Cycle 1
Health 2025-05-02 · Fire 2025-05-02
5 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Boothwyn, PA
Naamans Creek Country Manor
3-star overall rating with 3-star inspections with $8,190 in total fines with 5 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
1194 Naamans Creek Road, Boothwyn, PA
(610) 558-7840
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
90
Certified beds
Average residents
76
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1995-05-04
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
Hours and turnover
RN hours / resident day
0.82
Registered nurse staffing · state 0.78 · national 0.68
LPN hours / resident day
1.08
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
2.12
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
4.02
All reported nurse hours · state 3.89 · national 3.89
Licensed hours
1.90
RN + LPN hours · state 1.69 · national 1.54
Weekend hours
3.69
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.53
Weekend registered nurse coverage · state 0.55 · national 0.47
Physical therapist
0.04
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.89
CMS adjusted RN staffing hours
Adjusted total hours
4.36
CMS adjusted total nurse staffing hours
Case-mix index
1.26
Higher values indicate more complex resident acuity
RN turnover
56%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
54%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
8,375
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
26.94
Composite VBP score used to determine payment impact.
Payment multiplier
0.9844
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
6.23
Baseline 18.22% · Performance 18.55% · Measure score 6.23 · Achievement 6.23 · Improvement 0
Healthcare-associated infections
0.51
Baseline 4.87% · Performance 7.68% · Measure score 0.51 · Achievement 0.51 · Improvement 0
Total nurse turnover
1.84
Baseline 66.98% · Performance 57.14% · Measure score 1.84 · Achievement 1.60 · Improvement 1.84
Adjusted total nurse staffing
2.20
Baseline 4.58 hours · Performance 3.70 hours · Measure score 2.20 · Achievement 2.20 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 14.43% |
10.72%
3.7 pts worse
|
Worse than the National Rate · Eligible stays 234 · Observed rate 16.67% · Lower 95% interval 11.36% |
| Discharge to community | 60.28% |
50.57%
9.7 pts better
|
Better than the National Rate · Eligible stays 227 · Observed rate 57.27% · Lower 95% interval 53.26% |
| Medicare spending per beneficiary | 0.91 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 95.35% |
95.27%
0.1 pts better
|
Numerator 164 · Denominator 172 |
| Falls with major injury | 0.58% |
0.77%
0.2 pts better
|
Numerator 1 · Denominator 172 |
| Discharge self-care score | 40.14% |
53.69%
13.5 pts worse
|
Numerator 57 · Denominator 142 |
| Discharge mobility score | 33.8% |
50.94%
17.1 pts worse
|
Numerator 48 · Denominator 142 |
| Pressure ulcers or injuries, new or worsened | 2.33% |
2.29%
About the same
|
Numerator 4 · Denominator 172 · Adjusted rate 2.38% |
| Healthcare-associated infections requiring hospitalization | 7.68% |
7.12%
0.6 pts worse
|
No Different than the National Rate · Eligible stays 153 · Observed rate 7.84% · Lower 95% interval 4.78% |
| Staff COVID-19 vaccination coverage | 3.45% |
8.2%
4.7 pts worse
|
Numerator 4 · Denominator 116 |
| Staff flu vaccination coverage | 32.61% |
42%
9.4 pts worse
|
Numerator 45 · Denominator 138 |
| Discharge function score | 27.46% |
56.45%
29 pts worse
|
Numerator 39 · Denominator 142 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 90 · Denominator 90 |
| Transfer of health information to patient | 97.62% |
96.28%
1.3 pts better
|
Numerator 41 · Denominator 42 |
| Resident COVID-19 vaccinations up to date | 20.45% |
25.2%
4.8 pts worse
|
Numerator 18 · Denominator 88 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.0 |
1.7
0.3 pts worse
|
1.9
0.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.0 · Observed 2.9 · Expected 2.8 · 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 1.5 · Expected 1.9 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 73.5% |
86.9%
13.4 pts worse
|
93.4%
19.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 70.9% · Q2 74.5% · Q3 75.0% · Q4 74.0% · 4Q avg 73.5% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 82.3% |
93.5%
11.2 pts worse
|
95.5%
13.2 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 82.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.9% |
3.2%
1.7 pts worse
|
3.3%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.3% · Q2 5.5% · Q3 2.3% · Q4 4.0% · 4Q avg 4.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.5% |
6.5%
6 pts better
|
11.4%
10.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.0% · 4Q avg 0.5% |
| Percentage of long-stay residents who lose too much weight | 8.2% |
6.5%
1.7 pts worse
|
5.4%
2.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 12.5% · Q3 7.3% · Q4 11.1% · 4Q avg 8.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 8.7% |
19.9%
11.2 pts better
|
19.6%
10.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.8% · Q2 9.3% · Q3 7.0% · Q4 8.5% · 4Q avg 8.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 10.1% |
18.7%
8.6 pts better
|
16.7%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.9% · Q2 10.5% · Q3 11.8% · Q4 7.5% · 4Q avg 10.1% · 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 | 42.6% |
19.6%
23 pts worse
|
16.3%
26.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q2 39.2% · 4Q avg 42.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 27.0% |
18.3%
8.7 pts worse
|
14.9%
12.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.9% · Q2 34.7% · Q3 23.7% · Q4 25.6% · 4Q avg 27.0% · 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 | 2.6% |
1.7%
0.9 pts worse
|
1.7%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 4.0% · Q3 2.4% · Q4 2.0% · 4Q avg 2.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 23.4% |
26.4%
3 pts better
|
19.8%
3.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.4% · Q2 25.5% · Q3 22.9% · Q4 15.9% · 4Q avg 23.4% |
| Percentage of long-stay residents with pressure ulcers | 4.9% |
5.3%
0.4 pts better
|
5.1%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 2.1% · Q3 8.4% · Q4 6.3% · 4Q avg 4.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 61.8% |
68.9%
7.1 pts worse
|
81.7%
19.9 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 59.8% · Q2 57.1% · Q3 59.1% · Q4 71.6% · 4Q avg 61.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.0% |
9.8%
1.8 pts better
|
12.0%
4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.0% · Observed 8.0% · Expected 11.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.6% |
1.5%
0.9 pts better
|
1.6%
1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.7% · Q2 0.8% · Q3 0.7% · Q4 0.0% · 4Q avg 0.6% · 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 | 25.6% |
23.1%
2.5 pts worse
|
23.9%
1.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.6% · Observed 24.1% · Expected 22.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-05-17 · Fire 2024-05-17
5 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
5 fire-safety deficiencies
Top issue: Construction (1 deficiency)
Cycle 3
Health 2023-07-20 · Fire 2023-07-20
7 health deficiencies
Top issue: Resident Rights (3 deficiencies)
3 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-05-02
K342 · Smoke Deficiencies
Fire Safety
Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.
Corrected 2025-06-09
F · Potential for more than minimal harm
2025-05-02
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-06-09
F · Potential for more than minimal harm
2025-05-02
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-06-09
E · Potential for more than minimal harm
2024-05-17
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-07-30
E · Potential for more than minimal harm
2024-05-17
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-07-30
C · Minimal harm
2024-05-17
K100 · Construction Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2024-07-30
C · Minimal harm
2024-05-17
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-07-30
C · Minimal harm
2024-05-17
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-07-30
F · Potential for more than minimal harm
2023-07-20
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-10-06
E · Potential for more than minimal harm
2023-07-20
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2023-10-06
D · Potential for more than minimal harm
2023-07-20
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-10-06
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-05-02
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 2025-06-17
E · Potential for more than minimal harm
2025-05-02
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-06-17
E · Potential for more than minimal harm
2025-05-02
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-06-17
D · Potential for more than minimal harm
2025-05-02
F605 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Corrected 2025-06-17
D · Potential for more than minimal harm
2025-05-02
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 2025-06-17
D · Potential for more than minimal harm
2024-09-24
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 2024-10-15
E · Potential for more than minimal harm
2024-05-17
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 2024-07-08
D · Potential for more than minimal harm
2024-05-17
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 2024-07-08
D · Potential for more than minimal harm
2024-05-17
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-07-08
D · Potential for more than minimal harm
2024-05-17
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-07-08
D · Potential for more than minimal harm
2023-12-19
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 2024-01-19
E · Potential for more than minimal harm
2023-07-20
F574 · Resident Rights Deficiencies
Health
The resident has the right to receive notices in a format and a language he or she understands.
Corrected 2023-09-08
E · Potential for more than minimal harm
2023-07-20
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 2023-09-08
E · Potential for more than minimal harm
2023-07-20
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2023-09-08
E · Potential for more than minimal harm
2023-07-20
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 2023-09-08
D · Potential for more than minimal harm
2023-07-20
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-09-08
G · Actual harm
2023-05-09
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-05-24
Penalties and ownership
What sits behind the stars
$8,190
2023-05-09
Fine
Fine · fine $8,190
Fine
Ownership
Chr Consulting Services Inc
Operational/Managerial Control · Organization
Duggan, Timothy
Corporate Director · Individual
Evans, Angela
Operational/Managerial Control · Individual
Lake, Blair
Corporate Director · Individual
Leff, Alison
Operational/Managerial Control · Individual
Naamans Creek Care, Inc
5% Or Greater Direct Ownership Interest · Organization
Naamans Creek Care, Inc
Operational/Managerial Control · Organization
Pigg, Stephen
Corporate Officer · Individual
Waldrop, Mark
Corporate Director · Individual
Waldrop, Mark
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Encore At Windsor Hills
Wilmington, DE
5-star overall rating with 4-star inspections with $19,837 in total fines with 7 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#2
Encore At Wilmington
Wilmington, DE
2-star overall rating with 1-star inspections with $32,394 in total fines with 21 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#3
Kutz Rehabilitation And Nursing
Wilmington, DE
1-star overall rating with 1-star inspections with Special Focus status with abuse icon flag with $168,019 in total fines with 27 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
Jump out