Cycle 1
Health 2025-04-25 · Fire 2025-04-25
26 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (5 deficiencies)
5 fire-safety deficiencies
Top issue: Emergency Preparedness (5 deficiencies)
Flourtown, PA
Complete Care At Harston Hall LLC
1-star overall rating with 1-star inspections with abuse icon flag with $17,113 in total fines with 26 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
350 Haws Lane, Flourtown, PA
(215) 233-0700
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
120
Certified beds
Average residents
104
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Complete Care
Operator or chain grouping
Approved since
1989-06-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
85 facilities
Chain averages 3 overall / 3 health / 3 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
0.62
Registered nurse staffing · state 0.78 · national 0.68
LPN hours / resident day
1.01
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
1.96
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.59
All reported nurse hours · state 3.89 · national 3.89
Licensed hours
1.63
RN + LPN hours · state 1.69 · national 1.54
Weekend hours
3.22
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.27
Weekend registered nurse coverage · state 0.55 · national 0.47
Physical therapist
0.06
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.60
CMS adjusted RN staffing hours
Adjusted total hours
3.50
CMS adjusted total nurse staffing hours
Case-mix index
1.40
Higher values indicate more complex resident acuity
RN turnover
63%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
60%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
5,763
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
35.11
Composite VBP score used to determine payment impact.
Payment multiplier
0.9889
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.90
Baseline 17.94% · Performance 20.09% · Measure score 2.90 · Achievement 2.90 · Improvement 0
Healthcare-associated infections
3.16
Baseline 6.04% · Performance 6.89% · Measure score 3.16 · Achievement 3.16 · Improvement 0
Total nurse turnover
4.38
Baseline 60.30% · Performance 45.76% · Measure score 4.38 · Achievement 4.38 · Improvement 3.60
Adjusted total nurse staffing
3.60
Baseline 4.08 hours · Performance 4.10 hours · Measure score 3.60 · Achievement 3.60 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.22% |
10.72%
0.5 pts better
|
No Different than the National Rate · Eligible stays 47 · Observed rate 10.64% · Lower 95% interval 6.96% |
| Discharge to community | 47.37% |
50.57%
3.2 pts worse
|
No Different than the National Rate · Eligible stays 32 · Observed rate 31.25% · Lower 95% interval 29.79% |
| Medicare spending per beneficiary | 1.05 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 54 · Denominator 54 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 54 |
| Discharge self-care score | 63.64% |
53.69%
10 pts better
|
Numerator 21 · Denominator 33 |
| Discharge mobility score | 57.58% |
50.94%
6.6 pts better
|
Numerator 19 · Denominator 33 |
| Pressure ulcers or injuries, new or worsened | 7.41% |
2.29%
5.1 pts worse
|
Numerator 4 · Denominator 54 · Adjusted rate 4.63% |
| Healthcare-associated infections requiring hospitalization | 6.89% |
7.12%
0.2 pts better
|
No Different than the National Rate · Eligible stays 33 · Observed rate 9.09% · Lower 95% interval 3.9% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 182 |
| Staff flu vaccination coverage | 11.45% |
42%
30.6 pts worse
|
Numerator 26 · Denominator 227 |
| Discharge function score | 72.73% |
56.45%
16.3 pts better
|
Numerator 24 · Denominator 33 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 21 · Denominator 21 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 24 · Denominator 24 |
| Resident COVID-19 vaccinations up to date | 5.56% |
25.2%
19.6 pts worse
|
Numerator 2 · Denominator 36 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 3.0 |
1.7
1.3 pts worse
|
1.9
1.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.0 · Observed 2.9 · Expected 1.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.7 |
1.2
2.5 pts worse
|
1.8
1.9 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.7 · Observed 3.4 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 83.9% |
86.9%
3 pts worse
|
93.4%
9.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 81.0% · Q2 77.9% · Q3 90.9% · Q4 86.5% · 4Q avg 83.9% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 99.1% |
93.5%
5.6 pts better
|
95.5%
3.6 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 99.1% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.7% |
3.2%
0.5 pts better
|
3.3%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.0% · Q2 2.9% · Q3 3.0% · Q4 4.2% · 4Q avg 2.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 16.6% |
6.5%
10.1 pts worse
|
11.4%
5.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.0% · Q2 13.7% · Q3 15.6% · Q4 24.7% · 4Q avg 16.6% |
| Percentage of long-stay residents who lose too much weight | 8.4% |
6.5%
1.9 pts worse
|
5.4%
3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.2% · Q2 10.5% · Q3 7.8% · Q4 4.7% · 4Q avg 8.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 42.0% |
19.9%
22.1 pts worse
|
19.6%
22.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 44.4% · Q2 42.3% · Q3 39.6% · Q4 41.6% · 4Q avg 42.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 12.2% |
18.7%
6.5 pts better
|
16.7%
4.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.4% · Q2 6.7% · Q3 15.6% · Q4 14.8% · 4Q avg 12.2% · 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 | 14.6% |
19.6%
5 pts better
|
16.3%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.8% · Q2 8.2% · Q3 16.5% · Q4 25.5% · 4Q avg 14.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 12.5% |
18.3%
5.8 pts better
|
14.9%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.3% · Q2 17.9% · Q3 14.6% · Q4 12.0% · 4Q avg 12.5% · 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 | 0.3% |
1.7%
1.4 pts better
|
1.7%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 27.2% |
26.4%
0.8 pts worse
|
19.8%
7.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.8% · Q2 34.9% · Q3 27.2% · Q4 22.6% · 4Q avg 27.2% |
| 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 2.0% · Q2 3.5% · Q3 3.3% · Q4 2.1% · 4Q avg 2.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 55.7% |
68.9%
13.2 pts worse
|
81.7%
26 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 50.9% · Q2 52.2% · Q3 62.3% · Q4 56.4% · 4Q avg 55.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.7% |
9.8%
0.9 pts worse
|
12.0%
1.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.7% · Observed 12.5% · Expected 13.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.5%
1.5 pts better
|
1.6%
1.6 pts better
|
Short 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 short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 51.4% |
68.7%
17.3 pts worse
|
79.7%
28.3 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 51.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 22.3% |
23.1%
0.8 pts better
|
23.9%
1.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 22.3% · Observed 28.1% · Expected 30.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-06-21 · Fire 2024-06-21
28 health deficiencies
Top issue: Resident Rights (9 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2023-09-21 · Fire 2023-09-21
36 health deficiencies
Top issue: Resident Rights (9 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
C · Minimal harm
2025-04-25
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2025-06-10
C · Minimal harm
2025-04-25
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2025-06-10
B · Minimal harm
2025-04-25
E23 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for medical documentation.
Corrected 2025-06-10
B · Minimal harm
2025-04-25
E34 · Emergency Preparedness Deficiencies
Fire Safety
Provide a means of sharing information on occupancy/needs.
Corrected 2025-06-10
B · Minimal harm
2025-04-25
E7 · Emergency Preparedness Deficiencies
Fire Safety
Address patient/client population and determine types of services needed.
Corrected 2025-06-10
Inspection history
Recent health citations
D · Potential for more than minimal harm
2026-01-20
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.
Not marked corrected
D · Potential for more than minimal harm
2025-09-17
F557 · Resident Rights Deficiencies
Health
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Corrected 2025-10-10
D · Potential for more than minimal harm
2025-09-17
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-10-10
F · Potential for more than minimal harm
2025-04-25
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 2025-06-23
E · Potential for more than minimal harm
2025-04-25
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 2025-06-23
E · Potential for more than minimal harm
2025-04-25
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2025-06-23
E · Potential for more than minimal harm
2025-04-25
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2025-06-23
E · Potential for more than minimal harm
2025-04-25
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2025-06-23
E · Potential for more than minimal harm
2025-04-25
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2025-06-23
E · Potential for more than minimal harm
2025-04-25
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-06-23
D · Potential for more than minimal harm
2025-04-25
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 2025-06-23
D · Potential for more than minimal harm
2025-04-25
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2025-06-23
D · Potential for more than minimal harm
2025-04-25
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-06-23
D · Potential for more than minimal harm
2025-04-25
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 2025-06-23
D · Potential for more than minimal harm
2025-04-25
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-06-23
D · Potential for more than minimal harm
2025-04-25
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-06-23
D · Potential for more than minimal harm
2025-04-25
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-06-23
D · Potential for more than minimal harm
2025-04-25
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-06-23
D · Potential for more than minimal harm
2025-04-25
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2025-06-23
D · Potential for more than minimal harm
2025-04-25
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2025-06-23
D · Potential for more than minimal harm
2025-04-25
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 2025-06-23
D · Potential for more than minimal harm
2025-04-25
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 2025-06-23
D · Potential for more than minimal harm
2025-04-25
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 2025-06-23
D · Potential for more than minimal harm
2025-04-25
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2025-06-23
D · Potential for more than minimal harm
2025-04-25
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2025-06-23
D · Potential for more than minimal harm
2025-04-25
F943 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
Corrected 2025-06-23
D · Potential for more than minimal harm
2025-01-21
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-03-10
B · Minimal harm
2024-11-05
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2024-11-24
K · Immediate jeopardy
2024-08-15
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2024-08-01
J · Immediate jeopardy
2024-08-15
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 2024-08-01
E · Potential for more than minimal harm
2024-08-15
F895 · Administration Deficiencies
Health
Have a Compliance and Ethics Program.
Corrected 2024-09-20
D · Potential for more than minimal harm
2024-08-15
F576 · Resident Rights Deficiencies
Health
Ensure residents have reasonable access to and privacy in their use of communication methods.
Corrected 2024-09-20
D · Potential for more than minimal harm
2024-08-15
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2024-09-20
D · Potential for more than minimal harm
2024-08-15
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2024-09-20
E · Potential for more than minimal harm
2024-06-21
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 2024-08-12
E · Potential for more than minimal harm
2024-06-21
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2024-08-12
E · Potential for more than minimal harm
2024-06-21
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 2024-08-12
E · Potential for more than minimal harm
2024-06-21
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2024-08-12
E · Potential for more than minimal harm
2024-06-21
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-08-12
E · Potential for more than minimal harm
2024-06-21
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2024-08-12
E · Potential for more than minimal harm
2024-06-21
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2024-08-12
E · Potential for more than minimal harm
2024-06-21
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2024-08-12
E · Potential for more than minimal harm
2024-06-21
F803 · Nutrition and Dietary Deficiencies
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 2024-08-12
E · Potential for more than minimal harm
2024-06-21
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 2024-08-12
E · Potential for more than minimal harm
2024-06-21
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2024-08-12
E · Potential for more than minimal harm
2024-06-21
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2024-08-12
D · Potential for more than minimal harm
2024-06-21
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2024-08-12
D · Potential for more than minimal harm
2024-06-21
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2024-08-12
D · Potential for more than minimal harm
2024-06-21
F685 · Quality of Life and Care Deficiencies
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2024-08-12
D · Potential for more than minimal harm
2024-06-21
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 2024-08-12
D · Potential for more than minimal harm
2024-06-21
F699 · Quality of Life and Care Deficiencies
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2024-08-12
D · Potential for more than minimal harm
2024-06-21
F806 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2024-08-12
D · Potential for more than minimal harm
2024-06-21
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 2024-08-12
C · Minimal harm
2024-06-21
F577 · Resident Rights Deficiencies
Health
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Corrected 2024-08-12
F · Potential for more than minimal harm
2023-09-21
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 2023-10-20
E · Potential for more than minimal harm
2023-09-21
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 2023-10-20
E · Potential for more than minimal harm
2023-09-21
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-10-20
E · Potential for more than minimal harm
2023-09-21
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-10-20
E · Potential for more than minimal harm
2023-09-21
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2023-10-20
E · Potential for more than minimal harm
2023-09-21
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2023-10-20
D · Potential for more than minimal harm
2023-09-21
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2023-11-10
D · Potential for more than minimal harm
2023-09-21
F553 · Resident Rights Deficiencies
Health
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Corrected 2023-10-20
D · Potential for more than minimal harm
2023-09-21
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2023-10-20
D · Potential for more than minimal harm
2023-09-21
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2023-10-20
D · Potential for more than minimal harm
2023-09-21
F567 · Resident Rights Deficiencies
Health
Honor the resident's right to manage his or her financial affairs.
Corrected 2023-10-20
D · Potential for more than minimal harm
2023-09-21
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 2023-10-20
D · Potential for more than minimal harm
2023-09-21
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2023-10-20
D · Potential for more than minimal harm
2023-09-21
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2023-10-20
D · Potential for more than minimal harm
2023-09-21
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 2023-10-20
D · Potential for more than minimal harm
2023-09-21
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2023-10-20
D · Potential for more than minimal harm
2023-09-21
F606 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Not hire anyone with a finding of abuse, neglect, exploitation, or theft.
Corrected 2023-10-20
D · Potential for more than minimal harm
2023-09-21
F622 · Resident Rights Deficiencies
Health
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Corrected 2023-10-20
D · Potential for more than minimal harm
2023-09-21
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2023-10-20
D · Potential for more than minimal harm
2023-09-21
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 2023-10-20
D · Potential for more than minimal harm
2023-09-21
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 2023-10-20
D · Potential for more than minimal harm
2023-09-21
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-10-20
D · Potential for more than minimal harm
2023-09-21
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-10-20
D · Potential for more than minimal harm
2023-09-21
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 2023-10-20
D · Potential for more than minimal harm
2023-09-21
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-10-20
D · Potential for more than minimal harm
2023-09-21
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2023-10-20
D · Potential for more than minimal harm
2023-09-21
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 2023-10-20
D · Potential for more than minimal harm
2023-09-21
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2023-10-20
D · Potential for more than minimal harm
2023-09-21
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 2023-10-20
D · Potential for more than minimal harm
2023-09-21
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 2023-10-20
D · Potential for more than minimal harm
2023-09-21
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2023-10-20
D · Potential for more than minimal harm
2023-09-21
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-10-20
D · Potential for more than minimal harm
2023-09-21
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2023-10-20
D · Potential for more than minimal harm
2023-09-21
F940 · Administration Deficiencies
Health
Develop, implement, and/or maintain an effective training program for all new and existing staff members.
Corrected 2023-10-20
D · Potential for more than minimal harm
2023-09-21
F943 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
Corrected 2023-10-20
D · Potential for more than minimal harm
2023-06-28
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 2023-07-20
Penalties and ownership
What sits behind the stars
$8,556
2024-06-21
Fine
Fine · fine $8,556
Fine
$8,557
2024-06-21
Fine
Fine · fine $8,557
Fine
Ownership
Pc Pa Opcos LLC
5% Or Greater Direct Ownership Interest · Organization
Auge, Jason
Operational/Managerial Control · Individual
Levy, Joshua
Operational/Managerial Control · Individual
Pc Wta Opco Holdco LLC
5% Or Greater Indirect Ownership Interest · Organization
Peace Capital Holdings LLC (De)
5% Or Greater Indirect Ownership Interest · Organization
Schwartz, Hershel
Operational/Managerial Control · Individual
Shand, Jennifer
Operational/Managerial Control · Individual
Sms 2021 Trust
5% Or Greater Indirect Ownership Interest · Organization
Stein, Shalom
Corporate Officer · Individual
Welltower Inc
5% Or Greater Security Interest · Organization
Williams, Cameron
Operational/Managerial Control · Individual
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#2
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#3
Chestnut Hill Lodge Health And Rehab Ctr
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2-star overall rating with 3-star inspections with $16,301 in total fines with 10 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
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