Above average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Saint John Xxiii Home during CMS and state inspections, most recent first.
A facility failed to accurately code the MDS assessment for a resident with an indwelling catheter. Despite the resident having the catheter during the entire seven-day look-back period, the MDS was incorrectly coded as 'Always Continent' instead of 'not rated'. This error was confirmed by the RN Assessment Coordinator, violating the facility's responsibility to maintain accurate medical records.
A facility failed to maintain cleanliness of respiratory care equipment for a resident with A-Fib, anxiety, and high blood pressure. Despite a physician's order for continuous oxygen and regular cleaning of equipment, observations revealed a large amount of gray fluffy substance on the oxygen concentrator's filter. The DON confirmed the filter should have been cleaned.
The facility failed to document catheter changes for a resident with an indwelling catheter, as required by their policy. Despite the resident's statement that changes occur monthly, the Treatment Administration Records lacked evidence of these changes, confirmed by the DON.
The facility failed to maintain sanitary food service operations by not recording final rinse temperatures on the dish machine temperature log from February 1, 2024, to April 22, 2024, as required by policy. Only wash temperatures were recorded, which was confirmed by staff.
Inaccurate MDS Assessment for Resident with Indwelling Catheter
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected the status of a resident, identified as Resident R2. The MDS instructions for Section H Bladder and Bowel subsection H0300 Urinary Continence specify that urinary continence should be coded as 'not rated' if the resident had an indwelling bladder catheter during the seven-day look-back period. However, Resident R2's MDS assessments were inaccurately coded as 'Always Continent' despite having an indwelling catheter for the entire look-back period. Resident R2 was admitted with diagnoses including Benign Prostatic Hyperplasia, depression, gastro-esophageal reflux disease, and high blood pressure. A physician's order dated 3/4/24 confirmed the use of an indwelling catheter. The inaccurate coding was confirmed by the Registered Nurse Assessment Coordinator during an interview, acknowledging that the MDS assessments dated 5/30/24, 6/10/24, 9/10/24, 12/10/24, and 3/12/25 were incorrect. This discrepancy was a violation of the facility's responsibility to maintain accurate medical records as per the relevant Pennsylvania Code sections.
Failure to Maintain Cleanliness of Respiratory Equipment
Penalty
Summary
The facility failed to maintain cleanliness and prevent the spread of infection regarding respiratory care equipment for Resident R17. The facility's policy on oxygen administration, dated 3/24/25, required regular cleaning of oxygen equipment. Resident R17, who was admitted with diagnoses including Atrial Fibrillation, anxiety, and high blood pressure, had a physician's order for continuous oxygen at 2 liters per minute via nasal cannula due to low oxygen levels. The order also specified changing the tubing, O2 humidifier bottle, and cleaning the concentrator and filter as needed. Observations on 3/25/25 and 3/27/25 revealed that Resident R17 was using supplemental oxygen, but the oxygen concentrator's filter was covered with a large amount of gray fluffy substance. The Director of Nursing confirmed the presence of the dusty substance on the filter, indicating it should have been cleaned.
Incomplete Documentation of Catheter Changes
Penalty
Summary
The facility failed to maintain complete and accurate documentation regarding indwelling catheter changes for a resident with an indwelling catheter. The facility's policy on catheter care requires documentation of the date, time, procedure, signature, and title for catheter changes, and mandates that all indwelling urinary catheters be changed monthly unless otherwise ordered by a physician. However, a review of the Treatment Administration Records (TAR) for January and February 2025 revealed a lack of documentation indicating that the catheter change was completed as per the physician's orders for Resident R2. Resident R2, who was admitted with diagnoses including Benign Prostatic Hyperplasia, depression, gastro-esophageal reflux disease, and high blood pressure, had a physician's order for monthly catheter changes. Despite the resident's statement that the facility changes his catheter monthly, the Director of Nursing confirmed the absence of complete documentation in the treatment records regarding these catheter changes. This deficiency was identified during a review of facility policy, clinical records, and interviews with staff and the resident.
Failure to Maintain Sanitary Food Service Operations
Penalty
Summary
The facility failed to maintain sanitary food service operations in its kitchen. The facility's policy required that the dish machine temperature log be completed to ensure proper temperatures for sanitization, including recording both wash and final rinse temperatures. However, observations and staff interviews revealed that only wash temperatures were recorded from February 1, 2024, to April 22, 2024. This was confirmed by both Employee E1 and the Dietary Manager. The final rinse temperatures, which should be between 165 and 180 degrees Fahrenheit to ensure proper sanitization, were not recorded during this period.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Nursing homes near Hermitage
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hermitage Nursing And Rehabilitation | 1.6 mi | ★★★★★ | 5 | 0 |
| Clepper Manor | 2.7 mi | ★★★★★ | 0 | 0 |
| O'brien Memorial Health Care C | 4.4 mi | ★★★★★ | 6 | 0 |
| Addison Healthcare Center | 5.2 mi | ★★★★★ | 7 | 0 |
| Meadowbrook Manor | 8.8 mi | ★★★★★ | 8 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.