Cycle 1
Health 2025-06-13 · Fire 2025-06-13
1 health deficiencies
Top issue: Administration (1 deficiency)
3 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
West Chester, PA
Barclay Friends
4-star overall rating with 4-star inspections with $9,440 in total fines with 1 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
700 North Franklin, West Chester, PA
(610) 696-5211
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
64
Certified beds
Average residents
62
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Kendal
Operator or chain grouping
Approved since
1991-04-23
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.99
Registered nurse staffing
LPN hours / resident day
0.80
Licensed practical nurse staffing
Aide hours / resident day
2.66
Nurse aide staffing
Weekend hours
4.20
Weekend nurse staffing
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.8 |
1.7
0.1 pts worse
|
1.9
0.1 pts better
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.6 |
1.2
0.6 pts better
|
1.8
1.2 pts better
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 93.8% |
86.9%
6.9 pts better
|
93.4%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.5% |
93.5%
5 pts better
|
95.5%
3 pts better
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.1% |
3.2%
0.9 pts worse
|
3.3%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 1.5% |
6.5%
5 pts better
|
11.4%
9.9 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 2.4% |
6.5%
4.1 pts better
|
5.4%
3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 10.9% |
19.9%
9 pts better
|
19.6%
8.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 9.1% |
18.7%
9.6 pts better
|
16.7%
7.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents whose ability to walk independently worsened | 26.8% |
19.6%
7.2 pts worse
|
16.3%
10.5 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 33.0% |
18.3%
14.7 pts worse
|
14.9%
18.1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents with a urinary tract infection | 1.7% |
1.7%
About the same
|
1.7%
About the same
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 24.4% |
26.4%
2 pts better
|
19.8%
4.6 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 7.0% |
5.3%
1.7 pts worse
|
5.1%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 90.6% |
68.9%
21.7 pts better
|
81.7%
8.9 pts better
|
Short Stay · 2024Q4-2025Q3 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-05-17 · Fire 2024-05-17
0 health deficiencies
No concentrated health issue counts in this cycle.
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2023-07-20 · Fire 2023-07-20
0 health deficiencies
No concentrated health issue counts in this cycle.
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-06-13
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 2025-07-28
E · Potential for more than minimal harm
2025-06-13
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-07-28
E · Potential for more than minimal harm
2025-06-13
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-07-28
E · Potential for more than minimal harm
2024-05-17
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-06-14
D · Potential for more than minimal harm
2024-05-17
K133 · Construction Deficiencies
Fire Safety
Install a two-hour-resistant firewall separation.
Corrected 2024-06-14
D · Potential for more than minimal harm
2024-05-17
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 2024-06-14
D · Potential for more than minimal harm
2024-05-17
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-06-14
D · Potential for more than minimal harm
2023-07-20
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2023-08-14
D · Potential for more than minimal harm
2023-07-20
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-08-14
D · Potential for more than minimal harm
2023-07-20
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-08-14
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-06-13
F851 · Administration Deficiencies
Health
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Corrected 2025-08-01
Penalties and ownership
What sits behind the stars
$9,440
2023-06-12
Fine
Fine · fine $9,440
Fine
Ownership
Barclay Friends
Operational/Managerial Control · Organization
Boyd, Timothy
Corporate Director · Individual
Charter, David
Corporate Director · Individual
Davis, Matthew
Corporate Director · Individual
Functional Pathways Of Tennessee LLC
General Partnership Interest · Organization
Gemberling, Cendrine
Corporate Director · Individual
Gerhardt, John
Corporate Director · Individual
Gilbert, Ellen
Corporate Director · Individual
Gleason, Kevin
Corporate Director · Individual
Hacking, Marina
Corporate Director · Individual
Karp, Jolie
Corporate Director · Individual
Lawrence, Thomas
General Partnership Interest · Individual
Lawrence, Thomas
Corporate Director · Individual
Peace Church Risk Retention Group
General Partnership Interest · Organization
Pessognelli, Marianne
Corporate Director · Individual
Randolph, Terrance
Corporate Director · Individual
Rkl Llp
General Partnership Interest · Organization
Santangelo, Maria
Operational/Managerial Control · Individual
Santangelo, Maria
Corporate Officer · Individual
Scheuren, Michael
Corporate Director · Individual
Spangler, John
Corporate Director · Individual
The Kendal Corporation
General Partnership Interest · Organization
The Kendal Corporation
Operational/Managerial Control · Organization
Wilmington Trust Company
General Partnership Interest · Organization
Nearby options
Other facilities in reach
#1
Park Lane Post Acute LLC
West Chester, PA
4-star overall rating with 3-star inspections with 9 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
#2
West Chester Rehabilitation And Healthcare Center
West Chester, PA
2-star overall rating with 2-star inspections with $83,889 in total fines with 6 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Aventura At Pembrooke
West Chester, PA
1-star overall rating with 1-star inspections with 17 recent health deficiencies
Jump out