Cycle 1
Health 2025-11-21 · Fire 2025-11-21
10 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
2 fire-safety deficiencies
Top issue: Emergency Preparedness (2 deficiencies)
Hatboro, PA
Luther Woods Nursing And Rehabilitation Center
4-star overall rating with 3-star inspections with 10 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
313 County Line Road, Hatboro, PA
(215) 675-5005
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
140
Certified beds
Average residents
127
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Lifeworks Rehab
Operator or chain grouping
Approved since
1977-06-08
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
59 facilities
Chain averages 2 overall / 2 health / 2 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
0.66
Registered nurse staffing · state 0.78 · national 0.68
LPN hours / resident day
0.65
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
2.07
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.38
All reported nurse hours · state 3.89 · national 3.89
Licensed hours
1.31
RN + LPN hours · state 1.69 · national 1.54
Weekend hours
3.03
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.47
Weekend registered nurse coverage · state 0.55 · national 0.47
Physical therapist
0.08
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.67
CMS adjusted RN staffing hours
Adjusted total hours
3.46
CMS adjusted total nurse staffing hours
Case-mix index
1.34
Higher values indicate more complex resident acuity
RN turnover
25%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
38%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
9,937
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
21.98
Composite VBP score used to determine payment impact.
Payment multiplier
0.9828
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 21.37% · Performance 24.82% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
2.09
Baseline 8.27% · Performance 7.42% · Measure score 2.09 · Achievement 1.38 · Improvement 2.09
Total nurse turnover
5.98
Baseline 44.55% · Performance 39.25% · Measure score 5.98 · Achievement 5.98 · Improvement 2.19
Adjusted total nurse staffing
0.72
Baseline 3.22 hours · Performance 3.28 hours · Measure score 0.72 · Achievement 0.72 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.75% |
10.72%
1 pts worse
|
No Different than the National Rate · Eligible stays 267 · Observed rate 13.48% · Lower 95% interval 8.94% |
| Discharge to community | 49.87% |
50.57%
0.7 pts worse
|
No Different than the National Rate · Eligible stays 262 · Observed rate 41.98% · Lower 95% interval 43.79% |
| Medicare spending per beneficiary | 1.01 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 99.18% |
95.27%
3.9 pts better
|
Numerator 241 · Denominator 243 |
| Falls with major injury | 1.23% |
0.77%
0.5 pts worse
|
Numerator 3 · Denominator 243 |
| Discharge self-care score | 26.62% |
53.69%
27.1 pts worse
|
Numerator 41 · Denominator 154 |
| Discharge mobility score | 46.75% |
50.94%
4.2 pts worse
|
Numerator 72 · Denominator 154 |
| Pressure ulcers or injuries, new or worsened | 1.23% |
2.29%
1.1 pts better
|
Numerator 3 · Denominator 243 · Adjusted rate 1.49% |
| Healthcare-associated infections requiring hospitalization | 7.42% |
7.12%
0.3 pts worse
|
No Different than the National Rate · Eligible stays 210 · Observed rate 8.1% · Lower 95% interval 5.05% |
| Staff COVID-19 vaccination coverage | 4.64% |
8.2%
3.6 pts worse
|
Numerator 7 · Denominator 151 |
| Staff flu vaccination coverage | 88.39% |
42%
46.4 pts better
|
Numerator 137 · Denominator 155 |
| Discharge function score | 53.25% |
56.45%
3.2 pts worse
|
Numerator 82 · Denominator 154 |
| Transfer of health information to provider | 98.81% |
95.95%
2.9 pts better
|
Numerator 83 · Denominator 84 |
| Transfer of health information to patient | 98.86% |
96.28%
2.6 pts better
|
Numerator 87 · Denominator 88 |
| Resident COVID-19 vaccinations up to date | 22.31% |
25.2%
2.9 pts worse
|
Numerator 29 · Denominator 130 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.8 |
1.7
1.1 pts worse
|
1.9
0.9 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.8 · Observed 3.5 · Expected 2.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.9 |
1.2
0.3 pts better
|
1.8
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.9 · Observed 1.0 · Expected 1.8 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 63.3% |
86.9%
23.6 pts worse
|
93.4%
30.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 74.1% · Q2 71.1% · Q3 52.7% · Q4 54.2% · 4Q avg 63.3% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 96.0% |
93.5%
2.5 pts better
|
95.5%
0.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 96.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.1% |
3.2%
0.1 pts better
|
3.3%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.2% · Q2 4.4% · Q3 1.8% · Q4 0.9% · 4Q avg 3.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 17.1% |
6.5%
10.6 pts worse
|
11.4%
5.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.6% · Q2 21.5% · Q3 18.5% · Q4 20.9% · 4Q avg 17.1% |
| Percentage of long-stay residents who lose too much weight | 7.3% |
6.5%
0.8 pts worse
|
5.4%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 6.5% · Q3 9.6% · Q4 9.3% · 4Q avg 7.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 23.6% |
19.9%
3.7 pts worse
|
19.6%
4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.8% · Q2 21.0% · Q3 24.8% · Q4 24.2% · 4Q avg 23.6% |
| 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 11.2% · Q2 14.6% · Q3 11.7% · Q4 11.4% · 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 | 15.3% |
19.6%
4.3 pts better
|
16.3%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.7% · Q2 17.5% · Q3 25.2% · Q4 5.2% · 4Q avg 15.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 12.8% |
18.3%
5.5 pts better
|
14.9%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.1% · Q2 13.6% · Q3 17.2% · Q4 7.8% · 4Q avg 12.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.3% |
0.9%
0.6 pts better
|
1.0%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.1% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.5% |
1.7%
1.2 pts better
|
1.7%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.9% · Q2 0.0% · Q3 1.0% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 28.6% |
26.4%
2.2 pts worse
|
19.8%
8.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.3% · Q2 36.1% · Q3 27.5% · Q4 26.5% · 4Q avg 28.6% |
| Percentage of long-stay residents with pressure ulcers | 2.8% |
5.3%
2.5 pts better
|
5.1%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 3.4% · Q3 1.7% · Q4 3.5% · 4Q avg 2.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 61.7% |
68.9%
7.2 pts worse
|
81.7%
20 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 83.0% · Q2 81.5% · Q3 52.3% · Q4 31.7% · 4Q avg 61.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 6.5% |
9.8%
3.3 pts better
|
12.0%
5.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 6.5% · Observed 6.4% · Expected 11.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.9% |
1.5%
0.6 pts better
|
1.6%
0.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.9% · Q2 0.9% · Q3 0.9% · Q4 0.8% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 84.0% |
68.7%
15.3 pts better
|
79.7%
4.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 84.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 31.6% |
23.1%
8.5 pts worse
|
23.9%
7.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 31.6% · Observed 33.3% · Expected 25.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-12-12 · Fire 2024-12-12
3 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
1 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Cycle 3
Health 2024-03-22 · Fire 2024-03-22
5 health deficiencies
Top issue: Administration (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
C · Minimal harm
2025-11-21
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2026-01-05
C · Minimal harm
2025-11-21
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2026-01-05
C · Minimal harm
2024-12-12
E26 · Emergency Preparedness Deficiencies
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2025-01-31
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-12-03
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-12-12
D · Potential for more than minimal harm
2025-12-03
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 2025-12-12
D · Potential for more than minimal harm
2025-12-03
F775 · Administration Deficiencies
Health
Keep complete, dated laboratory records in the resident's record.
Corrected 2025-12-12
D · Potential for more than minimal harm
2025-12-03
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 2025-12-12
F · Potential for more than minimal harm
2025-11-21
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2025-12-29
E · Potential for more than minimal harm
2025-11-21
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 2025-12-29
E · Potential for more than minimal harm
2025-11-21
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 2025-12-29
D · Potential for more than minimal harm
2025-11-21
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 2025-12-29
D · Potential for more than minimal harm
2025-11-21
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-12-29
D · Potential for more than minimal harm
2025-11-21
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-12-29
D · Potential for more than minimal harm
2024-12-12
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-01-03
D · Potential for more than minimal harm
2024-12-12
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 2024-12-31
D · Potential for more than minimal harm
2024-08-21
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 2024-09-13
D · Potential for more than minimal harm
2024-03-22
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 2024-04-10
D · Potential for more than minimal harm
2024-03-22
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-04-11
D · Potential for more than minimal harm
2024-03-22
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 2024-04-10
D · Potential for more than minimal harm
2024-03-22
F847 · Administration Deficiencies
Health
Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
Corrected 2024-04-11
E · Potential for more than minimal harm
2023-03-02
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 2023-03-20
Penalties and ownership
What sits behind the stars
Ownership
Luther Woods Health Holdco LLC
5% Or Greater Direct Ownership Interest · Organization
Birnbaum, Israel
5% Or Greater Indirect Ownership Interest · Individual
Kohn, Avrohom
5% Or Greater Indirect Ownership Interest · Individual
Netzer, Michele
5% Or Greater Indirect Ownership Interest · Individual
Mclaughlin, Lynn
W-2 Managing Employee · Individual
Netzer, Michele
Corporate Director · Individual
Vita Healthcare Group LLC
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
#1
Majestic Oaks Rehabilitation And Nursing Center
Warminster, PA
1-star overall rating with 1-star inspections with $35,175 in total fines with 21 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#2
Ann's Choice
Warminster, PA
5-star overall rating with 4-star inspections with 4 recent health deficiencies
#3
Willow Grove Post Acute
Hatboro, PA
3-star overall rating with 2-star inspections with 20 recent health deficiencies with 15 fire-safety deficiencies in the latest cycle
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