8 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
1 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Easton, PA
4-star overall rating with 3-star inspections with 8 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
4100 Freemansburg Avenue, Easton, PA
(610) 330-9030
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
Beds
180
Certified beds
Average residents
171
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Marquis Health Services
Operator or chain grouping
Approved since
2001-07-12
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
81 facilities
Chain averages 3 overall / 3 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
RN hours / resident day
0.45
Registered nurse staffing · state 0.78 · national 0.68
LPN hours / resident day
0.80
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
2.18
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.43
All reported nurse hours · state 3.89 · national 3.89
Licensed hours
1.25
RN + LPN hours · state 1.69 · national 1.54
Weekend hours
3.14
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
0.04
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.44
CMS adjusted RN staffing hours
Adjusted total hours
3.41
CMS adjusted total nurse staffing hours
Case-mix index
1.38
Higher values indicate more complex resident acuity
RN turnover
16%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
29%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Program rank
1,192
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
59.01
Composite VBP score used to determine payment impact.
Payment multiplier
1.0142
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
5.73
Baseline 23.39% · Performance 19.43% · Measure score 5.73 · Achievement 4.33 · Improvement 5.73
Healthcare-associated infections
9.02
Baseline 5.72% · Performance 5.14% · Measure score 9.02 · Achievement 9.02 · Improvement 7.53
Total nurse turnover
7.69
Baseline 58.75% · Performance 32.26% · Measure score 7.69 · Achievement 7.69 · Improvement 7.31
Adjusted total nurse staffing
1.16
Baseline 3.24 hours · Performance 3.41 hours · Measure score 1.16 · Achievement 1.16 · Improvement 0.14
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.97% |
10.72%
0.8 pts better
|
No Different than the National Rate · Eligible stays 538 · Observed rate 9.67% · Lower 95% interval 8.12% |
| Discharge to community | 56.99% |
50.57%
6.4 pts better
|
Better than the National Rate · Eligible stays 557 · Observed rate 50.45% · Lower 95% interval 52.32% |
| Medicare spending per beneficiary | 0.9 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 88.94% |
95.27%
6.3 pts worse
|
Numerator 362 · Denominator 407 |
| Falls with major injury | 0.49% |
0.77%
0.3 pts better
|
Numerator 2 · Denominator 406 |
| Discharge self-care score | 61.65% |
53.69%
8 pts better
|
Numerator 164 · Denominator 266 |
| Discharge mobility score | 63.16% |
50.94%
12.2 pts better
|
Numerator 168 · Denominator 266 |
| Pressure ulcers or injuries, new or worsened | 0.49% |
2.29%
1.8 pts better
|
Numerator 2 · Denominator 406 · Adjusted rate 0.56% |
| Healthcare-associated infections requiring hospitalization | 5.14% |
7.12%
2 pts better
|
No Different than the National Rate · Eligible stays 304 · Observed rate 3.95% · Lower 95% interval 3.27% |
| Staff COVID-19 vaccination coverage | 1.02% |
8.2%
7.2 pts worse
|
Numerator 2 · Denominator 197 |
| Staff flu vaccination coverage | 30% |
42%
12 pts worse
|
Numerator 72 · Denominator 240 |
| Discharge function score | 74.44% |
56.45%
18 pts better
|
Numerator 198 · Denominator 266 |
| Transfer of health information to provider | 98.34% |
95.95%
2.4 pts better
|
Numerator 297 · Denominator 302 |
| Transfer of health information to patient | 93.55% |
96.28%
2.7 pts worse
|
Numerator 58 · Denominator 62 |
| Resident COVID-19 vaccinations up to date | 12.8% |
25.2%
12.4 pts worse
|
Numerator 27 · Denominator 211 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.9 |
1.7
0.2 pts worse
|
1.9
About the same
|
Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 1.5 · Expected 1.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.1 |
1.2
1.1 pts better
|
1.8
1.7 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.1 · Observed 0.1 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
86.9%
13.1 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.0% |
93.5%
3.5 pts better
|
95.5%
1.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.5% |
3.2%
0.7 pts better
|
3.3%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.9% · Q2 2.5% · Q3 1.8% · Q4 1.6% · 4Q avg 2.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 20.8% |
6.5%
14.3 pts worse
|
11.4%
9.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 34.4% · Q2 20.4% · Q3 13.1% · Q4 13.4% · 4Q avg 20.8% |
| Percentage of long-stay residents who lose too much weight | 2.2% |
6.5%
4.3 pts better
|
5.4%
3.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 0.9% · Q3 0.9% · Q4 5.2% · 4Q avg 2.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 24.7% |
19.9%
4.8 pts worse
|
19.6%
5.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.8% · Q2 29.3% · Q3 21.3% · Q4 21.2% · 4Q avg 24.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 13.2% |
18.7%
5.5 pts better
|
16.7%
3.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.1% · Q2 11.7% · Q3 12.4% · Q4 13.7% · 4Q avg 13.2% · 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 | 13.8% |
19.6%
5.8 pts better
|
16.3%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 13.9% · Q3 13.1% · Q4 27.0% · 4Q avg 13.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 10.4% |
18.3%
7.9 pts better
|
14.9%
4.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.3% · Q2 6.2% · Q3 7.5% · Q4 19.3% · 4Q avg 10.4% · 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 | 1.3% |
1.7%
0.4 pts better
|
1.7%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 0.0% · Q3 0.9% · Q4 0.8% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 18.7% |
26.4%
7.7 pts better
|
19.8%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 20.2% · Q2 20.1% · Q3 15.3% · Q4 19.0% · 4Q avg 18.7% |
| Percentage of long-stay residents with pressure ulcers | 3.0% |
5.3%
2.3 pts better
|
5.1%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 3.0% · Q3 3.0% · Q4 4.4% · 4Q avg 3.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 88.6% |
68.9%
19.7 pts better
|
81.7%
6.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 90.5% · Q2 83.6% · Q3 85.5% · Q4 95.7% · 4Q avg 88.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.1% |
9.8%
2.7 pts better
|
12.0%
4.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.1% · Observed 6.8% · Expected 10.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.5% |
1.5%
About the same
|
1.6%
0.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.4% · Q3 1.8% · Q4 3.7% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 75.7% |
68.7%
7 pts better
|
79.7%
4 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 75.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 30.2% |
23.1%
7.1 pts worse
|
23.9%
6.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 30.2% · Observed 27.4% · Expected 21.6% · Used in QM five-star |
Survey summary
Top issue: Quality of Life and Care (4 deficiencies)
1 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Top issue: Quality of Life and Care (2 deficiencies)
1 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Top issue: Nutrition and Dietary (2 deficiencies)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-05-14
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2024-05-15
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 2023-09-18
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-09-18
Inspection history
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-06-03
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-06-03
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-06-03
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-06-03
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2025-06-03
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2025-06-03
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2025-06-03
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2025-06-03
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-06-19
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-06-19
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-06-19
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-08-03
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2023-08-03
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2023-08-03
Penalties and ownership
5% Or Greater Direct Ownership Interest · Organization
5% Or Greater Security Interest · Organization
Operational/Managerial Control · Individual
Corporate Director · Individual
5% Or Greater Indirect Ownership Interest · Organization
Operational/Managerial Control · Individual
Operational/Managerial Control · Organization
5% Or Greater Indirect Ownership Interest · Organization
Operational/Managerial Control · Organization
Corporate Officer · Individual
5% Or Greater Indirect Ownership Interest · Organization
Operational/Managerial Control · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
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