Cycle 1
Health 2025-05-16 · Fire 2025-05-16
9 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
West Chester, PA
Park Lane Post Acute LLC
4-star overall rating with 3-star inspections with 9 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
1619 East Boot Road East Goshen, West Chester, PA
(484) 653-4400
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
68
Certified beds
Average residents
52
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Prestige Healthcare Administrative Services
Operator or chain grouping
Approved since
2002-11-27
CMS approved date
Coverage
Medicare
Participation flags
Chain footprint
15 facilities
Chain averages 3 overall / 3 health / 3 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
1.47
Registered nurse staffing · state 0.78 · national 0.68
LPN hours / resident day
0.87
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
4.53
All reported nurse hours · state 3.89 · national 3.89
Licensed hours
2.35
RN + LPN hours · state 1.69 · national 1.54
Weekend hours
4.25
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
1.06
Weekend registered nurse coverage · state 0.55 · national 0.47
Physical therapist
0.14
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
1.21
CMS adjusted RN staffing hours
Adjusted total hours
3.73
CMS adjusted total nurse staffing hours
Case-mix index
1.66
Higher values indicate more complex resident acuity
RN turnover
44%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
51%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
10,027
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
21.66
Composite VBP score used to determine payment impact.
Payment multiplier
0.9827
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 20.39% · Performance 24.44% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
3.57
Baseline 5.61% · Performance 6.77% · Measure score 3.57 · Achievement 3.57 · Improvement 0
Total nurse turnover
2.65
Baseline 45.65% · Performance 52.83% · Measure score 2.65 · Achievement 2.65 · Improvement 0
Adjusted total nurse staffing
2.44
Baseline 4.68 hours · Performance 3.77 hours · Measure score 2.44 · Achievement 2.44 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.38% |
10.72%
0.3 pts better
|
No Different than the National Rate · Eligible stays 501 · Observed rate 8.78% · Lower 95% interval 8.41% |
| Discharge to community | 61.03% |
50.57%
10.5 pts better
|
Better than the National Rate · Eligible stays 505 · Observed rate 58.81% · Lower 95% interval 56.72% |
| Medicare spending per beneficiary | 0.77 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 90.37% |
95.27%
4.9 pts worse
|
Numerator 319 · Denominator 353 |
| Falls with major injury | 0.57% |
0.77%
0.2 pts better
|
Numerator 2 · Denominator 353 |
| Discharge self-care score | 71.32% |
53.69%
17.6 pts better
|
Numerator 194 · Denominator 272 |
| Discharge mobility score | 67.28% |
50.94%
16.3 pts better
|
Numerator 183 · Denominator 272 |
| Pressure ulcers or injuries, new or worsened | 2.27% |
2.29%
About the same
|
Numerator 8 · Denominator 353 · Adjusted rate 2.56% |
| Healthcare-associated infections requiring hospitalization | 6.77% |
7.12%
0.4 pts better
|
No Different than the National Rate · Eligible stays 327 · Observed rate 5.5% · Lower 95% interval 4.65% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 97 |
| Staff flu vaccination coverage | 87.04% |
42%
45 pts better
|
Numerator 94 · Denominator 108 |
| Discharge function score | 73.16% |
56.45%
16.7 pts better
|
Numerator 199 · Denominator 272 |
| Transfer of health information to provider | 94.81% |
95.95%
1.1 pts worse
|
Numerator 73 · Denominator 77 |
| Transfer of health information to patient | 98.36% |
96.28%
2.1 pts better
|
Numerator 240 · Denominator 244 |
| Resident COVID-19 vaccinations up to date | 3.76% |
25.2%
21.4 pts worse
|
Numerator 7 · Denominator 186 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 25.9% |
86.9%
61 pts worse
|
93.4%
67.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 25.9% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 90.5% |
93.5%
3 pts worse
|
95.5%
5 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 90.5% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.7% |
3.2%
0.5 pts worse
|
3.3%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 3.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.7% |
6.5%
2.8 pts better
|
11.4%
7.7 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 3.7% |
| Percentage of long-stay residents who lose too much weight | 4.7% |
6.5%
1.8 pts better
|
5.4%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 4.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 15.9% |
19.9%
4 pts better
|
19.6%
3.7 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 15.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 17.6% |
18.7%
1.1 pts better
|
16.7%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 17.6% · 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 · 4Q avg 0.0% |
| Percentage of long-stay residents whose need for help with daily activities has increased | 6.5% |
18.3%
11.8 pts better
|
14.9%
8.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 6.5% · 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 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
1.7%
1.7 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 34.6% |
26.4%
8.2 pts worse
|
19.8%
14.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 34.6% |
| Percentage of long-stay residents with pressure ulcers | 0.0% |
5.3%
5.3 pts better
|
5.1%
5.1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 28.2% |
68.9%
40.7 pts worse
|
81.7%
53.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 24.3% · Q2 29.8% · Q3 29.1% · Q4 29.2% · 4Q avg 28.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 13.4% |
9.8%
3.6 pts worse
|
12.0%
1.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 13.4% · Observed 12.0% · Expected 10.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.4% |
1.5%
0.1 pts better
|
1.6%
0.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 1.3% · Q3 0.4% · Q4 0.9% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 41.9% |
68.7%
26.8 pts worse
|
79.7%
37.8 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 41.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.7% |
23.1%
0.6 pts worse
|
23.9%
0.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 23.7% · Observed 21.1% · Expected 21.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-04-19 · Fire 2024-04-19
12 health deficiencies
Top issue: Resident Assessment and Care Planning (6 deficiencies)
15 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Cycle 3
Health 2023-06-23 · Fire 2023-06-23
3 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
7 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-05-16
K100 · Construction Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2025-06-15
E · Potential for more than minimal harm
2025-05-16
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 2025-05-15
E · Potential for more than minimal harm
2025-05-16
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-05-15
E · Potential for more than minimal harm
2025-05-16
K325 · Smoke Deficiencies
Fire Safety
Have properly installed hallway dispensers for alcohol-based hand rub.
Corrected 2025-05-15
E · Potential for more than minimal harm
2025-05-16
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-05-15
E · Potential for more than minimal harm
2025-05-16
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-05-15
E · Potential for more than minimal harm
2025-05-16
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-05-15
C · Minimal harm
2025-05-16
E25 · Emergency Preparedness Deficiencies
Fire Safety
Create arrangements with other facilities to receive patients.
Corrected 2025-05-15
E · Potential for more than minimal harm
2024-04-19
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2024-05-30
E · Potential for more than minimal harm
2024-04-19
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-05-30
E · Potential for more than minimal harm
2024-04-19
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2024-05-30
E · Potential for more than minimal harm
2024-04-19
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 2024-05-30
E · Potential for more than minimal harm
2024-04-19
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-05-30
E · Potential for more than minimal harm
2024-04-19
K754 · Miscellaneous Deficiencies
Fire Safety
Provide properly sized and located linen or trash receptacles.
Corrected 2024-05-30
C · Minimal harm
2024-04-19
K100 · Construction Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2024-05-30
C · Minimal harm
2024-04-19
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-05-30
C · Minimal harm
2024-04-19
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-05-30
C · Minimal harm
2024-04-19
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-05-30
C · Minimal harm
2024-04-19
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-05-30
C · Minimal harm
2024-04-19
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-05-30
C · Minimal harm
2024-04-19
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-05-30
C · Minimal harm
2024-04-19
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 2024-05-30
C · Minimal harm
2024-04-19
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-05-30
F · Potential for more than minimal harm
2023-06-23
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-08-06
F · Potential for more than minimal harm
2023-06-23
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 2023-08-06
E · Potential for more than minimal harm
2023-06-23
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2023-08-06
E · Potential for more than minimal harm
2023-06-23
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2023-08-06
E · Potential for more than minimal harm
2023-06-23
K754 · Miscellaneous Deficiencies
Fire Safety
Provide properly sized and located linen or trash receptacles.
Corrected 2023-08-06
C · Minimal harm
2023-06-23
K100 · Construction Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2023-08-06
C · Minimal harm
2023-06-23
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-08-06
Inspection history
Recent health citations
D · Potential for more than minimal harm
2026-01-02
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 2026-02-10
E · Potential for more than minimal harm
2025-05-16
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-06-24
D · Potential for more than minimal harm
2025-05-16
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 2025-06-24
D · Potential for more than minimal harm
2025-05-16
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-06-24
D · Potential for more than minimal harm
2025-05-16
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-06-24
D · Potential for more than minimal harm
2025-05-16
F693 · Quality of Life and Care Deficiencies
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 2025-06-24
D · Potential for more than minimal harm
2025-05-16
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-06-24
D · Potential for more than minimal harm
2025-05-16
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 2025-06-24
D · Potential for more than minimal harm
2025-05-16
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 2025-06-24
F · Potential for more than minimal harm
2024-04-19
F642 · Resident Assessment and Care Planning Deficiencies
Health
Ensure a qualified health professional conducts resident assessments.
Corrected 2024-05-26
F · Potential for more than minimal harm
2024-04-19
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-05-26
E · Potential for more than minimal harm
2024-04-19
F636 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2024-05-26
E · Potential for more than minimal harm
2024-04-19
F638 · Resident Assessment and Care Planning Deficiencies
Health
Assure that each resident’s assessment is updated at least once every 3 months.
Corrected 2024-05-26
D · Potential for more than minimal harm
2024-04-19
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2024-05-26
D · Potential for more than minimal harm
2024-04-19
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-05-26
D · Potential for more than minimal harm
2024-04-19
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2024-05-26
D · Potential for more than minimal harm
2024-04-19
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 2024-05-26
D · Potential for more than minimal harm
2024-04-19
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-05-26
D · Potential for more than minimal harm
2024-04-19
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-05-26
D · Potential for more than minimal harm
2024-04-19
F690 · Quality of Life and Care Deficiencies
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 2024-05-26
D · Potential for more than minimal harm
2024-04-19
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 2024-05-26
D · Potential for more than minimal harm
2023-06-23
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-08-11
D · Potential for more than minimal harm
2023-06-23
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-08-11
D · Potential for more than minimal harm
2023-06-23
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-08-11
Penalties and ownership
What sits behind the stars
Ownership
Plpa Holdings LLC
5% Or Greater Direct Ownership Interest · Organization
Aysan Tr
5% Or Greater Indirect Ownership Interest · Organization
Buah Trust
5% Or Greater Indirect Ownership Interest · Organization
Copper De Trust
5% Or Greater Indirect Ownership Interest · Organization
Ellenbogen, Moss
Corporate Director · Individual
Gold De Trust
5% Or Greater Indirect Ownership Interest · Organization
Huyette, John
Operational/Managerial Control · Individual
Hykes, Jonathon
Operational/Managerial Control · Individual
Pa & De Noble Parentco LLC
5% Or Greater Indirect Ownership Interest · Organization
Silver De Trust
5% Or Greater Indirect Ownership Interest · Organization
Star Pa I Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Star Pa I Trust
5% Or Greater Indirect Ownership Interest · Organization
Nearby options
Other facilities in reach
#1
Barclay Friends
West Chester, PA
4-star overall rating with 4-star inspections with $9,440 in total fines with 1 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
West Chester Rehabilitation And Healthcare Center
West Chester, PA
2-star overall rating with 2-star inspections with $83,889 in total fines with 6 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Aventura At Pembrooke
West Chester, PA
1-star overall rating with 1-star inspections with 17 recent health deficiencies
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