Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
St John specialty Care Center
MARS, PA · 150 certified beds · Last Life Safety survey October 11, 2024
CMS Certification Number 395164 · first certified January 1967
Ownership
Independently operated (no chain recorded by CMS) · Non profit - Corporation
No change of ownership on CMS record since January 1, 2016, when the records begin.
Position within PA
26 citations — more than 91% of the 656 certified nursing homes in PA. Compared within PA rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 11 citations; the earlier surveys in the window averaged 7.5. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
Well past the typical window (August 2025 to October 2025), and past the point by which nine in ten PA facilities have been surveyed. This facility’s last Life Safety survey was October 2024. Facilities in PA are typically surveyed 10–12 months after the last one (median 11), measured over 1,113 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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4 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Physical environment (health survey)
6 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 26 Life Safety citations above. The Physical Environment Index
How that compares
Compared with the median facility in PA, and nationally. Surveyors differ markedly between states, so the PA figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 26 |
| Median facility in PA | 10 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| June 16, 2023 | 9 |
| December 1, 2023 | 6 |
| October 11, 2024 | 11 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 3 | 2024-10-11 |
| K-0293 | Have properly located and lighted "Exit" signs. | 2 | 2024-10-11 |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | 2 | 2024-10-11 |
| K-0324 | Provide properly protected cooking facilities. | 2 | 2024-10-11 |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | 2 | 2023-12-01 |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | 1 | 2023-06-16 |
| K-0914 | Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | 1 | 2023-12-01 |
| K-0912 | Have power receptacles that are properly grounded. | 1 | 2024-10-11 |
What the citations cover
- Smoke Deficiencies 10
- Gas, Vacuum, and Electrical Systems Deficiencies 7
- Egress Deficiencies 4
- Miscellaneous Deficiencies 3
- Other 2
| Category | Citations |
|---|---|
| Smoke Deficiencies | 10 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 7 |
| Egress Deficiencies | 4 |
| Miscellaneous Deficiencies | 3 |
| Services Deficiencies | 1 |
| Construction Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
October 11, 2024 — 11 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0100 | Meet other general requirements. | Deficient, Provider has date of correction (November 15, 2024) |
| K-0223 | Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Deficient, Provider has date of correction (November 15, 2024) |
| K-0293 | Have properly located and lighted "Exit" signs. | Deficient, Provider has date of correction (November 15, 2024) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (November 15, 2024) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (November 15, 2024) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (November 15, 2024) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (November 15, 2024) |
| K-0911 | Meet requirements for the installation and maintenance of electrical systems. | Deficient, Provider has date of correction (November 15, 2024) |
| K-0912 | Have power receptacles that are properly grounded. | Deficient, Provider has date of correction (November 15, 2024) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (November 15, 2024) |
| K-0923 | Have proper medical gas storage and administration areas. | Deficient, Provider has date of correction (November 15, 2024) |
December 1, 2023 — 6 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0311 | Have an enclosure around a vertical opening shaft. | Deficient, Provider has date of correction (February 4, 2024) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (February 4, 2024) |
| K-0753 | Have restrictions on the use of highly flammable decorations. | Deficient, Provider has date of correction (February 4, 2024) |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Deficient, Provider has date of correction (February 1, 2024) |
| K-0914 | Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Deficient, Provider has date of correction (February 4, 2024) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (February 4, 2024) |
June 16, 2023 — 9 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | Deficient, Provider has date of correction (August 4, 2023) |
| K-0293 | Have properly located and lighted "Exit" signs. | Deficient, Provider has date of correction (August 4, 2023) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (August 4, 2023) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (August 31, 2023) |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | Deficient, Provider has date of correction (August 4, 2023) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (August 4, 2023) |
| K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | Deficient, Provider has date of correction (August 4, 2023) |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Deficient, Provider has date of correction (August 4, 2023) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (August 31, 2023) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.