Cycle 1
Health 2025-04-10 · Fire 2025-04-10
11 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
2 fire-safety deficiencies
Top issue: Emergency Preparedness (2 deficiencies)
Pottstown, PA
Pottstown Skilled Nursing and Rehabilitation Cente
3-star overall rating with 3-star inspections with 11 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
724 North Charlotte St, Pottstown, PA
(610) 323-1837
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
150
Certified beds
Average residents
134
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Genesis Healthcare
Operator or chain grouping
Approved since
1978-02-08
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
193 facilities
Chain averages 2 overall / 2 health / 3 staffing / 3 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
0.65
Registered nurse staffing · state 0.78 · national 0.68
LPN hours / resident day
0.93
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
1.81
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.39
All reported nurse hours · state 3.89 · national 3.89
Licensed hours
1.57
RN + LPN hours · state 1.69 · national 1.54
Weekend hours
3.07
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.34
Weekend registered nurse coverage · state 0.55 · national 0.47
Physical therapist
0.12
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.65
CMS adjusted RN staffing hours
Adjusted total hours
3.41
CMS adjusted total nurse staffing hours
Case-mix index
1.36
Higher values indicate more complex resident acuity
RN turnover
50%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
45%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
6,709
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
31.95
Composite VBP score used to determine payment impact.
Payment multiplier
0.9868
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.22
Baseline 19.64% · Performance 19.01% · Measure score 5.22 · Achievement 5.22 · Improvement 1.89
Healthcare-associated infections
2.18
Baseline 5.44% · Performance 7.18% · Measure score 2.18 · Achievement 2.18 · Improvement 0
Total nurse turnover
4.01
Baseline 56.03% · Performance 47.27% · Measure score 4.01 · Achievement 4.01 · Improvement 2.31
Adjusted total nurse staffing
1.37
Baseline 3.44 hours · Performance 3.47 hours · Measure score 1.37 · Achievement 1.37 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.4% |
10.72%
0.7 pts worse
|
No Different than the National Rate · Eligible stays 244 · Observed rate 13.52% · Lower 95% interval 9.06% |
| Discharge to community | 53.23% |
50.57%
2.7 pts better
|
No Different than the National Rate · Eligible stays 231 · Observed rate 44.16% · Lower 95% interval 46.51% |
| Medicare spending per beneficiary | 0.83 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 83.15% |
95.27%
12.1 pts worse
|
Numerator 148 · Denominator 178 |
| Falls with major injury | 1.12% |
0.77%
0.4 pts worse
|
Numerator 2 · Denominator 178 |
| Discharge self-care score | 52.99% |
53.69%
0.7 pts worse
|
Numerator 62 · Denominator 117 |
| Discharge mobility score | 49.57% |
50.94%
1.4 pts worse
|
Numerator 58 · Denominator 117 |
| Pressure ulcers or injuries, new or worsened | 2.81% |
2.29%
0.5 pts worse
|
Numerator 5 · Denominator 178 · Adjusted rate 2.61% |
| Healthcare-associated infections requiring hospitalization | 7.18% |
7.12%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 164 · Observed rate 8.54% · Lower 95% interval 4.66% |
| Staff COVID-19 vaccination coverage | 1.61% |
8.2%
6.6 pts worse
|
Numerator 2 · Denominator 124 |
| Staff flu vaccination coverage | 51.79% |
42%
9.8 pts better
|
Numerator 159 · Denominator 307 |
| Discharge function score | 48.72% |
56.45%
7.7 pts worse
|
Numerator 57 · Denominator 117 |
| Transfer of health information to provider | 88.24% |
95.95%
7.7 pts worse
|
Numerator 60 · Denominator 68 |
| Transfer of health information to patient | 95.24% |
96.28%
1 pts worse
|
Numerator 60 · Denominator 63 |
| Resident COVID-19 vaccinations up to date | 26.92% |
25.2%
1.7 pts better
|
Numerator 28 · Denominator 104 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.2 |
1.7
0.5 pts worse
|
1.9
0.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.2 · Observed 2.6 · Expected 2.2 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.9 |
1.2
0.3 pts better
|
1.8
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.9 · Observed 1.0 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 89.3% |
86.9%
2.4 pts better
|
93.4%
4.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 88.6% · Q2 88.3% · Q3 89.9% · Q4 90.5% · 4Q avg 89.3% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 99.2% |
93.5%
5.7 pts better
|
95.5%
3.7 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 99.2% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.2% |
3.2%
2 pts worse
|
3.3%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.4% · Q2 5.4% · Q3 6.7% · Q4 4.3% · 4Q avg 5.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 13.3% |
6.5%
6.8 pts worse
|
11.4%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.5% · Q2 21.5% · Q3 8.8% · Q4 15.6% · 4Q avg 13.3% |
| Percentage of long-stay residents who lose too much weight | 7.2% |
6.5%
0.7 pts worse
|
5.4%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.8% · Q2 9.8% · Q3 9.2% · Q4 3.8% · 4Q avg 7.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 20.4% |
19.9%
0.5 pts worse
|
19.6%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.0% · Q2 16.0% · Q3 15.5% · Q4 30.0% · 4Q avg 20.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 21.9% |
18.7%
3.2 pts worse
|
16.7%
5.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.3% · Q2 20.3% · Q3 22.0% · Q4 20.0% · 4Q avg 21.9% · 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 | 28.8% |
19.6%
9.2 pts worse
|
16.3%
12.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.9% · Q2 29.1% · Q3 27.3% · Q4 32.4% · 4Q avg 28.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 31.0% |
18.3%
12.7 pts worse
|
14.9%
16.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.0% · Q2 31.1% · Q3 34.5% · Q4 30.8% · 4Q avg 31.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 3.5% |
0.9%
2.6 pts worse
|
1.0%
2.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 5.5% · Q3 2.5% · Q4 2.6% · 4Q avg 3.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.6% |
1.7%
0.1 pts better
|
1.7%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 0.9% · Q3 0.9% · Q4 0.9% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 24.1% |
26.4%
2.3 pts better
|
19.8%
4.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.3% · Q2 21.2% · Q3 29.4% · Q4 29.8% · 4Q avg 24.1% |
| Percentage of long-stay residents with pressure ulcers | 8.6% |
5.3%
3.3 pts worse
|
5.1%
3.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.8% · Q2 8.4% · Q3 8.9% · Q4 9.2% · 4Q avg 8.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 74.0% |
68.9%
5.1 pts better
|
81.7%
7.7 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 67.4% · Q2 65.2% · Q3 78.2% · Q4 88.7% · 4Q avg 74.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.4% |
9.8%
2.4 pts better
|
12.0%
4.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.4% · Observed 7.9% · Expected 11.9% · 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 2.7% · Q2 2.3% · Q3 0.8% · Q4 0.0% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 64.3% |
68.7%
4.4 pts worse
|
79.7%
15.4 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 64.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 22.4% |
23.1%
0.7 pts better
|
23.9%
1.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 22.4% · Observed 24.3% · Expected 25.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-06-27 · Fire 2024-06-27
5 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 3
Health 2023-05-05 · Fire 2023-05-05
10 health deficiencies
Top issue: Resident Rights (5 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
C · Minimal harm
2025-04-10
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2025-06-10
C · Minimal harm
2025-04-10
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2025-06-10
Inspection history
Recent health citations
E · Potential for more than minimal harm
2026-01-21
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 2026-02-10
C · Minimal harm
2026-01-21
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2026-02-10
D · Potential for more than minimal harm
2025-09-12
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-10-01
C · Minimal harm
2025-08-12
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Not marked corrected
E · Potential for more than minimal harm
2025-04-10
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 2025-05-13
D · Potential for more than minimal harm
2025-04-10
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-05-13
D · Potential for more than minimal harm
2025-04-10
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 2025-05-13
D · Potential for more than minimal harm
2025-04-10
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 2025-05-13
D · Potential for more than minimal harm
2025-04-10
F742 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
Corrected 2025-05-13
D · Potential for more than minimal harm
2025-04-10
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2025-05-13
C · Minimal harm
2025-04-10
F575 · Resident Rights Deficiencies
Health
Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency.
Corrected 2025-05-13
D · Potential for more than minimal harm
2024-06-27
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-07-26
D · Potential for more than minimal harm
2024-06-27
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-07-26
D · Potential for more than minimal harm
2024-06-27
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-07-26
D · Potential for more than minimal harm
2024-06-27
F688 · Quality of Life and Care Deficiencies
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 2024-07-26
D · Potential for more than minimal harm
2024-06-27
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-07-26
D · Potential for more than minimal harm
2023-05-15
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-06-26
D · Potential for more than minimal harm
2023-05-05
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2023-06-26
D · Potential for more than minimal harm
2023-05-05
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-06-26
D · Potential for more than minimal harm
2023-05-05
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 2023-06-26
D · Potential for more than minimal harm
2023-05-05
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 2023-06-26
D · Potential for more than minimal harm
2023-05-05
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-06-26
D · Potential for more than minimal harm
2023-05-05
F699 · Quality of Life and Care Deficiencies
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2023-06-26
D · Potential for more than minimal harm
2023-05-05
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2023-06-26
D · Potential for more than minimal harm
2023-05-05
F813 · Nutrition and Dietary Deficiencies
Health
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Corrected 2023-06-26
C · Minimal harm
2023-05-05
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 2023-06-26
Penalties and ownership
What sits behind the stars
Ownership
Genesis Pm Pa Operations LLC
5% Or Greater Direct Ownership Interest · Organization
Berg, Michael
Corporate Officer · Individual
Bridgeford, Laura
Corporate Officer · Individual
Fc-Gen Operations Investment LLC
5% Or Greater Indirect Ownership Interest · Organization
Feick, Dean
Operational/Managerial Control · Individual
Fishman, Steven
5% Or Greater Indirect Ownership Interest · Individual
Gen Operations I LLC
5% Or Greater Indirect Ownership Interest · Organization
Gen Operations Ii LLC
5% Or Greater Indirect Ownership Interest · Organization
Genesis Healthcare Inc
5% Or Greater Indirect Ownership Interest · Organization
Genesis Healthcare LLC
5% Or Greater Indirect Ownership Interest · Organization
Genesis Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Ghc Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Hccf Management Group Xi LLC
5% Or Greater Indirect Ownership Interest · Organization
Mendelson, Avi
Corporate Officer · Individual
Morris, Diane
Operational/Managerial Control · Individual
Sun Healthcare Group Inc
5% Or Greater Indirect Ownership Interest · Organization
Sundance Rehabilitation Holdco Inc
5% Or Greater Indirect Ownership Interest · Organization
Welltower Op LLC
5% Or Greater Indirect Ownership Interest · Organization
Whitman, Arnold
5% Or Greater Indirect Ownership Interest · Individual
Zac Properties Xi LLC
5% Or Greater Indirect Ownership Interest · Organization
Nearby options
Other facilities in reach
#1
Manatawny Center For Rehabilitation And Nursing
Pottstown, PA
4-star overall rating with 4-star inspections with $44,985 in total fines with 4 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
Sanatoga Center
Pottstown, PA
4-star overall rating with 4-star inspections with 4 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
#3
Frederick Living - Cedarwood
Frederick, PA
5-star overall rating with 5-star inspections with 1 fire-safety deficiencies in the latest cycle
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