7 health deficiencies
Top issue: Infection Control (3 deficiencies)
5 fire-safety deficiencies
Top issue: Emergency Preparedness (2 deficiencies)
Philadelphia, PA
3-star overall rating with 3-star inspections with 7 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
6950 Germantown Avenue, Philadelphia, PA
(215) 848-3306
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Beds
180
Certified beds
Average residents
172
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1976-10-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
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
RN hours / resident day
0.49
Registered nurse staffing · state 0.78 · national 0.68
LPN hours / resident day
0.92
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
2.31
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.71
All reported nurse hours · state 3.89 · national 3.89
Licensed hours
1.40
RN + LPN hours · state 1.69 · national 1.54
Weekend hours
3.34
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.26
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
0.55
CMS adjusted RN staffing hours
Adjusted total hours
4.17
CMS adjusted total nurse staffing hours
Case-mix index
1.22
Higher values indicate more complex resident acuity
RN turnover
20%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
32%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Program rank
4,664
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
39.04
Composite VBP score used to determine payment impact.
Payment multiplier
0.9921
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
0
Baseline 20.49% · Performance 21.50% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
5.51
Baseline 6.09% · Performance 6.19% · Measure score 5.51 · Achievement 5.51 · Improvement 0
Total nurse turnover
6.3
Baseline 28.26% · Performance 37.93% · Measure score 6.3 · Achievement 6.3 · Improvement 0
Adjusted total nurse staffing
3.81
Baseline 3.76 hours · Performance 4.16 hours · Measure score 3.81 · Achievement 3.81 · Improvement 1.50
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.2% |
10.72%
1.5 pts better
|
No Different than the National Rate · Eligible stays 108 · Observed rate 6.48% · Lower 95% interval 6.33% |
| Discharge to community | 51.45% |
50.57%
0.9 pts better
|
No Different than the National Rate · Eligible stays 63 · Observed rate 42.86% · Lower 95% interval 41.04% |
| Medicare spending per beneficiary | 0.84 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 91.49% |
95.27%
3.8 pts worse
|
Numerator 86 · Denominator 94 |
| Falls with major injury | 1.06% |
0.77%
0.3 pts worse
|
Numerator 1 · Denominator 94 |
| Discharge self-care score | 44.87% |
53.69%
8.8 pts worse
|
Numerator 35 · Denominator 78 |
| Discharge mobility score | 33.33% |
50.94%
17.6 pts worse
|
Numerator 26 · Denominator 78 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 94 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.19% |
7.12%
0.9 pts better
|
No Different than the National Rate · Eligible stays 63 · Observed rate 4.76% · Lower 95% interval 3.53% |
| Staff COVID-19 vaccination coverage | 0.55% |
8.2%
7.6 pts worse
|
Numerator 1 · Denominator 181 |
| Staff flu vaccination coverage | 90.28% |
42%
48.3 pts better
|
Numerator 325 · Denominator 360 |
| Discharge function score | 33.33% |
56.45%
23.1 pts worse
|
Numerator 26 · Denominator 78 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 0% |
25.2%
25.2 pts worse
|
Numerator 0 · Denominator 53 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.7 |
1.7
About the same
|
1.9
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 1.4 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.8 |
1.2
0.4 pts better
|
1.8
1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.8 · Observed 0.6 · Expected 1.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 81.3% |
86.9%
5.6 pts worse
|
93.4%
12.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 82.6% · Q2 82.7% · Q3 85.2% · Q4 74.9% · 4Q avg 81.3% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.7% |
93.5%
4.2 pts better
|
95.5%
2.2 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.7% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.1% |
3.2%
2.1 pts better
|
3.3%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.6% · Q2 0.6% · Q3 1.2% · Q4 1.8% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.2% |
6.5%
6.3 pts better
|
11.4%
11.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.7% · 4Q avg 0.2% |
| Percentage of long-stay residents who lose too much weight | 6.6% |
6.5%
0.1 pts worse
|
5.4%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.6% · Q2 6.9% · Q3 6.5% · Q4 3.9% · 4Q avg 6.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 7.0% |
19.9%
12.9 pts better
|
19.6%
12.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.7% · Q2 7.9% · Q3 6.1% · Q4 6.0% · 4Q avg 7.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 11.0% |
18.7%
7.7 pts better
|
16.7%
5.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.7% · Q2 13.0% · Q3 9.9% · Q4 8.4% · 4Q avg 11.0% · 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 | 18.0% |
19.6%
1.6 pts better
|
16.3%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.8% · Q2 17.0% · Q3 18.1% · Q4 14.1% · 4Q avg 18.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 23.6% |
18.3%
5.3 pts worse
|
14.9%
8.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.7% · Q2 28.2% · Q3 20.2% · Q4 24.4% · 4Q avg 23.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.4% |
0.9%
1.5 pts worse
|
1.0%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 3.7% · Q3 2.3% · Q4 0.9% · 4Q avg 2.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.8% |
1.7%
0.9 pts better
|
1.7%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 1.3% · Q3 0.0% · Q4 0.0% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 20.2% |
26.4%
6.2 pts better
|
19.8%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.7% · Q2 21.1% · Q3 19.2% · Q4 17.6% · 4Q avg 20.2% |
| Percentage of long-stay residents with pressure ulcers | 4.8% |
5.3%
0.5 pts better
|
5.1%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.9% · Q2 7.0% · Q3 4.5% · Q4 2.6% · 4Q avg 4.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 53.6% |
68.9%
15.3 pts worse
|
81.7%
28.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 48.1% · Q2 61.7% · Q3 56.1% · Q4 47.0% · 4Q avg 53.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 4.7% |
9.8%
5.1 pts better
|
12.0%
7.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 4.7% · Observed 4.5% · Expected 10.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.1% |
1.5%
0.4 pts better
|
1.6%
0.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 2.2% · Q3 0.0% · Q4 0.0% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 51.2% |
68.7%
17.5 pts worse
|
79.7%
28.5 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 51.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 20.9% |
23.1%
2.2 pts better
|
23.9%
3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 20.9% · Observed 19.1% · Expected 21.7% · Used in QM five-star |
Survey summary
Top issue: Infection Control (3 deficiencies)
5 fire-safety deficiencies
Top issue: Emergency Preparedness (2 deficiencies)
Top issue: Resident Assessment and Care Planning (3 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Top issue: Quality of Life and Care (1 deficiency)
7 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-10-18
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-10-18
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-10-18
Fire Safety
Develop a communication plan.
Corrected 2025-10-18
Fire Safety
Provide a means of sharing information on occupancy/needs.
Corrected 2025-10-18
Fire Safety
Use approved construction type or materials.
Corrected 2024-11-29
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-11-29
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-11-29
Fire Safety
Install properly constructed and protected linen or trash chutes.
Corrected 2024-11-29
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-11-29
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2024-11-29
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-02-16
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-02-16
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2024-02-16
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-02-16
Fire Safety
Install properly constructed and protected linen or trash chutes.
Corrected 2024-02-16
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-02-16
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-02-16
Inspection history
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 2025-12-17
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 2025-09-25
Health
Provide and implement an infection prevention and control program.
Corrected 2025-09-25
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2025-09-25
Health
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Corrected 2025-09-25
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 2025-09-25
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-09-25
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2024-11-19
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-11-19
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-11-19
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 2024-11-19
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2024-11-19
Health
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Corrected 2024-11-19
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-11-30
Penalties and ownership
5% Or Greater Direct Ownership Interest · Organization
Corporate Officer · Individual
Operational/Managerial Control · Individual
Corporate Director · Individual
Corporate Officer · Individual
Corporate Officer · Individual
Corporate Director · Individual
Corporate Director · Individual
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