Exton, PA

Exton Post Acute

3-star overall rating with 3-star inspections with $120,174 in total fines with 3 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle

501 Thomas Jones Way, Exton, PA

(610) 423-8600

Compare this facility

Overall

3 / 5

CMS overall stars

Health inspections

3 / 5

Survey and complaint cycles

Staffing

2 / 5

RN + nurse staffing

Quality measures

3 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

120

Certified beds

Average residents

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Marquis Health Services

Operator or chain grouping

Approved since

2018-08-16

CMS approved date

Coverage

Medicare

Participation flags

Chain footprint

81 facilities

Chain averages 3 overall / 3 health / 2 staffing / 4 quality stars

Changed ownership

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

0.92

Registered nurse staffing · state 0.78 · national 0.68

LPN hours / resident day

1.21

Licensed practical nurse staffing · state 0.91 · national 0.87

Aide hours / resident day

1.94

Nurse aide staffing · state 2.20 · national 2.35

Total nurse hours

4.08

All reported nurse hours · state 3.89 · national 3.89

Licensed hours

2.13

RN + LPN hours · state 1.69 · national 1.54

Weekend hours

3.83

Weekend nurse staffing · state 3.51 · national 3.43

Weekend RN hours

0.64

Weekend registered nurse coverage · state 0.55 · national 0.47

Physical therapist

0.23

Reported PT staffing · state 0.10 · national 0.07

Adjusted RN hours

0.75

CMS adjusted RN staffing hours

Adjusted total hours

3.33

CMS adjusted total nurse staffing hours

Case-mix index

1.67

Higher values indicate more complex resident acuity

RN turnover

71%

Annual RN turnover · state 43% · national 45%

Total nurse turnover

58%

Annual nurse turnover · state 47% · national 46%

SNF VBP

Value-based purchasing

Program rank

12,216

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

13.42

Composite VBP score used to determine payment impact.

Payment multiplier

0.9812

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

0.37

Baseline 23.13% · Performance 22.59% · Measure score 0.37 · Achievement 0 · Improvement 0.37

Healthcare-associated infections

3.67

Baseline 6.92% · Performance 6.74% · Measure score 3.67 · Achievement 3.67 · Improvement 0.42

Total nurse turnover

Baseline 63.93% · Performance 68.52% · Measure score 0 · Achievement 0 · Improvement 0

Adjusted total nurse staffing

1.33

Baseline 4.53 hours · Performance 3.46 hours · Measure score 1.33 · Achievement 1.33 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	10.43%	10.72% 0.3 pts better	No Different than the National Rate · Eligible stays 1210 · Observed rate 9.67% · Lower 95% interval 9.18%
Discharge to community	57.01%	50.57% 6.4 pts better	Better than the National Rate · Eligible stays 1260 · Observed rate 54.44% · Lower 95% interval 54.46%
Medicare spending per beneficiary	0.85	1.02 0.2 pts better
Drug regimen review with follow-up	98.73%	95.27% 3.5 pts better	Numerator 466 · Denominator 472
Falls with major injury	1.69%	0.77% 0.9 pts worse	Numerator 8 · Denominator 472
Discharge self-care score	48.13%	53.69% 5.6 pts worse	Numerator 90 · Denominator 187
Discharge mobility score	50.27%	50.94% 0.7 pts worse	Numerator 94 · Denominator 187
Pressure ulcers or injuries, new or worsened	4.45%	2.29% 2.2 pts worse	Numerator 21 · Denominator 472 · Adjusted rate 5.54%
Healthcare-associated infections requiring hospitalization	6.74%	7.12% 0.4 pts better	No Different than the National Rate · Eligible stays 572 · Observed rate 6.29% · Lower 95% interval 4.94%
Staff COVID-19 vaccination coverage	1.3%	8.2% 6.9 pts worse	Numerator 2 · Denominator 154
Staff flu vaccination coverage	69.84%	42% 27.8 pts better	Numerator 88 · Denominator 126
Discharge function score	51.87%	56.45% 4.6 pts worse	Numerator 97 · Denominator 187
Transfer of health information to provider	84.8%	95.95% 11.2 pts worse	Numerator 106 · Denominator 125
Transfer of health information to patient	94.1%	96.28% 2.2 pts worse	Numerator 303 · Denominator 322
Resident COVID-19 vaccinations up to date	7.77%	25.2% 17.4 pts worse	Numerator 16 · Denominator 206

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	52.4%	86.9% 34.5 pts worse	93.4% 41 pts worse	Long Stay · 2024Q4-2025Q3 · 4Q avg 52.4%
Percentage of long-stay residents experiencing one or more falls with major injury	19.0%	3.2% 15.8 pts worse	3.3% 15.7 pts worse	Long Stay · 2024Q4-2025Q3 · 4Q avg 19.0% · Used in QM five-star
Percentage of long-stay residents who received an antianxiety or hypnotic medication	15.0%	19.9% 4.9 pts better	19.6% 4.6 pts better	Long Stay · 2024Q4-2025Q3 · 4Q avg 15.0%
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 · 4Q avg 0.0%
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	48.3%	68.9% 20.6 pts worse	81.7% 33.4 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 17.1% · Q2 35.0% · Q3 66.0% · Q4 74.4% · 4Q avg 48.3%
Percentage of short-stay residents who had an outpatient emergency department visit	12.2%	9.8% 2.4 pts worse	12.0% 0.2 pts worse	Short Stay · 20240701-20250630 · Adjusted 12.2% · Observed 11.9% · Expected 10.9% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	1.2%	1.5% 0.3 pts better	1.6% 0.4 pts better	Short Stay · 2024Q4-2025Q3 · Q1 0.6% · Q2 1.4% · Q3 2.3% · Q4 0.7% · 4Q avg 1.2% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	31.0%	68.7% 37.7 pts worse	79.7% 48.7 pts worse	Short Stay · 2024Q3-2025Q2 · 4Q avg 31.0%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	24.2%	23.1% 1.1 pts worse	23.9% 0.3 pts worse	Short Stay · 20240701-20250630 · Adjusted 24.2% · Observed 22.3% · Expected 21.9% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-06-25 · Fire 2025-06-25

3 health deficiencies

Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)

5 fire-safety deficiencies

Top issue: Egress (2 deficiencies)

Cycle 2 Health 2025-01-16 · Fire 2025-01-16

17 health deficiencies

Top issue: Quality of Life and Care (7 deficiencies)

5 fire-safety deficiencies

Top issue: Egress (2 deficiencies)

Cycle 3 Health 2024-03-15 · Fire 2024-03-15

11 health deficiencies

Top issue: Quality of Life and Care (6 deficiencies)

5 fire-safety deficiencies

Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)

Fire safety

Fire-safety citations

E · Potential for more than minimal harm 2025-06-25

K291 · Egress Deficiencies

Fire Safety

Install emergency lighting that can last at least 1 1/2 hours.

Corrected 2025-06-20

D · Potential for more than minimal harm 2025-06-25

K225 · Egress Deficiencies

Fire Safety

Have stairways and smokeproof enclosures used as exits that meet safety requirements.

Corrected 2025-06-20

D · Potential for more than minimal harm 2025-06-25

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2025-06-20

C · Minimal harm 2025-06-25

K521 · Services Deficiencies

Fire Safety

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Corrected 2025-06-20

C · Minimal harm 2025-06-25

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2025-06-20

F · Potential for more than minimal harm 2025-01-16

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2025-03-25

E · Potential for more than minimal harm 2025-01-16

K211 · Egress Deficiencies

Fire Safety

Keep aisles, corridors, and exits free of obstruction in case of emergency.

Corrected 2025-03-25

E · Potential for more than minimal harm 2025-01-16

K225 · Egress Deficiencies

Fire Safety

Have stairways and smokeproof enclosures used as exits that meet safety requirements.

Corrected 2025-04-16

E · Potential for more than minimal harm 2025-01-16

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 2025-03-25

E · Potential for more than minimal harm 2025-01-16

K923 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have proper medical gas storage and administration areas.

Corrected 2025-03-25

E · Potential for more than minimal harm 2024-03-15

K225 · Egress Deficiencies

Fire Safety

Have stairways and smokeproof enclosures used as exits that meet safety requirements.

Corrected 2024-04-12

E · Potential for more than minimal harm 2024-03-15

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 2024-04-12

E · Potential for more than minimal harm 2024-03-15

K351 · Smoke Deficiencies

Fire Safety

Install an approved automatic sprinkler system.

Corrected 2024-04-12

E · Potential for more than minimal harm 2024-03-15

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2024-04-12

E · Potential for more than minimal harm 2024-03-15

K929 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure precautions for handling oxygen cylinders and equipment are correctly followed.

Corrected 2024-04-12

Inspection history

Recent health citations

D · Potential for more than minimal harm 2025-12-15

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2026-01-06

D · Potential for more than minimal harm 2025-06-25

F606 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Not hire anyone with a finding of abuse, neglect, exploitation, or theft.

Corrected 2025-07-15

G · Actual harm 2025-04-15

F760 · Pharmacy Service Deficiencies

Health

Ensure that residents are free from significant medication errors.

Corrected 2025-04-14

G · Actual harm 2025-01-16

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2025-02-18

G · Actual harm 2025-01-16

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2025-02-18

E · Potential for more than minimal harm 2025-01-16

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-02-18

D · Potential for more than minimal harm 2025-01-16

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 2025-02-18

D · Potential for more than minimal harm 2025-01-16

F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Respond appropriately to all alleged violations.

Corrected 2025-02-18

D · Potential for more than minimal harm 2025-01-16

F686 · Quality of Life and Care Deficiencies

Health

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected 2025-02-18

D · Potential for more than minimal harm 2025-01-16

F692 · Quality of Life and Care Deficiencies

Health

Provide enough food/fluids to maintain a resident's health.

Corrected 2025-02-18

D · Potential for more than minimal harm 2025-01-16

F730 · Nursing and Physician Services Deficiencies

Health

Observe each nurse aide's job performance and give regular training.

Corrected 2025-02-18

D · Potential for more than minimal harm 2025-01-16

F758 · Pharmacy Service Deficiencies

Health

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Corrected 2025-02-18

D · Potential for more than minimal harm 2025-01-16

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 2025-02-18

G · Actual harm 2024-08-22

F686 · Quality of Life and Care Deficiencies

Health

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected 2024-10-07

D · Potential for more than minimal harm 2024-08-22

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 2024-10-07

D · Potential for more than minimal harm 2024-06-10

F692 · Quality of Life and Care Deficiencies

Health

Provide enough food/fluids to maintain a resident's health.

Corrected 2024-06-28

D · Potential for more than minimal harm 2024-06-10

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 2024-06-28

E · Potential for more than minimal harm 2024-04-25

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 2024-05-04

D · Potential for more than minimal harm 2024-04-25

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 2024-05-04

G · Actual harm 2024-03-15

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2024-04-16

G · Actual harm 2024-03-15

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2024-04-16

E · Potential for more than minimal harm 2024-03-15

F730 · Nursing and Physician Services Deficiencies

Health

Observe each nurse aide's job performance and give regular training.

Corrected 2024-04-16

E · Potential for more than minimal harm 2024-03-15

F760 · Pharmacy Service Deficiencies

Health

Ensure that residents are free from significant medication errors.

Corrected 2024-04-16

E · Potential for more than minimal harm 2024-03-15

F947 · Nursing and Physician Services Deficiencies

Health

Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.

Corrected 2024-04-16

D · Potential for more than minimal harm 2024-03-15

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 2024-04-16

D · Potential for more than minimal harm 2024-03-15

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 2024-04-16

D · Potential for more than minimal harm 2024-03-15

F692 · Quality of Life and Care Deficiencies

Health

Provide enough food/fluids to maintain a resident's health.

Corrected 2024-04-16

D · Potential for more than minimal harm 2024-03-15

F770 · Administration Deficiencies

Health

Provide timely, quality laboratory services/tests to meet the needs of residents.

Corrected 2024-04-16

D · Potential for more than minimal harm 2024-01-27

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2024-02-27

G · Actual harm 2023-12-19

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2024-01-23

D · Potential for more than minimal harm 2023-11-01

F686 · Quality of Life and Care Deficiencies

Health

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected 2023-12-19

Penalties and ownership

What sits behind the stars

$15,935 2025-04-15

Fine

Fine · fine $15,935

Fine

$66,420 2025-01-16

Fine

Fine · fine $66,420

Fine

$13,575 2024-08-22

Fine

Fine · fine $13,575

Fine

$8,400 2024-01-27

Fine

Fine · fine $8,400

Fine

$8,401 2024-01-27

Fine

Fine · fine $8,401

Fine

$7,443 2023-11-01

Fine

Fine · fine $7,443

Fine

Ownership

Exton Operator LLC

5% Or Greater Direct Ownership Interest · Organization

100% 1 facilities 2025-01-01

Cox-Malescio, Gigi

Operational/Managerial Control · Individual

0% 1 facilities 2025-02-24

Cox-Malescio, Gigi

Corporate Director · Individual

0% 1 facilities 2025-02-24

Manufacturers & Traders Trust Company

5% Or Greater Security Interest · Organization

0% 12 facilities 2025-01-01

Manufacturers & Traders Trust Company

5% Or Greater Mortgage Interest · Organization

0% 12 facilities 2025-01-01

Marquis Limited LLC

Operational/Managerial Control · Organization

0% 65 facilities 2025-01-01

Moore, Cameron

Operational/Managerial Control · Individual

0% 1 facilities 2025-01-01

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