Yeadon, PA

Providence Rehab And Hlthcare Ctratmercyfitzgerald

3-star overall rating with 2-star inspections with abuse icon flag with 9 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle

600 South Wycombe Ave, Yeadon, PA

(610) 626-8065

Compare this facility

Overall

3 / 5

CMS overall stars

Health inspections

2 / 5

Survey and complaint cycles

Staffing

2 / 5

RN + nurse staffing

Quality measures

5 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

129

Certified beds

Average residents

118

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Marquis Health Services

Operator or chain grouping

Approved since

1996-06-13

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

81 facilities

Chain averages 3 overall / 3 health / 2 staffing / 4 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

0.65

Registered nurse staffing · state 0.78 · national 0.68

LPN hours / resident day

1.02

Licensed practical nurse staffing · state 0.91 · national 0.87

Aide hours / resident day

1.97

Nurse aide staffing · state 2.20 · national 2.35

Total nurse hours

3.64

All reported nurse hours · state 3.89 · national 3.89

Licensed hours

1.67

RN + LPN hours · state 1.69 · national 1.54

Weekend hours

3.08

Weekend nurse staffing · state 3.51 · national 3.43

Weekend RN hours

0.36

Weekend registered nurse coverage · state 0.55 · national 0.47

Physical therapist

0.09

Reported PT staffing · state 0.10 · national 0.07

Adjusted RN hours

0.54

CMS adjusted RN staffing hours

Adjusted total hours

3.04

CMS adjusted total nurse staffing hours

Case-mix index

1.63

Higher values indicate more complex resident acuity

RN turnover

46%

Annual RN turnover · state 43% · national 45%

Total nurse turnover

54%

Annual nurse turnover · state 47% · national 46%

SNF VBP

Value-based purchasing

Program rank

10,314

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

Performance score

20.80

Composite VBP score used to determine payment impact.

Payment multiplier

0.9825

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

Baseline 22.26% · Performance 26.41% · Measure score 0 · Achievement 0 · Improvement 0

Healthcare-associated infections

2.28

Baseline 9.73% · Performance 8.41% · Measure score 2.28 · Achievement 0 · Improvement 2.28

Total nurse turnover

4.92

Baseline 51.89% · Performance 43.57% · Measure score 4.92 · Achievement 4.92 · Improvement 2.58

Adjusted total nurse staffing

1.13

Baseline 2.77 hours · Performance 3.26 hours · Measure score 1.13 · Achievement 0.65 · Improvement 1.13

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	12.69%	10.72% 2 pts worse	No Different than the National Rate · Eligible stays 218 · Observed rate 17.89% · Lower 95% interval 10.22%
Discharge to community	39.39%	50.57% 11.2 pts worse	Worse than the National Rate · Eligible stays 259 · Observed rate 29.34% · Lower 95% interval 31.97%
Medicare spending per beneficiary	1.21	1.02 0.2 pts worse
Drug regimen review with follow-up	99.24%	95.27% 4 pts better	Numerator 261 · Denominator 263
Falls with major injury	1.14%	0.77% 0.4 pts worse	Numerator 3 · Denominator 263
Discharge self-care score	59.88%	53.69% 6.2 pts better	Numerator 103 · Denominator 172
Discharge mobility score	56.98%	50.94% 6 pts better	Numerator 98 · Denominator 172
Pressure ulcers or injuries, new or worsened	0.76%	2.29% 1.5 pts better	Numerator 2 · Denominator 263 · Adjusted rate 0.58%
Healthcare-associated infections requiring hospitalization	8.41%	7.12% 1.3 pts worse	No Different than the National Rate · Eligible stays 199 · Observed rate 10.55% · Lower 95% interval 5.53%
Staff COVID-19 vaccination coverage	0.56%	8.2% 7.6 pts worse	Numerator 1 · Denominator 180
Staff flu vaccination coverage	6.45%	42% 35.5 pts worse	Numerator 16 · Denominator 248
Discharge function score	61.63%	56.45% 5.2 pts better	Numerator 106 · Denominator 172
Transfer of health information to provider	96.3%	95.95% 0.3 pts better	Numerator 78 · Denominator 81
Transfer of health information to patient	99.25%	96.28% 3 pts better	Numerator 132 · Denominator 133
Resident COVID-19 vaccinations up to date	2.48%	25.2% 22.7 pts worse	Numerator 3 · Denominator 121

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	1.5	1.7 0.2 pts better	1.9 0.4 pts better	Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 2.3 · Expected 2.9 · 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 0.9 · Expected 1.8 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	95.7%	86.9% 8.8 pts better	93.4% 2.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 94.4% · Q2 93.2% · Q3 98.6% · Q4 97.0% · 4Q avg 95.7%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	94.9%	93.5% 1.4 pts better	95.5% 0.6 pts worse	Long Stay · 2024Q3-2025Q2 · 4Q avg 94.9%
Percentage of long-stay residents experiencing one or more falls with major injury	3.9%	3.2% 0.7 pts worse	3.3% 0.6 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 5.5% · Q3 4.3% · Q4 1.5% · 4Q avg 3.9% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	30.6%	6.5% 24.1 pts worse	11.4% 19.2 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 26.2% · Q2 25.0% · Q3 26.2% · Q4 45.9% · 4Q avg 30.6%
Percentage of long-stay residents who lose too much weight	20.6%	6.5% 14.1 pts worse	5.4% 15.2 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 14.7% · Q2 28.4% · Q3 16.9% · Q4 22.4% · 4Q avg 20.6%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	10.2%	19.9% 9.7 pts better	19.6% 9.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 11.4% · Q2 14.5% · Q3 7.9% · Q4 6.3% · 4Q avg 10.2%
Percentage of long-stay residents who received an antipsychotic medication	2.1%	18.7% 16.6 pts better	16.7% 14.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 5.5% · Q2 2.5% · Q3 0.0% · Q4 0.0% · 4Q avg 2.1% · 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	7.6%	19.6% 12 pts better	16.3% 8.7 pts better	Long Stay · 2024Q4-2025Q3 · 4Q avg 7.6% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	7.1%	18.3% 11.2 pts better	14.9% 7.8 pts better	Long Stay · 2024Q4-2025Q3 · Q1 13.8% · Q2 4.8% · Q3 1.8% · Q4 7.1% · 4Q avg 7.1% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	1.4%	0.9% 0.5 pts worse	1.0% 0.4 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 2.0% · Q3 1.1% · Q4 1.3% · 4Q avg 1.4% · 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	30.9%	26.4% 4.5 pts worse	19.8% 11.1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 29.2% · Q2 28.7% · Q3 35.0% · Q4 31.1% · 4Q avg 30.9%
Percentage of long-stay residents with pressure ulcers	7.8%	5.3% 2.5 pts worse	5.1% 2.7 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 7.7% · Q2 8.0% · Q3 7.5% · Q4 8.0% · 4Q avg 7.8% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	87.3%	68.9% 18.4 pts better	81.7% 5.6 pts better	Short Stay · 2024Q4-2025Q3 · Q1 87.5% · Q2 88.0% · Q3 86.6% · Q4 87.0% · 4Q avg 87.3%
Percentage of short-stay residents who had an outpatient emergency department visit	5.9%	9.8% 3.9 pts better	12.0% 6.1 pts better	Short Stay · 20240701-20250630 · Adjusted 5.9% · Observed 5.9% · Expected 11.0% · 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 0.8% · Q2 0.8% · Q3 0.0% · Q4 0.4% · 4Q avg 0.5% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	85.4%	68.7% 16.7 pts better	79.7% 5.7 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 85.4%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	19.2%	23.1% 3.9 pts better	23.9% 4.7 pts better	Short Stay · 20240701-20250630 · Adjusted 19.2% · Observed 21.8% · Expected 27.1% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2026-01-14 · Fire 2026-01-14

9 health deficiencies

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

4 fire-safety deficiencies

Top issue: Smoke (2 deficiencies)

Cycle 2 Health 2025-01-15 · Fire 2025-01-15

13 health deficiencies

Top issue: Resident Assessment and Care Planning (3 deficiencies)

8 fire-safety deficiencies

Top issue: Smoke (3 deficiencies)

Cycle 3 Health 2024-02-07 · Fire 2024-02-07

7 health deficiencies

Top issue: Nutrition and Dietary (2 deficiencies)

1 fire-safety deficiencies

Top issue: Smoke (1 deficiency)

Fire safety

Fire-safety citations

E · Potential for more than minimal harm 2026-01-14

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2026-02-16

E · Potential for more than minimal harm 2026-01-14

K372 · Smoke Deficiencies

Fire Safety

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Corrected 2026-02-16

E · Potential for more than minimal harm 2026-01-14

K761 · Miscellaneous Deficiencies

Fire Safety

To conduct inspection, testing and maintenance of fire doors by qualified individuals.

Corrected 2026-02-16

C · Minimal harm 2026-01-14

E4 · Emergency Preparedness Deficiencies

Fire Safety

Develop and maintain an Emergency Preparedness Program (EP).

Corrected 2026-02-16

F · Potential for more than minimal harm 2025-01-15

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2025-03-15

F · Potential for more than minimal harm 2025-01-15

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2025-03-15

F · Potential for more than minimal harm 2025-01-15

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2025-03-15

E · Potential for more than minimal harm 2025-01-15

K211 · Egress Deficiencies

Fire Safety

Keep aisles, corridors, and exits free of obstruction in case of emergency.

Corrected 2025-03-15

E · Potential for more than minimal harm 2025-01-15

K222 · Egress Deficiencies

Fire Safety

Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

Corrected 2025-03-15

E · Potential for more than minimal harm 2025-01-15

K355 · Smoke Deficiencies

Fire Safety

Properly select, install, inspect, or maintain portable fire extinguishes.

Corrected 2025-03-15

E · Potential for more than minimal harm 2025-01-15

K511 · Services Deficiencies

Fire Safety

Have properly installed electrical wiring and gas equipment.

Corrected 2025-03-15

B · Minimal harm 2025-01-15

E26 · Emergency Preparedness Deficiencies

Fire Safety

Establish roles under a Waiver declared by secretary.

Corrected 2025-03-15

E · Potential for more than minimal harm 2024-02-07

K355 · Smoke Deficiencies

Fire Safety

Properly select, install, inspect, or maintain portable fire extinguishes.

Corrected 2024-03-11

Inspection history

Recent health citations

D · Potential for more than minimal harm 2026-01-14

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 2026-02-09

D · Potential for more than minimal harm 2026-01-14

F684 · Quality of Life and Care Deficiencies

Health

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

Corrected 2026-02-09

D · Potential for more than minimal harm 2026-01-14

F695 · Quality of Life and Care Deficiencies

Health

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

Corrected 2026-02-09

D · Potential for more than minimal harm 2026-01-02

F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Protect each resident from the wrongful use of the resident's belongings or money.

Not marked corrected

D · Potential for more than minimal harm 2025-05-06

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 2025-05-27

D · Potential for more than minimal harm 2025-04-23

F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Respond appropriately to all alleged violations.

Corrected 2025-05-19

D · Potential for more than minimal harm 2025-04-23

F694 · Quality of Life and Care Deficiencies

Health

Provide for the safe, appropriate administration of IV fluids for a resident when needed.

Corrected 2025-05-19

D · Potential for more than minimal harm 2025-04-23

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-05-19

D · Potential for more than minimal harm 2025-04-01

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 2025-04-21