12 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Windber, PA
2-star overall rating with 2-star inspections with $16,036 in total fines with 12 recent health deficiencies
277 Hoffman Avenue, Windber, PA
(814) 467-5505
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Beds
127
Certified beds
Average residents
113
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1967-01-01
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
RN hours / resident day
0.47
Registered nurse staffing · state 0.78 · national 0.68
LPN hours / resident day
1.12
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
2.50
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
4.09
All reported nurse hours · state 3.89 · national 3.89
Licensed hours
1.59
RN + LPN hours · state 1.69 · national 1.54
Weekend hours
3.89
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.30
Weekend registered nurse coverage · state 0.55 · national 0.47
Physical therapist
0.05
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.51
CMS adjusted RN staffing hours
Adjusted total hours
4.46
CMS adjusted total nurse staffing hours
Case-mix index
1.25
Higher values indicate more complex resident acuity
RN turnover
47%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
40%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Program rank
3,719
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
42.97
Composite VBP score used to determine payment impact.
Payment multiplier
0.9959
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
0
Baseline 21.75% · Performance 22.42% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
2.9
Baseline 7.92% · Performance 6.97% · Measure score 2.9 · Achievement 2.9 · Improvement 2.76
Total nurse turnover
7.87
Baseline 37.23% · Performance 31.53% · Measure score 7.87 · Achievement 7.87 · Improvement 4.10
Adjusted total nurse staffing
6.42
Baseline 4.17 hours · Performance 4.91 hours · Measure score 6.42 · Achievement 6.42 · Improvement 4.06
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.82% |
10.72%
0.9 pts better
|
No Different than the National Rate · Eligible stays 89 · Observed rate 7.87% · Lower 95% interval 7.17% |
| Discharge to community | 47.15% |
50.57%
3.4 pts worse
|
No Different than the National Rate · Eligible stays 68 · Observed rate 41.18% · Lower 95% interval 35.83% |
| Medicare spending per beneficiary | 0.85 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 55 · Denominator 55 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 55 |
| Discharge self-care score | 38.1% |
53.69%
15.6 pts worse
|
Numerator 16 · Denominator 42 |
| Discharge mobility score | 40.48% |
50.94%
10.5 pts worse
|
Numerator 17 · Denominator 42 |
| Pressure ulcers or injuries, new or worsened | 5.45% |
2.29%
3.2 pts worse
|
Numerator 3 · Denominator 55 · Adjusted rate 4.6% |
| Healthcare-associated infections requiring hospitalization | 6.97% |
7.12%
0.2 pts better
|
No Different than the National Rate · Eligible stays 50 · Observed rate 6% · Lower 95% interval 3.35% |
| Staff COVID-19 vaccination coverage | 1% |
8.2%
7.2 pts worse
|
Numerator 2 · Denominator 201 |
| Staff flu vaccination coverage | 24.74% |
42%
17.3 pts worse
|
Numerator 47 · Denominator 190 |
| Discharge function score | 50% |
56.45%
6.5 pts worse
|
Numerator 21 · Denominator 42 |
| Transfer of health information to provider | 96.67% |
95.95%
0.7 pts better
|
Numerator 29 · Denominator 30 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 60% |
25.2%
34.8 pts better
|
Numerator 15 · Denominator 25 |
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 1.7 · Expected 1.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.9 |
1.2
0.3 pts better
|
1.8
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.9 · Observed 0.9 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.1% |
86.9%
11.2 pts better
|
93.4%
4.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 96.8% · Q3 96.8% · Q4 99.0% · 4Q avg 98.1% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 99.0% |
93.5%
5.5 pts better
|
95.5%
3.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 99.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.6% |
3.2%
1.6 pts better
|
3.3%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 0.0% · Q3 1.1% · Q4 3.9% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 27.5% |
6.5%
21 pts worse
|
11.4%
16.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.5% · Q2 38.4% · Q3 30.8% · Q4 12.4% · 4Q avg 27.5% |
| Percentage of long-stay residents who lose too much weight | 4.7% |
6.5%
1.8 pts better
|
5.4%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.2% · Q2 6.6% · Q3 5.0% · Q4 2.3% · 4Q avg 4.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 17.9% |
19.9%
2 pts better
|
19.6%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.2% · Q2 12.8% · Q3 20.5% · Q4 22.5% · 4Q avg 17.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 6.6% |
18.7%
12.1 pts better
|
16.7%
10.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 6.2% · Q3 4.4% · Q4 11.5% · 4Q avg 6.6% · 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 | 12.4% |
19.6%
7.2 pts better
|
16.3%
3.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.2% · Q2 10.1% · Q3 6.6% · Q4 18.2% · 4Q avg 12.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 14.5% |
18.3%
3.8 pts better
|
14.9%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.9% · Q2 18.8% · Q3 13.5% · Q4 15.7% · 4Q avg 14.5% · 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 | 1.1% |
1.7%
0.6 pts better
|
1.7%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 2.2% · Q3 0.0% · Q4 1.0% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 27.6% |
26.4%
1.2 pts worse
|
19.8%
7.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.3% · Q2 28.7% · Q3 25.8% · Q4 34.3% · 4Q avg 27.6% |
| Percentage of long-stay residents with pressure ulcers | 3.0% |
5.3%
2.3 pts better
|
5.1%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 5.4% · Q3 1.0% · Q4 4.3% · 4Q avg 3.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 89.7% |
68.9%
20.8 pts better
|
81.7%
8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 86.7% · Q2 90.1% · Q3 89.3% · Q4 91.8% · 4Q avg 89.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 5.1% |
9.8%
4.7 pts better
|
12.0%
6.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 5.1% · Observed 4.8% · Expected 10.5% · 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 2.3% · Q2 0.0% · Q3 1.6% · Q4 0.0% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 91.6% |
68.7%
22.9 pts better
|
79.7%
11.9 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 91.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 29.3% |
23.1%
6.2 pts worse
|
23.9%
5.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 29.3% · Observed 29.0% · Expected 23.6% · Used in QM five-star |
Survey summary
Top issue: Quality of Life and Care (4 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Top issue: Quality of Life and Care (6 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Top issue: Pharmacy Service (4 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Inspection history
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-05-26
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-05-26
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2025-05-26
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-05-26
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 2025-05-26
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-05-26
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-06-27
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-05-26
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 2025-05-26
Health
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Corrected 2025-05-26
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2025-05-26
Health
Provide and implement an infection prevention and control program.
Corrected 2025-05-26
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-12-11
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-12-11
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-10-16
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-10-16
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-07-30
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-06-17
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 2024-06-17
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 2024-06-17
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-06-17
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-06-17
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-06-17
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2024-06-17
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2024-06-17
Health
Keep residents' personal and medical records private and confidential.
Corrected 2024-04-29
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-04-29
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-03-04
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-04-29
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-03-01
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-03-04
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 2023-12-06
Health
Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.
Corrected 2023-12-06
Health
Provide and implement an infection prevention and control program.
Corrected 2023-10-27
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-05-08
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
Corrected 2023-05-08
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-05-08
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-05-08
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-05-08
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 2023-05-08
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2023-05-08
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-05-08
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2023-05-08
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-05-08
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-05-08
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-05-08
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-05-08
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2023-05-08
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2023-05-08
Health
Provide and implement an infection prevention and control program.
Corrected 2023-05-08
Penalties and ownership
Fine · fine $8,018
Fine
Fine · fine $8,018
Fine
Corporate Director · Individual
Operational/Managerial Control · Individual
Corporate Officer · Individual
Corporate Director · Individual
Corporate Director · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Corporate Director · Individual
Nearby options
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3-star overall rating with 3-star inspections with $16,800 in total fines with 7 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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