Cycle 1
Health 2025-03-03 · Fire 2025-03-03
4 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Flourtown, PA
Saint Joseph Villa
5-star overall rating with 4-star inspections with $8,278 in total fines with 4 recent health deficiencies
110 West Wissahickon Ave, Flourtown, PA
(215) 836-4179
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
106
Certified beds
Average residents
97
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1970-02-11
CMS approved date
Coverage
Medicare + Medicaid
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
1.43
Registered nurse staffing · state 0.78 · national 0.68
LPN hours / resident day
0.44
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
3.32
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
5.19
All reported nurse hours · state 3.89 · national 3.89
Licensed hours
1.87
RN + LPN hours · state 1.69 · national 1.54
Weekend hours
4.71
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.95
Weekend registered nurse coverage · state 0.55 · national 0.47
Physical therapist
0.15
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
1.57
CMS adjusted RN staffing hours
Adjusted total hours
5.68
CMS adjusted total nurse staffing hours
Case-mix index
1.25
Higher values indicate more complex resident acuity
RN turnover
9%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
15%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,088
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
41.33
Composite VBP score used to determine payment impact.
Payment multiplier
0.9942
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 21.45% · Performance 22.40% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 5.85% · Performance 7.90% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
10
Baseline 27.36% · Performance 23.39% · Measure score 10 · Achievement 10 · Improvement 9
Adjusted total nurse staffing
6.53
Baseline 4.69 hours · Performance 4.94 hours · Measure score 6.53 · Achievement 6.53 · Improvement 1.75
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 8.88% |
10.72%
1.8 pts better
|
No Different than the National Rate · Eligible stays 205 · Observed rate 5.85% · Lower 95% interval 6.34% |
| Discharge to community | 43.1% |
50.57%
7.5 pts worse
|
Worse than the National Rate · Eligible stays 183 · Observed rate 40.44% · Lower 95% interval 36.99% |
| Medicare spending per beneficiary | 0.95 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 74.13% |
95.27%
21.1 pts worse
|
Numerator 106 · Denominator 143 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 143 |
| Discharge self-care score | 48.57% |
53.69%
5.1 pts worse
|
Numerator 51 · Denominator 105 |
| Discharge mobility score | 57.14% |
50.94%
6.2 pts better
|
Numerator 60 · Denominator 105 |
| Pressure ulcers or injuries, new or worsened | 3.5% |
2.29%
1.2 pts worse
|
Numerator 5 · Denominator 143 · Adjusted rate 3.93% |
| Healthcare-associated infections requiring hospitalization | 7.89% |
7.12%
0.8 pts worse
|
No Different than the National Rate · Eligible stays 130 · Observed rate 6.92% · Lower 95% interval 5.06% |
| Staff COVID-19 vaccination coverage | 1.72% |
8.2%
6.5 pts worse
|
Numerator 6 · Denominator 349 |
| Staff flu vaccination coverage | 100% |
42%
58 pts better
|
Numerator 360 · Denominator 360 |
| Discharge function score | 48.57% |
56.45%
7.9 pts worse
|
Numerator 51 · Denominator 105 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 37 · Denominator 37 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 80 · Denominator 80 |
| Resident COVID-19 vaccinations up to date | 28.4% |
25.2%
3.2 pts better
|
Numerator 23 · Denominator 81 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.5 |
1.7
0.8 pts worse
|
1.9
0.6 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.5 · Observed 1.8 · Expected 1.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.3 |
1.2
0.1 pts worse
|
1.8
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.0 · Expected 1.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 96.0% |
86.9%
9.1 pts better
|
93.4%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 97.5% · Q2 97.5% · Q3 94.0% · Q4 94.9% · 4Q avg 96.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.8% |
93.5%
5.3 pts better
|
95.5%
3.3 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.8% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.8% |
3.2%
0.4 pts better
|
3.3%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.9% · Q2 3.7% · Q3 1.2% · Q4 1.3% · 4Q avg 2.8% · 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 2.1% |
6.5%
4.4 pts better
|
5.4%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 0.0% · Q3 2.8% · Q4 4.3% · 4Q avg 2.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 18.1% |
19.9%
1.8 pts better
|
19.6%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.6% · Q2 16.9% · Q3 20.8% · Q4 16.9% · 4Q avg 18.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 9.6% |
18.7%
9.1 pts better
|
16.7%
7.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.6% · Q2 11.1% · Q3 9.8% · Q4 10.2% · 4Q avg 9.6% · 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 | 20.5% |
19.6%
0.9 pts worse
|
16.3%
4.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.0% · Q2 18.3% · Q3 22.6% · Q4 21.1% · 4Q avg 20.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 23.5% |
18.3%
5.2 pts worse
|
14.9%
8.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 32.9% · Q2 21.1% · Q3 19.7% · Q4 20.3% · 4Q avg 23.5% · 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 1.3% · Q2 1.3% · Q3 1.9% · Q4 0.0% · 4Q avg 1.2% · 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 | 25.0% |
26.4%
1.4 pts better
|
19.8%
5.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.4% · Q2 32.0% · Q3 18.8% · Q4 24.8% · 4Q avg 25.0% |
| Percentage of long-stay residents with pressure ulcers | 11.1% |
5.3%
5.8 pts worse
|
5.1%
6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.7% · Q2 11.7% · Q3 11.8% · Q4 10.0% · 4Q avg 11.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 77.6% |
68.9%
8.7 pts better
|
81.7%
4.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 89.1% · Q2 83.1% · Q3 75.5% · Q4 62.5% · 4Q avg 77.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.7% |
9.8%
1.1 pts better
|
12.0%
3.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.7% · Observed 7.1% · Expected 9.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.6% |
1.5%
0.9 pts better
|
1.6%
1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 1.1% · Q3 0.0% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 88.8% |
68.7%
20.1 pts better
|
79.7%
9.1 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 88.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 28.8% |
23.1%
5.7 pts worse
|
23.9%
4.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 28.8% · Observed 21.3% · Expected 17.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-04-26 · Fire 2024-04-26
2 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2023-07-17 · Fire 2023-07-17
3 health deficiencies
Top issue: Infection Control (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Inspection history
Recent health citations
G · Actual harm
2025-03-03
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 2025-04-04
D · Potential for more than minimal harm
2025-03-03
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 2025-04-04
D · Potential for more than minimal harm
2025-03-03
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-04-04
D · Potential for more than minimal harm
2025-03-03
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2025-04-04
E · Potential for more than minimal harm
2024-04-26
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 2024-05-31
D · Potential for more than minimal harm
2024-04-26
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 2024-05-31
E · Potential for more than minimal harm
2023-07-17
F809 · Nutrition and Dietary Deficiencies
Health
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
Corrected 2023-08-11
D · Potential for more than minimal harm
2023-07-17
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2023-08-11
D · Potential for more than minimal harm
2023-07-17
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-08-11
Penalties and ownership
What sits behind the stars
$8,278
2025-03-03
Fine
Fine · fine $8,278
Fine
Ownership
Dunn, Irene
Corporate Officer · Individual
Mandes, Nancy
Corporate Director · Individual
Wise, Catherine
Operational/Managerial Control · Individual
Wise, Catherine
Corporate Director · Individual
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