement 1.87 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure Facility National Note
Potentially preventable 30-day readmission 9.2%
10.72%
1.5 pts better
No Different than the National Rate · Eligible stays 150 · Observed rate 6% · Lower 95% interval 6.21%
Discharge to community 48.49%
50.57%
2.1 pts worse
No Different than the National Rate · Eligible stays 122 · Observed rate 44.26% · Lower 95% interval 41.22%
Medicare spending per beneficiary 0.68
1.02
0.3 pts better
Drug regimen review with follow-up 100%
95.27%
4.7 pts better
Numerator 108 · Denominator 108
Falls with major injury 0%
0.77%
0.8 pts better
Numerator 0 · Denominator 108
Discharge self-care score 58.06%
53.69%
4.4 pts better
Numerator 54 · Denominator 93
Discharge mobility score 45.16%
50.94%
5.8 pts worse
Numerator 42 · Denominator 93
Pressure ulcers or injuries, new or worsened 2.78%
2.29%
0.5 pts worse
Numerator 3 · Denominator 108 · Adjusted rate 2.8%
Healthcare-associated infections requiring hospitalization 5.82%
7.12%
1.3 pts better
No Different than the National Rate · Eligible stays 110 · Observed rate 3.64% · Lower 95% interval 3.38%
Staff COVID-19 vaccination coverage 0%
8.2%
8.2 pts worse
Numerator 0 · Denominator 482
Staff flu vaccination coverage 60.09%
42%
18.1 pts better
Numerator 128 · Denominator 213
Discharge function score 64.52%
56.45%
8.1 pts better
Numerator 60 · Denominator 93
Transfer of health information to provider Not Available
95.95%
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly.
Transfer of health information to patient 100%
96.28%
3.7 pts better
Numerator 69 · Denominator 69
Resident COVID-19 vaccinations up to date 27.27%
25.2%
2.1 pts better
Numerator 15 · Denominator 55

Quality measures

Resident outcomes and process scores

Measure Facility State National Note
Number of hospitalizations per 1000 long-stay resident days 1.5
1.7
0.2 pts better
1.9
0.4 pts better
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.1 · Expected 1.4 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days 0.7
1.2
0.5 pts better
1.8
1.1 pts better
Long Stay · 20240701-20250630 · Adjusted 0.7 · Observed 0.6 · Expected 1.3 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine 91.6%
86.9%
4.7 pts better
93.4%
1.8 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 93.3% · Q2 90.9% · Q3 90.4% · Q4 91.7% · 4Q avg 91.6%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine 86.5%
93.5%
7 pts worse
95.5%
9 pts worse
Long Stay · 2024Q3-2025Q2 · 4Q avg 86.5%
Percentage of long-stay residents experiencing one or more falls with major injury 4.3%
3.2%
1.1 pts worse
3.3%
1 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 3.8% · Q3 4.0% · Q4 5.0% · 4Q avg 4.3% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms 11.4%
6.5%
4.9 pts worse
11.4%
About the same
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 8.1% · Q3 20.9% · Q4 18.1% · 4Q avg 11.4%
Percentage of long-stay residents who lose too much weight 7.0%
6.5%
0.5 pts worse
5.4%
1.6 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 3.9% · Q2 9.3% · Q3 8.5% · Q4 5.9% · 4Q avg 7.0%
Percentage of long-stay residents who received an antianxiety or hypnotic medication 17.4%
19.9%
2.5 pts better
19.6%
2.2 pts better
Long Stay · 2024Q4-2025Q3 · Q1 18.7% · Q2 17.8% · Q3 16.7% · Q4 16.5% · 4Q avg 17.4%
Percentage of long-stay residents who received an antipsychotic medication 16.6%
18.7%
2.1 pts better
16.7%
0.1 pts better
Long Stay · 2024Q4-2025Q3 · Q1 18.7% · Q2 17.4% · Q3 16.3% · Q4 13.8% · 4Q avg 16.6% · 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 40.0%
19.6%
20.4 pts worse
16.3%
23.7 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 54.0% · Q2 24.2% · Q3 38.8% · Q4 42.4% · 4Q avg 40.0% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased 26.8%
18.3%
8.5 pts worse
14.9%
11.9 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 33.7% · Q2 23.0% · Q3 22.5% · Q4 28.0% · 4Q avg 26.8% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder 1.2%
0.9%
0.3 pts worse
1.0%
0.2 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 0.7% · Q2 2.5% · Q3 1.3% · Q4 0.0% · 4Q avg 1.2% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection 2.6%
1.7%
0.9 pts worse
1.7%
0.9 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 2.3% · Q3 1.6% · Q4 4.2% · 4Q avg 2.6% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence 32.8%
26.4%
6.4 pts worse
19.8%
13 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 32.0% · Q2 34.1% · Q3 34.0% · Q4 30.9% · 4Q avg 32.8%
Percentage of long-stay residents with pressure ulcers 2.7%
5.3%
2.6 pts better
5.1%
2.4 pts better
Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 1.4% · Q3 3.1% · Q4 3.8% · 4Q avg 2.7% · 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 84.2% · Q2 83.9% · Q3 89.3% · Q4 90.9% · 4Q avg 87.4%
Percentage of short-stay residents who had an outpatient emergency department visit 10.0%
9.8%
0.2 pts worse
12.0%
2 pts better
Short Stay · 20240701-20250630 · Adjusted 10.0% · Observed 9.2% · Expected 10.3% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication 1.4%
1.5%
0.1 pts better
1.6%
0.2 pts better
Short Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 1.4% · Q3 0.9% · Q4 1.7% · 4Q avg 1.4% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine 87.2%
68.7%
18.5 pts better
79.7%
7.5 pts better
Short Stay · 2024Q3-2025Q2 · 4Q avg 87.2%
Percentage of short-stay residents who were rehospitalized after a nursing home admission 20.2%
23.1%
2.9 pts better
23.9%
3.7 pts better
Short Stay · 20240701-20250630 · Adjusted 20.2% · Observed 16.7% · Expected 19.6% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-12-02 · Fire 2025-12-02

21 health deficiencies

Top issue: Quality of Life and Care (7 deficiencies)

10 fire-safety deficiencies

Top issue: Smoke (5 deficiencies)

Cycle 2 Health 2024-11-22 · Fire 2024-11-22

18 health deficiencies

Top issue: Quality of Life and Care (6 deficiencies)

5 fire-safety deficiencies

Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)

Cycle 3 Health 2023-11-20 · Fire 2023-11-20

17 health deficiencies

Top issue: Quality of Life and Care (5 deficiencies)

6 fire-safety deficiencies

Top issue: Smoke (5 deficiencies)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2025-12-02

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2025-11-13

E · Potential for more than minimal harm 2025-12-02

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2025-11-13

E · Potential for more than minimal harm 2025-12-02

K374 · Smoke Deficiencies

Fire Safety

Install smoke barrier doors that can resist smoke for at least 20 minutes.

Corrected 2025-11-13

D · Potential for more than minimal harm 2025-12-02

K225 · Egress Deficiencies

Fire Safety

Have stairways and smokeproof enclosures used as exits that meet safety requirements.

Corrected 2025-11-13

D · Potential for more than minimal harm 2025-12-02

K321 · Smoke Deficiencies

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 2025-11-13

D · Potential for more than minimal harm 2025-12-02

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2025-11-13

C · Minimal harm 2025-12-02

E36 · Emergency Preparedness Deficiencies

Fire Safety

Establish emergency prep training and testing.

Corrected 2025-11-13

C · Minimal harm 2025-12-02

E6 · Emergency Preparedness Deficiencies

Fire Safety

Conduct risk assessment and an All-Hazards approach.

Corrected 2025-11-13

C · Minimal harm 2025-12-02

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2025-11-13

C · Minimal harm 2025-12-02

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2025-11-13

E · Potential for more than minimal harm 2024-11-22

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2025-01-02

D · Potential for more than minimal harm 2024-11-22

K374 · Smoke Deficiencies

Fire Safety

Install smoke barrier doors that can resist smoke for at least 20 minutes.

Corrected 2025-01-02

D · Potential for more than minimal harm 2024-11-22

K521 · Services Deficiencies

Fire Safety

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Corrected 2025-01-02

D · Potential for more than minimal harm 2024-11-22

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2025-01-02

D · Potential for more than minimal harm 2024-11-22

K923 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have proper medical gas storage and administration areas.

Corrected 2025-01-02

E · Potential for more than minimal harm 2023-11-20

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2024-01-11

D · Potential for more than minimal harm 2023-11-20

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2024-01-11

D · Potential for more than minimal harm 2023-11-20

K372 · Smoke Deficiencies

Fire Safety

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Corrected 2024-01-11

D · Potential for more than minimal harm 2023-11-20

K374 · Smoke Deficiencies

Fire Safety

Install smoke barrier doors that can resist smoke for at least 20 minutes.

Corrected 2024-01-11

C · Minimal harm 2023-11-20

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2024-01-11

C · Minimal harm 2023-11-20

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2024-01-11

Inspection history

Recent health citations

F · Potential for more than minimal harm 2025-12-02

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 2025-12-03

E · Potential for more than minimal harm 2025-12-02

F583 · Resident Rights Deficiencies

Health

Keep residents' personal and medical records private and confidential.

Corrected 2025-12-03

E · Potential for more than minimal harm 2025-12-02

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 2025-12-03

E · Potential for more than minimal harm 2025-12-02

F628 · Resident Rights Deficiencies

Health

Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.

Corrected 2025-12-03

E · Potential for more than minimal harm 2025-12-02

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 2025-12-03

E · Potential for more than minimal harm 2025-12-02

F638 · Resident Assessment and Care Planning Deficiencies

Health

Assure that each resident’s assessment is updated at least once every 3 months.

Corrected 2025-12-03

E · Potential for more than minimal harm 2025-12-02

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2025-12-03

E · Potential for more than minimal harm 2025-12-02

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-12-03

D · Potential for more than minimal harm 2025-12-02

F554 · Resident Rights Deficiencies

Health

Allow residents to self-administer drugs if determined clinically appropriate.

Corrected 2025-12-03

D · Potential for more than minimal harm 2025-12-02

F558 · Resident Rights Deficiencies

Health

Reasonably accommodate the needs and preferences of each resident.

Corrected 2025-12-03

D · Potential for more than minimal harm 2025-12-02

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2025-12-03

D · Potential for more than minimal harm 2025-12-02

F688 · Quality of Life and Care Deficiencies

Health

Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

Corrected 2025-12-03

D · Potential for more than minimal harm 2025-12-02

F694 · Quality of Life and Care Deficiencies

Health

Provide for the safe, appropriate administration of IV fluids for a resident when needed.

Corrected 2025-12-03

D · Potential for more than minimal harm 2025-12-02

F755 · Pharmacy Service Deficiencies

Health

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Corrected 2025-12-03

D · Potential for more than minimal harm 2025-12-02

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 2025-12-03

H · Actual harm 2025-10-15

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 2025-11-18

H · Actual harm 2025-10-15

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 2025-11-18

J · Immediate jeopardy 2025-05-23

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 2025-06-20

E · Potential for more than minimal harm 2025-05-23

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 2025-06-20

D · Potential for more than minimal harm 2025-05-23

F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Corrected 2025-06-20

G · Actual harm 2025-05-08

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 2025-05-29

E · Potential for more than minimal harm 2024-11-22

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 2025-01-02

E · Potential for more than minimal harm 2024-11-22

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2025-01-02

D · Potential for more than minimal harm 2024-11-22

F554 · Resident Rights Deficiencies

Health

Allow residents to self-administer drugs if determined clinically appropriate.

Corrected 2025-01-02

D · Potential for more than minimal harm 2024-11-22

F638 · Resident Assessment and Care Planning Deficiencies

Health

Assure that each resident’s assessment is updated at least once every 3 months.

Corrected 2025-01-02

D · Potential for more than minimal harm 2024-11-22

F641 · Resident Assessment and Care Planning Deficiencies

Health

Ensure each resident receives an accurate assessment.

Corrected 2025-01-02

D · Potential for more than minimal harm 2024-11-22

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 2025-01-02

D · Potential for more than minimal harm 2024-11-22

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 2025-01-02

D · Potential for more than minimal harm 2024-11-22

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2025-01-02

D · Potential for more than minimal harm 2024-11-22

F686 · Quality of Life and Care Deficiencies

Health

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected 2025-01-02

D · Potential for more than minimal harm 2024-11-22

F688 · Quality of Life and Care Deficiencies

Health

Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

Corrected 2025-01-02

D · Potential for more than minimal harm 2024-11-22

F728 · Nursing and Physician Services Deficiencies

Health

Ensure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training.

Corrected 2025-01-02

D · Potential for more than minimal harm 2024-11-22

F744 · Quality of Life and Care Deficiencies

Health

Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

Corrected 2025-01-02

D · Potential for more than minimal harm 2024-11-22

F808 · Nutrition and Dietary Deficiencies

Health

Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.

Corrected 2025-01-02

D · Potential for more than minimal harm 2024-11-22

F810 · Nutrition and Dietary Deficiencies

Health

Provide special eating equipment and utensils for residents who need them and appropriate assistance.

Corrected 2025-01-02

C · Minimal harm 2024-11-22

F625 · Resident Rights Deficiencies

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 2025-01-02

D · Potential for more than minimal harm 2024-07-09

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 2024-07-03

D · Potential for more than minimal harm 2024-03-20

F800 · Nutrition and Dietary Deficiencies

Health

Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.

Corrected 2024-04-22

D · Potential for more than minimal harm 2024-03-20

F842 · Resident Assessment and Care Planning Deficiencies

Health

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Corrected 2024-04-22

F · Potential for more than minimal harm 2023-11-20

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 2024-01-01

F · Potential for more than minimal harm 2023-11-20

F814 · Nutrition and Dietary Deficiencies

Health

Dispose of garbage and refuse properly.

Corrected 2024-01-01

E · Potential for more than minimal harm 2023-11-20

F801 · Nutrition and Dietary Deficiencies

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 2024-01-01

D · Potential for more than minimal harm 2023-11-20

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 2024-01-01

D · Potential for more than minimal harm 2023-11-20

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 2024-01-01

D · Potential for more than minimal harm 2023-11-20

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 2024-01-01

D · Potential for more than minimal harm 2023-11-20

F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Corrected 2024-01-01

D · Potential for more than minimal harm 2023-11-20

F637 · Resident Assessment and Care Planning Deficiencies

Health

Assess the resident when there is a significant change in condition

Corrected 2024-01-01

D · Potential for more than minimal harm 2023-11-20

F656 · Resident Assessment and Care Planning Deficiencies

Health

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Corrected 2024-01-01

D · Potential for more than minimal harm 2023-11-20

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2024-01-01

D · Potential for more than minimal harm 2023-11-20

F686 · Quality of Life and Care Deficiencies

Health

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected 2024-01-01

D · Potential for more than minimal harm 2023-11-20

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 2024-01-01

D · Potential for more than minimal harm 2023-11-20

F692 · Quality of Life and Care Deficiencies

Health

Provide enough food/fluids to maintain a resident's health.

Corrected 2024-01-01

D · Potential for more than minimal harm 2023-11-20

F745 · Quality of Life and Care Deficiencies

Health

Provide medically-related social services to help each resident achieve the highest possible quality of life.

Corrected 2024-01-01

D · Potential for more than minimal harm 2023-11-20

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 2024-01-01

D · Potential for more than minimal harm 2023-11-20

F849 · Administration Deficiencies

Health

Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.

Corrected 2024-01-01

D · Potential for more than minimal harm 2023-11-20

F883 · Infection Control Deficiencies

Health

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Corrected 2024-01-01

Penalties and ownership

What sits behind the stars

$8,278 2025-05-08

Fine

Fine · fine $8,278

Fine

$49,608 2025-05-08

Fine

Fine · fine $49,608

Fine

Ownership

Dorman, John

Corporate Director · Individual

0% 3 facilities 2021-05-14
Frank, Robert

Corporate Director · Individual

0% 2 facilities 2024-09-27
Gray, Roberta

Corporate Director · Individual

0% 4 facilities 2021-05-14
Gray, Roberta

Corporate Officer · Individual

0% 4 facilities 2017-01-01
Lin, Michael

Corporate Director · Individual

0% 3 facilities 2021-05-14
Malisky, J

Operational/Managerial Control · Individual

0% 2 facilities 2017-01-01
Malisky, J

Corporate Officer · Individual

0% 2 facilities 2021-05-14
Massella, Joan

Corporate Director · Individual

0% 2 facilities 2021-05-14
Pieffer, James

Corporate Director · Individual

0% 5 facilities 2021-05-14
Presbyterian Seniorcare

5% Or Greater Direct Ownership Interest · Organization

0% 5 facilities 1984-04-01

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