Cycle 1
Health 2025-06-13 · Fire 2025-06-13
3 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
5 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
West Grove, PA
Preston Residence
5-star overall rating with 4-star inspections with 3 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
200 Sycamore Drive, West Grove, PA
(610) 869-6767
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
38
Certified beds
Average residents
27
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2004-05-19
CMS approved date
Coverage
Medicare
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
0.87
Registered nurse staffing · state 0.78 · national 0.68
LPN hours / resident day
1.05
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
2.64
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
4.55
All reported nurse hours · state 3.89 · national 3.89
Licensed hours
1.92
RN + LPN hours · state 1.69 · national 1.54
Weekend hours
4.26
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.64
Weekend registered nurse coverage · state 0.55 · national 0.47
Physical therapist
0.17
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.93
CMS adjusted RN staffing hours
Adjusted total hours
4.86
CMS adjusted total nurse staffing hours
Case-mix index
1.28
Higher values indicate more complex resident acuity
RN turnover
33%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
32%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
328
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
73.06
Composite VBP score used to determine payment impact.
Payment multiplier
1.0238
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.69
Baseline 19.60% · Performance 18.79% · Measure score 5.69 · Achievement 5.69 · Improvement 2.63
Healthcare-associated infections
10
Baseline 5.14% · Performance 4.84% · Measure score 10 · Achievement 10 · Improvement 9
Total nurse turnover
6.23
Performance 38.23% · Measure score 6.23 · Achievement 6.23 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.57% |
10.72%
1.8 pts worse
|
No Different than the National Rate · Eligible stays 284 · Observed rate 11.62% · Lower 95% interval 9.37% |
| Discharge to community | 67.79% |
50.57%
17.2 pts better
|
Better than the National Rate · Eligible stays 277 · Observed rate 68.59% · Lower 95% interval 62.31% |
| Medicare spending per beneficiary | 0.87 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 94% |
95.27%
1.3 pts worse
|
Numerator 94 · Denominator 100 |
| Falls with major injury | 1% |
0.77%
0.2 pts worse
|
Numerator 1 · Denominator 100 |
| Discharge self-care score | 67.07% |
53.69%
13.4 pts better
|
Numerator 55 · Denominator 82 |
| Discharge mobility score | 52.44% |
50.94%
1.5 pts better
|
Numerator 43 · Denominator 82 |
| Pressure ulcers or injuries, new or worsened | 1% |
2.29%
1.3 pts better
|
Numerator 1 · Denominator 100 · Adjusted rate 1.2% |
| Healthcare-associated infections requiring hospitalization | 4.84% |
7.12%
2.3 pts better
|
No Different than the National Rate · Eligible stays 141 · Observed rate 0.71% · Lower 95% interval 2.57% |
| Staff COVID-19 vaccination coverage | 2.27% |
8.2%
5.9 pts worse
|
Numerator 1 · Denominator 44 |
| Staff flu vaccination coverage | 85.51% |
42%
43.5 pts better
|
Numerator 59 · Denominator 69 |
| Discharge function score | 69.51% |
56.45%
13.1 pts better
|
Numerator 57 · Denominator 82 |
| 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 | 90% |
96.28%
6.3 pts worse
|
Numerator 63 · Denominator 70 |
| Resident COVID-19 vaccinations up to date | 69.23% |
25.2%
44 pts better
|
Numerator 27 · Denominator 39 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.6 |
1.7
0.1 pts better
|
1.9
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 2.8 · Expected 3.3 · 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 1.3 · Expected 2.2 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 39.0% |
86.9%
47.9 pts worse
|
93.4%
54.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 39.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.7% |
3.2%
1.5 pts better
|
3.3%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 1.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.9% |
6.5%
4.6 pts better
|
11.4%
9.5 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 1.9% |
| Percentage of long-stay residents who lose too much weight | 9.5% |
6.5%
3 pts worse
|
5.4%
4.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 9.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 17.0% |
19.9%
2.9 pts better
|
19.6%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 17.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 8.3% |
18.7%
10.4 pts better
|
16.7%
8.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 8.3% · 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 | 38.9% |
18.3%
20.6 pts worse
|
14.9%
24 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 38.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.0% |
0.9%
1.1 pts worse
|
1.0%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 2.0% · 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 | 32.8% |
26.4%
6.4 pts worse
|
19.8%
13 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 32.8% |
| Percentage of long-stay residents with pressure ulcers | 5.8% |
5.3%
0.5 pts worse
|
5.1%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 5.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 36.8% |
68.9%
32.1 pts worse
|
81.7%
44.9 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 49.1% · Q2 55.7% · Q3 22.2% · Q4 5.3% · 4Q avg 36.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 5.1% |
9.8%
4.7 pts better
|
12.0%
6.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 5.1% · Observed 4.4% · Expected 9.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.5% |
1.5%
1 pts better
|
1.6%
1.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.5% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 85.0% |
68.7%
16.3 pts better
|
79.7%
5.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 85.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 15.7% |
23.1%
7.4 pts better
|
23.9%
8.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 15.7% · Observed 13.2% · Expected 20.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-07-11 · Fire 2024-07-11
1 health deficiencies
Top issue: Infection Control (1 deficiency)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Cycle 3
Health 2023-08-30 · Fire 2023-08-30
2 health deficiencies
Top issue: Resident Assessment and Care Planning (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-06-13
K325 · Smoke Deficiencies
Fire Safety
Have properly installed hallway dispensers for alcohol-based hand rub.
Corrected 2025-08-24
E · Potential for more than minimal harm
2025-06-13
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-08-24
C · Minimal harm
2025-06-13
E30 · Emergency Preparedness Deficiencies
Fire Safety
List the names and contact information of those in the facility.
Corrected 2025-08-24
C · Minimal harm
2025-06-13
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-08-24
C · Minimal harm
2025-06-13
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-08-24
E · Potential for more than minimal harm
2024-07-11
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-07-24
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-06-13
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-08-12
D · Potential for more than minimal harm
2025-06-13
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-08-12
D · Potential for more than minimal harm
2025-06-13
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2025-08-12
D · Potential for more than minimal harm
2024-07-11
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-07-12
D · Potential for more than minimal harm
2023-08-30
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 2023-09-28
D · Potential for more than minimal harm
2023-08-30
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-09-28
Penalties and ownership
What sits behind the stars
Ownership
Jenner's Pond Inc.
5% Or Greater Direct Ownership Interest · Organization
Jenner's Pond Inc.
5% Or Greater Indirect Ownership Interest · Organization
Franiak, Kenneth
Operational/Managerial Control · Individual
Franiak, Kenneth
Corporate Officer · Individual
Jenner's Pond Inc.
Operational/Managerial Control · Organization
Tracy, Georgine
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Twin Pines Health Care Center
West Grove, PA
5-star overall rating with 4-star inspections with 8 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#2
Oxford Health Center
Oxford, PA
4-star overall rating with 4-star inspections with 2 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#3
Kendal At Longwood
Kennett Square, PA
5-star overall rating with 5-star inspections
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