Phoenixville, PA

Phoenix Center For Rehabilitation And Nursing,the

2-star overall rating with 1-star inspections with $40,095 in total fines with 8 recent health deficiencies

833 South Main Street, Phoenixville, PA

(610) 580-0100

Compare this facility

Overall

2 / 5

CMS overall stars

Health inspections

1 / 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

138

Certified beds

Average residents

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Lme Family Holdings

Operator or chain grouping

Approved since

1970-07-20

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

15 facilities

Chain averages 2 overall / 2 health / 3 staffing / 3 quality stars

Changed ownership

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

0.44

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

2.13

Nurse aide staffing · state 2.20 · national 2.35

Total nurse hours

3.47

All reported nurse hours · state 3.89 · national 3.89

Licensed hours

1.34

RN + LPN hours · state 1.69 · national 1.54

Weekend hours

3.20

Weekend nurse staffing · state 3.51 · national 3.43

Weekend RN hours

0.31

Weekend registered nurse coverage · state 0.55 · national 0.47

Physical therapist

0.03

Reported PT staffing · state 0.10 · national 0.07

Adjusted RN hours

0.50

CMS adjusted RN staffing hours

Adjusted total hours

3.92

CMS adjusted total nurse staffing hours

Case-mix index

1.21

Higher values indicate more complex resident acuity

RN turnover

22%

Annual RN turnover · state 43% · national 45%

Total nurse turnover

64%

Annual nurse turnover · state 47% · national 46%

SNF VBP

Value-based purchasing

Program rank

12,325

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

12.87

Composite VBP score used to determine payment impact.

Payment multiplier

0.9811

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

1.45

Baseline 19.01% · Performance 20.76% · Measure score 1.45 · Achievement 1.45 · Improvement 0

Healthcare-associated infections

Baseline 5.64% · Performance 9.23% · Measure score 0 · Achievement 0 · Improvement 0

Total nurse turnover

0.87

Baseline 65.91% · Performance 60.29% · Measure score 0.87 · Achievement 0.83 · Improvement 0.87

Adjusted total nurse staffing

2.83

Baseline 3.84 hours · Performance 3.88 hours · Measure score 2.83 · Achievement 2.83 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	9.68%	10.72% 1 pts better	No Different than the National Rate · Eligible stays 74 · Observed rate 8.11% · Lower 95% interval 6.2%
Discharge to community	62.01%	50.57% 11.4 pts better	No Different than the National Rate · Eligible stays 38 · Observed rate 57.89% · Lower 95% interval 47.64%
Medicare spending per beneficiary	0.56	1.02 0.5 pts better
Drug regimen review with follow-up	100%	95.27% 4.7 pts better	Numerator 62 · Denominator 62
Falls with major injury	0%	0.77% 0.8 pts better	Numerator 0 · Denominator 62
Discharge self-care score	57.45%	53.69% 3.8 pts better	Numerator 27 · Denominator 47
Discharge mobility score	38.3%	50.94% 12.6 pts worse	Numerator 18 · Denominator 47
Pressure ulcers or injuries, new or worsened	0%	2.29% 2.3 pts better	Numerator 0 · Denominator 62 · Adjusted rate 0%
Healthcare-associated infections requiring hospitalization	9.23%	7.12% 2.1 pts worse	No Different than the National Rate · Eligible stays 55 · Observed rate 16.36% · Lower 95% interval 5.52%
Staff COVID-19 vaccination coverage	0%	8.2% 8.2 pts worse	Numerator 0 · Denominator 88
Staff flu vaccination coverage	21.28%	42% 20.7 pts worse	Numerator 30 · Denominator 141
Discharge function score	61.7%	56.45% 5.2 pts better	Numerator 29 · Denominator 47
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly.
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date	0%	25.2% 25.2 pts worse	Numerator 0 · Denominator 35

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	2.4	1.7 0.7 pts worse	1.9 0.5 pts worse	Long Stay · 20240701-20250630 · Adjusted 2.4 · Observed 2.6 · Expected 2.1 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	1.6	1.2 0.4 pts worse	1.8 0.2 pts better	Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 1.6 · Expected 1.7 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	28.7%	86.9% 58.2 pts worse	93.4% 64.7 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 33.3% · Q2 33.8% · Q3 24.7% · Q4 23.8% · 4Q avg 28.7%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	65.9%	93.5% 27.6 pts worse	95.5% 29.6 pts worse	Long Stay · 2024Q3-2025Q2 · 4Q avg 65.9%
Percentage of long-stay residents experiencing one or more falls with major injury	2.6%	3.2% 0.6 pts better	3.3% 0.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 2.6% · Q3 2.6% · Q4 3.8% · 4Q avg 2.6% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	15.0%	6.5% 8.5 pts worse	11.4% 3.6 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 13.6% · Q3 7.2% · Q4 32.9% · 4Q avg 15.0%
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 11.5% · Q2 10.1% · Q3 5.8% · Q4 5.7% · 4Q avg 8.2%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	20.1%	19.9% 0.2 pts worse	19.6% 0.5 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 15.6% · Q2 20.8% · Q3 20.8% · Q4 22.5% · 4Q avg 20.1%
Percentage of long-stay residents who received an antipsychotic medication	13.7%	18.7% 5 pts better	16.7% 3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 15.2% · Q2 8.9% · Q3 16.4% · Q4 13.6% · 4Q avg 13.7% · Used in QM five-star
Percentage of long-stay residents who were physically restrained	0.3%	0.2% 0.1 pts worse	0.1% 0.2 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3%
Percentage of long-stay residents whose ability to walk independently worsened	8.0%	19.6% 11.6 pts better	16.3% 8.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 8.0% · Q2 14.4% · Q3 8.5% · Q4 2.6% · 4Q avg 8.0% · Used in QM five-star
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 · Q1 8.5% · Q2 7.6% · Q3 5.7% · Q4 4.4% · 4Q avg 6.5% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.8%	0.9% 0.1 pts better	1.0% 0.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.2% · Q3 1.2% · Q4 0.9% · 4Q avg 0.8% · 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 · 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 new or worsened bowel or bladder incontinence	30.2%	26.4% 3.8 pts worse	19.8% 10.4 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 35.1% · Q2 22.2% · Q3 39.3% · Q4 24.9% · 4Q avg 30.2%
Percentage of long-stay residents with pressure ulcers	4.4%	5.3% 0.9 pts better	5.1% 0.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 7.0% · Q2 4.5% · Q3 5.5% · Q4 1.1% · 4Q avg 4.4% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	15.6%	68.9% 53.3 pts worse	81.7% 66.1 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 26.1% · Q2 14.9% · Q3 14.3% · Q4 8.0% · 4Q avg 15.6%
Percentage of short-stay residents who had an outpatient emergency department visit	9.9%	9.8% 0.1 pts worse	12.0% 2.1 pts better	Short Stay · 20240701-20250630 · Adjusted 9.9% · Observed 10.6% · Expected 12.0% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	0.8%	1.5% 0.7 pts better	1.6% 0.8 pts better	Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.8% · 4Q avg 0.8% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	26.7%	68.7% 42 pts worse	79.7% 53 pts worse	Short Stay · 2024Q3-2025Q2 · 4Q avg 26.7%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	14.8%	23.1% 8.3 pts better	23.9% 9.1 pts better	Short Stay · 20240701-20250630 · Adjusted 14.8% · Observed 15.2% · Expected 24.4% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-08-01 · Fire 2025-08-01

8 health deficiencies

Top issue: Quality of Life and Care (3 deficiencies)

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Cycle 2 Health 2024-08-22 · Fire 2024-08-22

12 health deficiencies

Top issue: Quality of Life and Care (5 deficiencies)

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Cycle 3 Health 2023-09-22 · Fire 2023-09-22

9 health deficiencies

Top issue: Quality of Life and Care (4 deficiencies)

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Inspection history

Recent health citations

D · Potential for more than minimal harm 2025-09-02

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 2025-09-25

E · Potential for more than minimal harm 2025-08-01

F628 · Resident Rights Deficiencies

Health

Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.

Corrected 2025-09-15

D · Potential for more than minimal harm 2025-08-01

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 2025-09-15

D · Potential for more than minimal harm 2025-08-01

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2025-09-15

D · Potential for more than minimal harm 2025-08-01

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 2025-09-15

L · Immediate jeopardy 2025-06-02

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 2025-06-02

D · Potential for more than minimal harm 2025-06-02

F835 · Administration Deficiencies

Health

Administer the facility in a manner that enables it to use its resources effectively and efficiently.

Corrected 2025-06-02

D · Potential for more than minimal harm 2025-03-20

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-04-04

D · Potential for more than minimal harm 2025-02-20

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 2025-03-20

D · Potential for more than minimal harm 2024-12-31

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 2025-01-31

D · Potential for more than minimal harm 2024-11-21

F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Corrected 2024-12-15

F · Potential for more than minimal harm 2024-08-22

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-09-30

E · Potential for more than minimal harm 2024-08-22

F692 · Quality of Life and Care Deficiencies

Health

Provide enough food/fluids to maintain a resident's health.

Corrected 2024-09-30

D · Potential for more than minimal harm 2024-08-22

F578 · Resident Rights Deficiencies

Health

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

Corrected 2024-09-30

D · Potential for more than minimal harm 2024-08-22

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 2024-09-30

D · Potential for more than minimal harm 2024-08-22

F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Respond appropriately to all alleged violations.

Corrected 2024-09-30

D · Potential for more than minimal harm 2024-08-22

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2024-09-30

D · Potential for more than minimal harm 2024-08-22

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 2024-09-30

D · Potential for more than minimal harm 2024-08-22

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 2024-09-30

D · Potential for more than minimal harm 2024-03-20

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2024-04-12

E · Potential for more than minimal harm 2023-09-22

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 2023-10-06

E · Potential for more than minimal harm 2023-09-22