Haverford, PA

Quadrangle

2-star overall rating with 2-star inspections with $8,278 in total fines with 17 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle

3300 Darby Road, Haverford, PA

(610) 642-3000

Compare this facility

Overall

2 / 5

CMS overall stars

Health inspections

2 / 5

Survey and complaint cycles

Staffing

4 / 5

RN + nurse staffing

Quality measures

4 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

Certified beds

Average residents

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Healthpeak Properties, Inc.

Operator or chain grouping

Approved since

1989-07-03

CMS approved date

Coverage

Medicare

Participation flags

Chain footprint

15 facilities

Chain averages 3 overall / 3 health / 4 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

1.23

Registered nurse staffing · state 0.78 · national 0.68

LPN hours / resident day

1.27

Licensed practical nurse staffing · state 0.91 · national 0.87

Aide hours / resident day

2.99

Nurse aide staffing · state 2.20 · national 2.35

Total nurse hours

5.49

All reported nurse hours · state 3.89 · national 3.89

Licensed hours

2.50

RN + LPN hours · state 1.69 · national 1.54

Weekend hours

5.06

Weekend nurse staffing · state 3.51 · national 3.43

Weekend RN hours

0.89

Weekend registered nurse coverage · state 0.55 · national 0.47

Physical therapist

0.22

Reported PT staffing · state 0.10 · national 0.07

Adjusted RN hours

1.18

CMS adjusted RN staffing hours

Adjusted total hours

5.28

CMS adjusted total nurse staffing hours

Case-mix index

1.42

Higher values indicate more complex resident acuity

RN turnover

Annual RN turnover

Total nurse turnover

Annual nurse turnover

SNF VBP

Value-based purchasing

Program rank

1,140

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

Performance score

59.52

Composite VBP score used to determine payment impact.

Payment multiplier

1.0147

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

3.64

Baseline 23.28% · Performance 20.69% · Measure score 3.64 · Achievement 1.60 · Improvement 3.64

Healthcare-associated infections

4.93

Baseline 5.63% · Performance 6.36% · Measure score 4.93 · Achievement 4.93 · Improvement 0

Total nurse turnover

Performance 23.94% · Measure score 10 · Achievement 10 · This facility did not have sufficient data to calculate a baseline period measure result.

Adjusted total nurse staffing

5.24

Baseline 4.34 hours · Performance 4.57 hours · Measure score 5.24 · Achievement 5.24 · Improvement 1.08

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	10.54%	10.72% 0.2 pts better	No Different than the National Rate · Eligible stays 512 · Observed rate 9.96% · Lower 95% interval 8.25%
Discharge to community	64.98%	50.57% 14.4 pts better	Better than the National Rate · Eligible stays 542 · Observed rate 60.52% · Lower 95% interval 59.79%
Medicare spending per beneficiary	0.88	1.02 0.1 pts better
Drug regimen review with follow-up	99.73%	95.27% 4.5 pts better	Numerator 364 · Denominator 365
Falls with major injury	1.37%	0.77% 0.6 pts worse	Numerator 5 · Denominator 365
Discharge self-care score	30.57%	53.69% 23.1 pts worse	Numerator 81 · Denominator 265
Discharge mobility score	46.79%	50.94% 4.1 pts worse	Numerator 124 · Denominator 265
Pressure ulcers or injuries, new or worsened	0.82%	2.29% 1.5 pts better	Numerator 3 · Denominator 365 · Adjusted rate 0.92%
Healthcare-associated infections requiring hospitalization	6.36%	7.12% 0.8 pts better	No Different than the National Rate · Eligible stays 334 · Observed rate 5.39% · Lower 95% interval 4.54%
Staff COVID-19 vaccination coverage	91.84%	8.2% 83.6 pts better	Numerator 90 · Denominator 98
Staff flu vaccination coverage	87.5%	42% 45.5 pts better	Numerator 70 · Denominator 80
Discharge function score	46.79%	56.45% 9.7 pts worse	Numerator 124 · Denominator 265
Transfer of health information to provider	100%	95.95% 4 pts better	Numerator 197 · Denominator 197
Transfer of health information to patient	99.24%	96.28% 3 pts better	Numerator 131 · Denominator 132
Resident COVID-19 vaccinations up to date	21.65%	25.2% 3.6 pts worse	Numerator 42 · Denominator 194

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	0.8	1.7 0.9 pts better	1.9 1.1 pts better	Long Stay · 20240701-20250630 · Adjusted 0.8 · Observed 1.0 · Expected 2.2 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	2.7	1.2 1.5 pts worse	1.8 0.9 pts worse	Long Stay · 20240701-20250630 · Adjusted 2.7 · Observed 2.9 · Expected 1.7 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	85.2%	86.9% 1.7 pts worse	93.4% 8.2 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 90.5% · Q3 91.3% · Q4 73.1% · 4Q avg 85.2%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	90.5%	93.5% 3 pts worse	95.5% 5 pts worse	Long Stay · 2024Q3-2025Q2 · 4Q avg 90.5%
Percentage of long-stay residents experiencing one or more falls with major injury	1.1%	3.2% 2.1 pts better	3.3% 2.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q3 0.0% · Q4 0.0% · 4Q avg 1.1% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	0.0%	6.5% 6.5 pts better	11.4% 11.4 pts better	Long Stay · 2024Q4-2025Q3 · Q3 0.0% · Q4 0.0% · 4Q avg 0.0%
Percentage of long-stay residents who lose too much weight	1.6%	6.5% 4.9 pts better	5.4% 3.8 pts better	Long Stay · 2024Q4-2025Q3 · 4Q avg 1.6%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	15.9%	19.9% 4 pts better	19.6% 3.7 pts better	Long Stay · 2024Q4-2025Q3 · Q4 10.0% · 4Q avg 15.9%
Percentage of long-stay residents who received an antipsychotic medication	12.5%	18.7% 6.2 pts better	16.7% 4.2 pts better	Long Stay · 2024Q4-2025Q3 · 4Q avg 12.5% · 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% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0%
Percentage of long-stay residents whose ability to walk independently worsened	18.2%	19.6% 1.4 pts better	16.3% 1.9 pts worse	Long Stay · 2024Q4-2025Q3 · 4Q avg 18.2% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	16.7%	18.3% 1.6 pts better	14.9% 1.8 pts worse	Long Stay · 2024Q4-2025Q3 · 4Q avg 16.7% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	1.2%	0.9% 0.3 pts worse	1.0% 0.2 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q4 1.9% · 4Q avg 1.2% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	2.4%	1.7% 0.7 pts worse	1.7% 0.7 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q3 9.1% · Q4 0.0% · 4Q avg 2.4% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	36.0%	26.4% 9.6 pts worse	19.8% 16.2 pts worse	Long Stay · 2024Q4-2025Q3 · Q4 30.2% · 4Q avg 36.0%
Percentage of long-stay residents with pressure ulcers	9.5%	5.3% 4.2 pts worse	5.1% 4.4 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 9.3% · Q3 11.7% · Q4 7.2% · 4Q avg 9.5% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	49.1%	68.9% 19.8 pts worse	81.7% 32.6 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 48.4% · Q2 48.4% · Q3 49.6% · Q4 50.6% · 4Q avg 49.1%
Percentage of short-stay residents who had an outpatient emergency department visit	15.0%	9.8% 5.2 pts worse	12.0% 3 pts worse	Short Stay · 20240701-20250630 · Adjusted 15.0% · Observed 12.8% · Expected 9.5% · 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 0.9% · Q2 1.8% · Q3 2.0% · Q4 1.1% · 4Q avg 1.5% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	47.1%	68.7% 21.6 pts worse	79.7% 32.6 pts worse	Short Stay · 2024Q3-2025Q2 · 4Q avg 47.1%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	22.5%	23.1% 0.6 pts better	23.9% 1.4 pts better	Short Stay · 20240701-20250630 · Adjusted 22.5% · Observed 20.2% · Expected 21.4% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-04-03 · Fire 2025-04-03

17 health deficiencies

Top issue: Quality of Life and Care (5 deficiencies)

7 fire-safety deficiencies

Top issue: Smoke (3 deficiencies)

Cycle 2 Health 2024-05-22 · Fire 2024-05-22

11 health deficiencies

Top issue: Nutrition and Dietary (2 deficiencies)

13 fire-safety deficiencies

Top issue: Smoke (5 deficiencies)

Cycle 3 Health 2023-08-07 · Fire 2023-08-07

8 health deficiencies

Top issue: Quality of Life and Care (3 deficiencies)

4 fire-safety deficiencies

Top issue: Egress (2 deficiencies)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2025-04-03

K291 · Egress Deficiencies

Fire Safety

Install emergency lighting that can last at least 1 1/2 hours.

Corrected 2025-06-10

F · Potential for more than minimal harm 2025-04-03

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2025-06-10

F · Potential for more than minimal harm 2025-04-03

K355 · Smoke Deficiencies

Fire Safety

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

Corrected 2025-06-10

F · Potential for more than minimal harm 2025-04-03

K761 · Miscellaneous Deficiencies

Fire Safety

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

Corrected 2025-06-10

F · Potential for more than minimal harm 2025-04-03

K914 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.

Corrected 2025-06-10

E · Potential for more than minimal harm 2025-04-03

K311 · Smoke Deficiencies

Fire Safety

Have an enclosure around a vertical opening shaft.

Corrected 2025-06-10

C · Minimal harm 2025-04-03

E39 · Emergency Preparedness Deficiencies

Fire Safety

Conduct testing and exercise requirements.

Corrected 2025-06-10

F · Potential for more than minimal harm 2024-05-22

K521 · Services Deficiencies

Fire Safety

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Corrected 2024-09-24

F · Potential for more than minimal harm 2024-05-22

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

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

Corrected 2024-09-24

E · Potential for more than minimal harm 2024-05-22

K131 · Construction Deficiencies

Fire Safety

Meet requirements for sections of health care facilities separated by fire resistive construction.

Corrected 2024-09-24

E · Potential for more than minimal harm 2024-05-22

K293 · Egress Deficiencies

Fire Safety

Have properly located and lighted "Exit" signs.

Corrected 2024-08-12

E · Potential for more than minimal harm 2024-05-22

K345 · Smoke Deficiencies

Fire Safety

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

Corrected 2024-08-12

E · Potential for more than minimal harm 2024-05-22

K362 · Smoke Deficiencies

Fire Safety

Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.

Corrected 2024-09-24

E · Potential for more than minimal harm 2024-05-22

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2024-09-24

E · Potential for more than minimal harm 2024-05-22

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2024-08-12

E · Potential for more than minimal harm 2024-05-22

K761 · Miscellaneous Deficiencies

Fire Safety

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

Corrected 2024-09-24

E · Potential for more than minimal harm 2024-05-22

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2024-08-12

C · Minimal harm 2024-05-22

E39 · Emergency Preparedness Deficiencies

Fire Safety

Conduct testing and exercise requirements.

Corrected 2024-09-24

C · Minimal harm 2024-05-22

K346 · Smoke Deficiencies

Fire Safety

Follow proper procedures when the fire alarm was out of service for more than 4 hours.

Corrected 2024-09-24

C · Minimal harm 2024-05-22

K355 · Smoke Deficiencies

Fire Safety

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

Corrected 2024-09-24

F · Potential for more than minimal harm 2023-08-07

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 2023-10-15

E · Potential for more than minimal harm 2023-08-07

K225 · Egress Deficiencies

Fire Safety

Have stairways and smokeproof enclosures used as exits that meet safety requirements.

Corrected 2023-10-15

E · Potential for more than minimal harm 2023-08-07

K351 · Smoke Deficiencies

Fire Safety

Install an approved automatic sprinkler system.

Corrected 2023-10-15

E · Potential for more than minimal harm 2023-08-07

K355 · Smoke Deficiencies

Fire Safety

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

Corrected 2023-10-15

Inspection history

Recent health citations

D · Potential for more than minimal harm 2025-09-03

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-09-24

D · Potential for more than minimal harm 2025-06-12

F585 · Resident Rights Deficiencies

Health

Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

Corrected 2025-06-30

F · Potential for more than minimal harm 2025-04-03

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2025-06-02

F · Potential for more than minimal harm 2025-04-03

F814 · Nutrition and Dietary Deficiencies

Health

Dispose of garbage and refuse properly.

Corrected 2025-06-02

E · Potential for more than minimal harm 2025-04-03

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 2025-06-02

D · Potential for more than minimal harm 2025-04-03

F582 · Resident Rights Deficiencies

Health

Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

Corrected 2025-06-02

D · Potential for more than minimal harm 2025-04-03

F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Corrected 2025-06-02

D · Potential for more than minimal harm 2025-04-03

F641 · Resident Assessment and Care Planning Deficiencies

Health

Ensure each resident receives an accurate assessment.

Corrected 2025-06-02

D · Potential for more than minimal harm 2025-04-03

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 2025-06-02

D · Potential for more than minimal harm 2025-04-03

F684 · Quality of Life and Care Deficiencies

Health

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

Corrected 2025-06-02

D · Potential for more than minimal harm 2025-04-03

F687 · Quality of Life and Care Deficiencies

Health

Provide appropriate foot care.

Corrected 2025-06-02

D · Potential for more than minimal harm 2025-04-03

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 2025-06-02

D · Potential for more than minimal harm 2025-04-03

F694 · Quality of Life and Care Deficiencies

Health

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

Corrected 2025-06-02

D · Potential for more than minimal harm 2025-04-03

F695 · Quality of Life and Care Deficiencies

Health

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

Corrected 2025-06-02

D · Potential for more than minimal harm 2025-04-03

F726 · Nursing and Physician Services Deficiencies

Health

Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

Corrected 2025-06-02

D · Potential for more than minimal harm 2025-04-03

F755 · Pharmacy Service Deficiencies

Health

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Corrected 2025-06-02

D · Potential for more than minimal harm 2025-04-03

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-06-02

G · Actual harm 2025-01-16

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 2025-01-16

D · Potential for more than minimal harm 2025-01-16

F759 · Pharmacy Service Deficiencies

Health

Ensure medication error rates are not 5 percent or greater.

Corrected 2025-02-14

E · Potential for more than minimal harm 2024-05-22

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2024-06-28

E · Potential for more than minimal harm 2024-05-22

F814 · Nutrition and Dietary Deficiencies

Health

Dispose of garbage and refuse properly.

Corrected 2024-06-28

D · Potential for more than minimal harm 2024-05-22

F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Respond appropriately to all alleged violations.

Corrected 2024-06-28

D · Potential for more than minimal harm 2024-05-22

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 2024-06-13

D · Potential for more than minimal harm 2024-05-22

F625 · Resident Rights Deficiencies

Health

Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.

Corrected 2024-06-28

D · Potential for more than minimal harm 2024-05-22

F692 · Quality of Life and Care Deficiencies

Health

Provide enough food/fluids to maintain a resident's health.

Corrected 2024-06-28

D · Potential for more than minimal harm 2024-05-22

F726 · Nursing and Physician Services Deficiencies

Health

Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

Corrected 2024-06-28

D · Potential for more than minimal harm 2024-05-22

F760 · Pharmacy Service Deficiencies

Health

Ensure that residents are free from significant medication errors.

Corrected 2024-06-28

D · Potential for more than minimal harm 2024-05-22

F868 · Administration Deficiencies

Health

Have the Quality Assessment and Assurance group have the required members and meet at least quarterly

Corrected 2024-06-28

D · Potential for more than minimal harm 2023-08-07

F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Respond appropriately to all alleged violations.

Corrected 2023-10-07

D · Potential for more than minimal harm 2023-08-07

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 2023-10-07

D · Potential for more than minimal harm 2023-08-07

F661 · Resident Assessment and Care Planning Deficiencies

Health

Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.

Corrected 2023-10-07

D · Potential for more than minimal harm 2023-08-07

F684 · Quality of Life and Care Deficiencies

Health

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

Corrected 2023-10-07

D · Potential for more than minimal harm 2023-08-07

F692 · Quality of Life and Care Deficiencies

Health

Provide enough food/fluids to maintain a resident's health.

Corrected 2023-10-07

D · Potential for more than minimal harm 2023-08-07

F695 · Quality of Life and Care Deficiencies

Health

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

Corrected 2023-10-07

D · Potential for more than minimal harm 2023-08-07

F758 · Pharmacy Service Deficiencies

Health

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Corrected 2023-10-07

D · Potential for more than minimal harm 2023-08-07

F838 · Administration Deficiencies

Health

Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.

Corrected 2023-10-07

Penalties and ownership

What sits behind the stars

$8,278 2025-01-16

Fine

Fine · fine $8,278

Fine