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

Staffing

Hours and turnover

RN hours / resident day

0.65

Registered nurse staffing

LPN hours / resident day

1.02

Licensed practical nurse staffing

Aide hours / resident day

1.97

Nurse aide staffing

Weekend hours

3.08

Weekend nurse staffing

RN turnover

46%

Annual RN turnover

Total nurse turnover

54%

Annual nurse turnover

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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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

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