Cycle 1
Health 2025-02-13 · Fire 2025-02-13
0 health deficiencies
No concentrated health issue counts in this cycle.
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
West Chester, PA
Pocopson Home
5-star overall rating with 4-star inspections with $16,036 in total fines
1695 Lenape Road, West Chester, PA
(610) 793-1212
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
275
Certified beds
Average residents
163
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1977-04-01
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
0.53
Registered nurse staffing · state 0.78 · national 0.68
LPN hours / resident day
1.23
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
2.36
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
4.11
All reported nurse hours · state 3.89 · national 3.89
Licensed hours
1.75
RN + LPN hours · state 1.69 · national 1.54
Weekend hours
3.57
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.27
Weekend registered nurse coverage · state 0.55 · national 0.47
Physical therapist
0.05
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.66
CMS adjusted RN staffing hours
Adjusted total hours
5.12
CMS adjusted total nurse staffing hours
Case-mix index
1.10
Higher values indicate more complex resident acuity
RN turnover
6%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
36%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
944
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
61.86
Composite VBP score used to determine payment impact.
Payment multiplier
1.0169
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
8.18
Baseline 21.93% · Performance 17.68% · Measure score 8.18 · Achievement 8.10 · Improvement 8.18
Healthcare-associated infections
2.20
Baseline 5.50% · Performance 7.18% · Measure score 2.20 · Achievement 2.20 · Improvement 0
Total nurse turnover
9
Baseline 84.85% · Performance 27.50% · Measure score 9 · Achievement 8.85 · Improvement 9
Adjusted total nurse staffing
5.37
Baseline 3.60 hours · Performance 4.60 hours · Measure score 5.37 · Achievement 5.37 · Improvement 4.11
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.6% |
10.72%
1.1 pts better
|
No Different than the National Rate · Eligible stays 99 · Observed rate 6.06% · Lower 95% interval 6.46% |
| Discharge to community | 40.02% |
50.57%
10.5 pts worse
|
No Different than the National Rate · Eligible stays 66 · Observed rate 33.33% · Lower 95% interval 27.17% |
| Medicare spending per beneficiary | 0.72 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 67 · Denominator 67 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 67 |
| Discharge self-care score | 34.69% |
53.69%
19 pts worse
|
Numerator 17 · Denominator 49 |
| Discharge mobility score | 20.41% |
50.94%
30.5 pts worse
|
Numerator 10 · Denominator 49 |
| Pressure ulcers or injuries, new or worsened | 4.48% |
2.29%
2.2 pts worse
|
Numerator 3 · Denominator 67 · Adjusted rate 3.7% |
| Healthcare-associated infections requiring hospitalization | 7.18% |
7.12%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 49 · Observed rate 6.12% · Lower 95% interval 3.79% |
| Staff COVID-19 vaccination coverage | 2.54% |
8.2%
5.7 pts worse
|
Numerator 6 · Denominator 236 |
| Staff flu vaccination coverage | 87.73% |
42%
45.7 pts better
|
Numerator 236 · Denominator 269 |
| Discharge function score | 38.78% |
56.45%
17.7 pts worse
|
Numerator 19 · Denominator 49 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 27 · Denominator 27 |
| Resident COVID-19 vaccinations up to date | 36.11% |
25.2%
10.9 pts better
|
Numerator 13 · Denominator 36 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.3 |
1.7
0.6 pts worse
|
1.9
0.4 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.3 · Observed 1.8 · Expected 1.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.8 |
1.2
0.4 pts better
|
1.8
1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.8 · Observed 0.7 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.2% |
86.9%
12.3 pts better
|
93.4%
5.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 98.8% · Q3 98.7% · Q4 99.4% · 4Q avg 99.2% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 99.4% |
93.5%
5.9 pts better
|
95.5%
3.9 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 99.4% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.5% |
3.2%
1.7 pts better
|
3.3%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 1.9% · Q3 1.3% · Q4 1.2% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.8% |
6.5%
5.7 pts better
|
11.4%
10.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.6% · Q2 1.3% · Q3 0.6% · Q4 0.7% · 4Q avg 0.8% |
| Percentage of long-stay residents who lose too much weight | 5.4% |
6.5%
1.1 pts better
|
5.4%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 4.7% · Q2 7.2% · Q3 5.8% · Q4 4.2% · 4Q avg 5.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 14.5% |
19.9%
5.4 pts better
|
19.6%
5.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.4% · Q2 14.7% · Q3 13.4% · Q4 14.6% · 4Q avg 14.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 16.1% |
18.7%
2.6 pts better
|
16.7%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 20.8% · Q2 18.6% · Q3 12.6% · Q4 12.2% · 4Q avg 16.1% · 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 | 11.1% |
19.6%
8.5 pts better
|
16.3%
5.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.4% · Q2 10.5% · Q3 14.0% · Q4 9.4% · 4Q avg 11.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 14.3% |
18.3%
4 pts better
|
14.9%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.7% · Q2 15.0% · Q3 11.9% · Q4 13.4% · 4Q avg 14.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.2% |
0.9%
0.7 pts better
|
1.0%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.6% · Q4 0.0% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.5% |
1.7%
1.2 pts better
|
1.7%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.6% · Q3 0.6% · Q4 0.6% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 26.0% |
26.4%
0.4 pts better
|
19.8%
6.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.4% · Q2 29.2% · Q3 25.8% · Q4 26.8% · 4Q avg 26.0% |
| Percentage of long-stay residents with pressure ulcers | 4.1% |
5.3%
1.2 pts better
|
5.1%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.6% · Q2 5.7% · Q3 2.9% · Q4 3.2% · 4Q avg 4.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 92.4% |
68.9%
23.5 pts better
|
81.7%
10.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 97.7% · Q2 92.7% · Q3 86.0% · Q4 93.5% · 4Q avg 92.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 14.5% |
9.8%
4.7 pts worse
|
12.0%
2.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 14.5% · Observed 13.3% · Expected 10.3% · 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 · 4Q avg 1.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 96.4% |
68.7%
27.7 pts better
|
79.7%
16.7 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 96.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 31.7% |
23.1%
8.6 pts worse
|
23.9%
7.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 31.7% · Observed 28.3% · Expected 21.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-03-22 · Fire 2024-03-22
1 health deficiencies
Top issue: Infection Control (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2023-04-27 · Fire 2023-04-27
8 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (3 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
2024-03-22
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-04-05
G · Actual harm
2024-02-14
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2024-03-08
G · Actual harm
2024-02-14
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 2024-03-08
D · Potential for more than minimal harm
2024-02-14
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 2024-03-08
D · Potential for more than minimal harm
2024-02-14
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-03-08
D · Potential for more than minimal harm
2023-04-27
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 2023-05-14
D · Potential for more than minimal harm
2023-04-27
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 2023-05-14
D · Potential for more than minimal harm
2023-04-27
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 2023-05-14
D · Potential for more than minimal harm
2023-04-27
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 2023-05-14
Penalties and ownership
What sits behind the stars
$8,018
2024-02-14
Fine
Fine · fine $8,018
Fine
$8,018
2024-02-14
Fine
Fine · fine $8,018
Fine
Ownership
Mancill, Thomas
Operational/Managerial Control · Individual
Mckenna, Jacqueline
Operational/Managerial Control · Individual
Mckenna, Jacqueline
Corporate Director · Individual
Mckenna, Jacqueline
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
#1
Crosslands
Kennett Square, PA
5-star overall rating with 4-star inspections with $12,735 in total fines with 3 recent health deficiencies
#2
Kendal At Longwood
Kennett Square, PA
5-star overall rating with 5-star inspections
#3
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
Jump out