Cycle 1
Health 2024-09-13 · Fire 2024-09-13
2 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
7 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
West Brandywine, PA
Inn At Freedom Village,the
5-star overall rating with 4-star inspections with 2 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
35 Freedom Boulevard, West Brandywine, PA
(484) 288-2300
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
60
Certified beds
Average residents
46
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Healthpeak Properties, Inc.
Operator or chain grouping
Approved since
1998-12-24
CMS approved date
Coverage
Medicare
Participation flags
Chain footprint
15 facilities
Chain averages 3 overall / 3 health / 4 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
1.09
Registered nurse staffing · state 0.78 · national 0.68
LPN hours / resident day
0.96
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
2.43
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
4.48
All reported nurse hours · state 3.89 · national 3.89
Licensed hours
2.05
RN + LPN hours · state 1.69 · national 1.54
Weekend hours
4.09
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.80
Weekend registered nurse coverage · state 0.55 · national 0.47
Physical therapist
0.11
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
1.08
CMS adjusted RN staffing hours
Adjusted total hours
4.41
CMS adjusted total nurse staffing hours
Case-mix index
1.39
Higher values indicate more complex resident acuity
RN turnover
41%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
39%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
2,115
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
51.66
Composite VBP score used to determine payment impact.
Payment multiplier
1.0061
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.77
Baseline 20.98% · Performance 19.22% · Measure score 4.77 · Achievement 4.77 · Improvement 3.95
Healthcare-associated infections
6.42
Baseline 4.88% · Performance 5.92% · Measure score 6.42 · Achievement 6.42 · Improvement 0
Total nurse turnover
4.46
Baseline 53.95% · Performance 45.45% · Measure score 4.46 · Achievement 4.46 · Improvement 2.42
Adjusted total nurse staffing
5.01
Baseline 4.65 hours · Performance 4.50 hours · Measure score 5.01 · Achievement 5.01 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.96% |
10.72%
1.2 pts worse
|
No Different than the National Rate · Eligible stays 238 · Observed rate 11.34% · Lower 95% interval 8.75% |
| Discharge to community | 63.22% |
50.57%
12.6 pts better
|
Better than the National Rate · Eligible stays 220 · Observed rate 63.64% · Lower 95% interval 57.79% |
| Medicare spending per beneficiary | 0.68 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 99.21% |
95.27%
3.9 pts better
|
Numerator 126 · Denominator 127 |
| Falls with major injury | 0.79% |
0.77%
About the same
|
Numerator 1 · Denominator 127 |
| Discharge self-care score | 43.27% |
53.69%
10.4 pts worse
|
Numerator 45 · Denominator 104 |
| Discharge mobility score | 45.19% |
50.94%
5.8 pts worse
|
Numerator 47 · Denominator 104 |
| Pressure ulcers or injuries, new or worsened | 1.57% |
2.29%
0.7 pts better
|
Numerator 2 · Denominator 127 · Adjusted rate 1.69% |
| Healthcare-associated infections requiring hospitalization | 5.92% |
7.12%
1.2 pts better
|
No Different than the National Rate · Eligible stays 131 · Observed rate 3.82% · Lower 95% interval 3.27% |
| Staff COVID-19 vaccination coverage | 2.24% |
8.2%
6 pts worse
|
Numerator 3 · Denominator 134 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 48.08% |
56.45%
8.4 pts worse
|
Numerator 50 · Denominator 104 |
| Transfer of health information to provider | 47.83% |
95.95%
48.1 pts worse
|
Numerator 11 · Denominator 23 |
| Transfer of health information to patient | 98.75% |
96.28%
2.5 pts better
|
Numerator 79 · Denominator 80 |
| Resident COVID-19 vaccinations up to date | 59.42% |
25.2%
34.2 pts better
|
Numerator 41 · Denominator 69 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.6 |
1.7
0.1 pts better
|
1.9
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 1.3 · Expected 1.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.3 |
1.2
0.1 pts worse
|
1.8
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.1 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 73.0% |
86.9%
13.9 pts worse
|
93.4%
20.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 64.9% · Q2 71.4% · Q3 73.5% · Q4 83.9% · 4Q avg 73.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
93.5%
6.5 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.7% |
3.2%
2.5 pts better
|
3.3%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.9% · Q4 0.0% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 8.8% |
6.5%
2.3 pts worse
|
11.4%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.1% · Q2 6.9% · Q3 15.4% · Q4 8.0% · 4Q avg 8.8% |
| Percentage of long-stay residents who lose too much weight | 7.9% |
6.5%
1.4 pts worse
|
5.4%
2.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 8.3% · Q3 13.0% · Q4 8.0% · 4Q avg 7.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 19.2% |
19.9%
0.7 pts better
|
19.6%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.2% · Q2 19.2% · Q3 26.1% · Q4 15.4% · 4Q avg 19.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 8.8% |
18.7%
9.9 pts better
|
16.7%
7.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.6% · Q4 4.5% · 4Q avg 8.8% · 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 | 11.4% |
19.6%
8.2 pts better
|
16.3%
4.9 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 11.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 12.9% |
18.3%
5.4 pts better
|
14.9%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.1% · Q2 19.2% · Q3 13.6% · Q4 12.0% · 4Q avg 12.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.6% |
0.9%
0.3 pts better
|
1.0%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.3% · Q3 0.0% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.7% |
1.7%
2 pts worse
|
1.7%
2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.0% · Q3 8.8% · Q4 3.3% · 4Q avg 3.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 32.2% |
26.4%
5.8 pts worse
|
19.8%
12.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.8% · Q2 34.6% · Q3 46.7% · Q4 20.7% · 4Q avg 32.2% |
| Percentage of long-stay residents with pressure ulcers | 3.6% |
5.3%
1.7 pts better
|
5.1%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.5% · Q2 3.3% · Q3 1.7% · Q4 4.0% · 4Q avg 3.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 68.0% |
68.9%
0.9 pts worse
|
81.7%
13.7 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 46.9% · Q2 77.7% · Q3 72.3% · Q4 74.5% · 4Q avg 68.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 12.0% |
9.8%
2.2 pts worse
|
12.0%
About the same
|
Short Stay · 20240701-20250630 · Adjusted 12.0% · Observed 10.3% · Expected 9.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.3% |
1.5%
0.2 pts better
|
1.6%
0.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.4% · Q3 2.5% · Q4 1.3% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 83.8% |
68.7%
15.1 pts better
|
79.7%
4.1 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 83.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 25.7% |
23.1%
2.6 pts worse
|
23.9%
1.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.7% · Observed 21.6% · Expected 20.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-10-20 · Fire 2023-10-20
1 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
7 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2022-12-08 · Fire 2022-12-08
2 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
5 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-09-13
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-12-20
E · Potential for more than minimal harm
2024-09-13
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2024-11-11
E · Potential for more than minimal harm
2024-09-13
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 2024-11-11
E · Potential for more than minimal harm
2024-09-13
K754 · Miscellaneous Deficiencies
Fire Safety
Provide properly sized and located linen or trash receptacles.
Corrected 2024-11-11
C · Minimal harm
2024-09-13
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-11-11
C · Minimal harm
2024-09-13
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-11-11
C · Minimal harm
2024-09-13
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-11-11
E · Potential for more than minimal harm
2023-10-20
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-12-11
E · Potential for more than minimal harm
2023-10-20
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-12-11
E · Potential for more than minimal harm
2023-10-20
K531 · Services Deficiencies
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2023-12-11
C · Minimal harm
2023-10-20
K100 · Construction Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2023-12-11
C · Minimal harm
2023-10-20
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-12-11
C · Minimal harm
2023-10-20
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-12-11
C · Minimal harm
2023-10-20
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2023-12-11
E · Potential for more than minimal harm
2022-12-08
K929 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure precautions for handling oxygen cylinders and equipment are correctly followed.
Corrected 2022-12-23
C · Minimal harm
2022-12-08
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2022-12-23
C · Minimal harm
2022-12-08
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2022-12-23
C · Minimal harm
2022-12-08
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-12-23
C · Minimal harm
2022-12-08
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-12-23
Inspection history
Recent health citations
D · Potential for more than minimal harm
2024-09-13
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-10-10
D · Potential for more than minimal harm
2024-09-13
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 2024-10-10
D · Potential for more than minimal harm
2023-10-20
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-11-24
D · Potential for more than minimal harm
2022-12-08
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-01-15
D · Potential for more than minimal harm
2022-12-08
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-01-15
Penalties and ownership
What sits behind the stars
Ownership
Geyer, Danielle
Operational/Managerial Control · Individual
Life Care Services LLC
Operational/Managerial Control · Organization
Malawi, Lorna
Operational/Managerial Control · Individual
Malawi, Lorna
Corporate Officer · Individual
Ulichney, Andrew
Operational/Managerial Control · Individual
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