Cycle 1
Health 2025-08-29 · Fire 2025-08-29
3 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
2 fire-safety deficiencies
Top issue: Emergency Preparedness (2 deficiencies)
Philadelphia, PA
Paul's Run
5-star overall rating with 4-star inspections with 3 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
9896 Bustleton Avenue, Philadelphia, PA
(215) 934-3000
Overall
5 / 5
CMS overall stars
Health inspections
4 / 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
119
Certified beds
Average residents
109
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1987-08-10
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
0.90
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
2.37
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
4.09
All reported nurse hours · state 3.89 · national 3.89
Licensed hours
1.72
RN + LPN hours · state 1.69 · national 1.54
Weekend hours
3.67
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.74
Weekend registered nurse coverage · state 0.55 · national 0.47
Physical therapist
0.06
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.77
CMS adjusted RN staffing hours
Adjusted total hours
3.85
CMS adjusted total nurse staffing hours
Case-mix index
1.45
Higher values indicate more complex resident acuity
RN turnover
18%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
26%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,086
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
41.35
Composite VBP score used to determine payment impact.
Payment multiplier
0.9943
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.74
Baseline 22.49% · Performance 20.72% · Measure score 2.74 · Achievement 1.54 · Improvement 2.74
Healthcare-associated infections
2.37
Baseline 5.75% · Performance 7.13% · Measure score 2.37 · Achievement 2.37 · Improvement 0
Total nurse turnover
8.59
Performance 28.57% · Measure score 8.59 · Achievement 8.59 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
2.85
Baseline 3.58 hours · Performance 3.89 hours · Measure score 2.85 · Achievement 2.85 · Improvement 0.91
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.96% |
10.72%
0.2 pts worse
|
No Different than the National Rate · Eligible stays 417 · Observed rate 10.07% · Lower 95% interval 8.75% |
| Discharge to community | 65.74% |
50.57%
15.2 pts better
|
Better than the National Rate · Eligible stays 420 · Observed rate 59.76% · Lower 95% interval 61.37% |
| Medicare spending per beneficiary | 0.74 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 99.29% |
95.27%
4 pts better
|
Numerator 278 · Denominator 280 |
| Falls with major injury | 1.43% |
0.77%
0.7 pts worse
|
Numerator 4 · Denominator 280 |
| Discharge self-care score | 77.36% |
53.69%
23.7 pts better
|
Numerator 164 · Denominator 212 |
| Discharge mobility score | 74.06% |
50.94%
23.1 pts better
|
Numerator 157 · Denominator 212 |
| Pressure ulcers or injuries, new or worsened | 1.79% |
2.29%
0.5 pts better
|
Numerator 5 · Denominator 280 · Adjusted rate 1.39% |
| Healthcare-associated infections requiring hospitalization | 7.13% |
7.12%
About the same
|
No Different than the National Rate · Eligible stays 272 · Observed rate 6.25% · Lower 95% interval 4.85% |
| Staff COVID-19 vaccination coverage | 5% |
8.2%
3.2 pts worse
|
Numerator 8 · Denominator 160 |
| Staff flu vaccination coverage | 32.24% |
42%
9.8 pts worse
|
Numerator 69 · Denominator 214 |
| Discharge function score | 81.6% |
56.45%
25.1 pts better
|
Numerator 173 · Denominator 212 |
| Transfer of health information to provider | 96.88% |
95.95%
0.9 pts better
|
Numerator 62 · Denominator 64 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 161 · Denominator 161 |
| Resident COVID-19 vaccinations up to date | 32.12% |
25.2%
6.9 pts better
|
Numerator 44 · Denominator 137 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.4 |
1.7
0.3 pts better
|
1.9
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.5 · Expected 2.1 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.6 |
1.2
0.6 pts better
|
1.8
1.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.6 · Observed 0.6 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 50.0% |
86.9%
36.9 pts worse
|
93.4%
43.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 43.7% · Q2 53.4% · Q3 49.4% · Q4 53.7% · 4Q avg 50.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.9% |
93.5%
4.4 pts better
|
95.5%
2.4 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.1% |
3.2%
1.1 pts better
|
3.3%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 2.3% · Q3 2.4% · Q4 2.4% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.3% |
6.5%
6.2 pts better
|
11.4%
11.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.2% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% |
| Percentage of long-stay residents who lose too much weight | 6.3% |
6.5%
0.2 pts better
|
5.4%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.0% · Q2 6.7% · Q3 1.3% · Q4 9.6% · 4Q avg 6.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 17.6% |
19.9%
2.3 pts better
|
19.6%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.1% · Q2 19.5% · Q3 15.4% · Q4 18.7% · 4Q avg 17.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 10.6% |
18.7%
8.1 pts better
|
16.7%
6.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.5% · Q2 15.9% · Q3 7.4% · Q4 2.9% · 4Q avg 10.6% · 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 · 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 | 23.9% |
19.6%
4.3 pts worse
|
16.3%
7.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 33.2% · Q2 31.8% · Q3 10.0% · Q4 22.7% · 4Q avg 23.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 19.1% |
18.3%
0.8 pts worse
|
14.9%
4.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.7% · Q2 21.3% · Q3 13.3% · Q4 19.2% · 4Q avg 19.1% · 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 1.2% · Q2 0.0% · 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 | 0.6% |
1.7%
1.1 pts better
|
1.7%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.2% · Q4 1.2% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 28.3% |
26.4%
1.9 pts worse
|
19.8%
8.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.9% · Q2 37.8% · Q3 19.7% · Q4 28.4% · 4Q avg 28.3% |
| Percentage of long-stay residents with pressure ulcers | 4.2% |
5.3%
1.1 pts better
|
5.1%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 5.1% · Q3 5.2% · Q4 5.0% · 4Q avg 4.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 28.4% |
68.9%
40.5 pts worse
|
81.7%
53.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 20.1% · Q2 43.5% · Q3 35.2% · Q4 16.0% · 4Q avg 28.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.6% |
9.8%
2.2 pts better
|
12.0%
4.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.6% · Observed 6.7% · Expected 9.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.5%
1.5 pts better
|
1.6%
1.6 pts better
|
Short 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 short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 60.6% |
68.7%
8.1 pts worse
|
79.7%
19.1 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 60.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 28.7% |
23.1%
5.6 pts worse
|
23.9%
4.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 28.7% · Observed 25.0% · Expected 20.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-10-18 · Fire 2024-10-18
5 health deficiencies
Top issue: Infection Control (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2024-01-02 · Fire 2024-01-02
7 health deficiencies
Top issue: Infection Control (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
C · Minimal harm
2025-08-29
E30 · Emergency Preparedness Deficiencies
Fire Safety
List the names and contact information of those in the facility.
Corrected 2025-10-10
C · Minimal harm
2025-08-29
E9 · Emergency Preparedness Deficiencies
Fire Safety
Include a process for Emergency Preparedness collaboration.
Corrected 2025-10-10
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-08-29
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-10-22
D · Potential for more than minimal harm
2025-08-29
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 2025-10-22
D · Potential for more than minimal harm
2025-08-29
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-10-22
E · Potential for more than minimal harm
2024-10-18
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-11-18
D · Potential for more than minimal harm
2024-10-18
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 2024-11-18
D · Potential for more than minimal harm
2024-10-18
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-11-18
D · Potential for more than minimal harm
2024-10-18
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2024-11-18
B · Minimal harm
2024-10-18
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 2024-11-18
D · Potential for more than minimal harm
2024-01-02
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-02-22
D · Potential for more than minimal harm
2024-01-02
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 2024-02-22
D · Potential for more than minimal harm
2024-01-02
F691 · Quality of Life and Care Deficiencies
Health
Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.
Corrected 2024-02-22
D · Potential for more than minimal harm
2024-01-02
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-02-22
D · Potential for more than minimal harm
2024-01-02
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 2024-02-22
D · Potential for more than minimal harm
2024-01-02
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-02-22
C · Minimal harm
2024-01-02
F882 · Infection Control Deficiencies
Health
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Corrected 2024-02-22
Penalties and ownership
What sits behind the stars
Ownership
Liberty Lutheran Services
5% Or Greater Direct Ownership Interest · Organization
Barnum, John
Corporate Officer · Individual
Bortz, Beverly
Corporate Director · Individual
Breckenridge, Linda
Corporate Director · Individual
Fisher, Luanne
Corporate Officer · Individual
Galante, Michael
W-2 Managing Employee · Individual
Himler, James
Corporate Director · Individual
Hines, William
W-2 Managing Employee · Individual
Hopke, Fred
Corporate Director · Individual
Liberty Lutheran Services
Operational/Managerial Control · Organization
Matthias-Long, Wayne
Corporate Director · Individual
Myers, Joan
Corporate Officer · Individual
Redner, Dolores
W-2 Managing Employee · Individual
Steitz, Pamela
Corporate Director · Individual
Stettler, Dave
Corporate Director · Individual
Nearby options
Other facilities in reach
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Oakwood Healthcare & Rehabilitation Center
Philadelphia, PA
3-star overall rating with 3-star inspections with $5,269 in total fines with 7 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
St John Neumann Ctr For Rehab & Healthcare
Philadelphia, PA
2-star overall rating with 2-star inspections with $26,043 in total fines with 10 recent health deficiencies
#3
Chapel Manor
Philadelphia, PA
1-star overall rating with 1-star inspections with abuse icon flag with $120,333 in total fines with 17 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
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