14 health deficiencies
Top issue: Pharmacy Service (4 deficiencies)
6 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Spring House, PA
2-star overall rating with 2-star inspections with 14 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
905 Penllyn Pike, Spring House, PA
(215) 646-1500
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Beds
120
Certified beds
Average residents
100
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1977-03-01
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
RN hours / resident day
0.38
Registered nurse staffing · state 0.78 · national 0.68
LPN hours / resident day
1.08
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
1.92
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.37
All reported nurse hours · state 3.89 · national 3.89
Licensed hours
1.46
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
0.26
Weekend registered nurse coverage · state 0.55 · national 0.47
Physical therapist
0.07
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.47
CMS adjusted RN staffing hours
Adjusted total hours
4.17
CMS adjusted total nurse staffing hours
Case-mix index
1.11
Higher values indicate more complex resident acuity
RN turnover
73%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
60%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Program rank
4,997
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
37.81
Composite VBP score used to determine payment impact.
Payment multiplier
0.9910
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
5.57
Baseline 26.87% · Performance 20.89% · Measure score 5.57 · Achievement 1.16 · Improvement 5.57
Healthcare-associated infections
5.05
Baseline 10.56% · Performance 7.47% · Measure score 5.05 · Achievement 1.21 · Improvement 5.05
Total nurse turnover
1.08
Baseline 49.38% · Performance 59.26% · Measure score 1.08 · Achievement 1.08 · Improvement 0
Adjusted total nurse staffing
3.42
Baseline 3.54 hours · Performance 4.05 hours · Measure score 3.42 · Achievement 3.42 · Improvement 1.77
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.99% |
10.72%
0.3 pts worse
|
No Different than the National Rate · Eligible stays 59 · Observed rate 11.86% · Lower 95% interval 7.67% |
| Discharge to community | 35.61% |
50.57%
15 pts worse
|
No Different than the National Rate · Eligible stays 31 · Observed rate 19.35% · Lower 95% interval 24.38% |
| Medicare spending per beneficiary | 1.04 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 97.59% |
95.27%
2.3 pts better
|
Numerator 81 · Denominator 83 |
| Falls with major injury | 2.41% |
0.77%
1.6 pts worse
|
Numerator 2 · Denominator 83 |
| Discharge self-care score | 74% |
53.69%
20.3 pts better
|
Numerator 37 · Denominator 50 |
| Discharge mobility score | 60% |
50.94%
9.1 pts better
|
Numerator 30 · Denominator 50 |
| Pressure ulcers or injuries, new or worsened | 2.41% |
2.29%
0.1 pts worse
|
Numerator 2 · Denominator 83 · Adjusted rate 1.98% |
| Healthcare-associated infections requiring hospitalization | 7.47% |
7.12%
0.3 pts worse
|
No Different than the National Rate · Eligible stays 44 · Observed rate 9.09% · Lower 95% interval 4.51% |
| Staff COVID-19 vaccination coverage | 4% |
8.2%
4.2 pts worse
|
Numerator 5 · Denominator 125 |
| Staff flu vaccination coverage | 15.33% |
42%
26.7 pts worse
|
Numerator 21 · Denominator 137 |
| Discharge function score | 64% |
56.45%
7.5 pts better
|
Numerator 32 · Denominator 50 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 28 · Denominator 28 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 25.53% |
25.2%
0.3 pts better
|
Numerator 12 · Denominator 47 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 3.9 |
1.7
2.2 pts worse
|
1.9
2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.9 · Observed 4.2 · Expected 2.1 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.8 |
1.2
0.6 pts worse
|
1.8
About the same
|
Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 1.9 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 81.6% |
86.9%
5.3 pts worse
|
93.4%
11.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 98.8% · Q2 96.5% · Q3 78.3% · Q4 57.6% · 4Q avg 81.6% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
93.5%
6.5 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.1% |
3.2%
0.1 pts better
|
3.3%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 4.7% · Q3 2.2% · Q4 2.0% · 4Q avg 3.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.7% |
6.5%
3.8 pts better
|
11.4%
8.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 1.3% · Q3 2.2% · Q4 5.3% · 4Q avg 2.7% |
| Percentage of long-stay residents who lose too much weight | 8.9% |
6.5%
2.4 pts worse
|
5.4%
3.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.3% · Q2 10.1% · Q3 7.1% · Q4 9.2% · 4Q avg 8.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 18.0% |
19.9%
1.9 pts better
|
19.6%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.1% · Q2 20.7% · Q3 18.0% · Q4 16.3% · 4Q avg 18.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 30.9% |
18.7%
12.2 pts worse
|
16.7%
14.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.0% · Q2 30.2% · Q3 39.3% · Q4 34.4% · 4Q avg 30.9% · 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 | 3.7% |
19.6%
15.9 pts better
|
16.3%
12.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 2.5% · Q3 1.9% · Q4 7.6% · 4Q avg 3.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 6.0% |
18.3%
12.3 pts better
|
14.9%
8.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.6% · Q2 4.9% · Q3 3.4% · Q4 6.6% · 4Q avg 6.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.5% |
0.9%
0.4 pts better
|
1.0%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.1% · Q3 0.0% · Q4 0.7% · 4Q avg 0.5% · 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 | 22.1% |
26.4%
4.3 pts better
|
19.8%
2.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.1% · Q2 26.7% · Q3 19.9% · Q4 22.8% · 4Q avg 22.1% |
| Percentage of long-stay residents with pressure ulcers | 5.7% |
5.3%
0.4 pts worse
|
5.1%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.7% · Q2 3.9% · Q3 4.8% · Q4 7.3% · 4Q avg 5.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 13.4% |
68.9%
55.5 pts worse
|
81.7%
68.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 37.3% · Q2 13.4% · Q3 4.6% · Q4 5.3% · 4Q avg 13.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 19.0% |
9.8%
9.2 pts worse
|
12.0%
7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 19.0% · Observed 21.8% · Expected 12.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.2% |
1.5%
0.3 pts better
|
1.6%
0.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q2 0.0% · Q3 0.0% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 17.9% |
68.7%
50.8 pts worse
|
79.7%
61.8 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 17.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 41.7% |
23.1%
18.6 pts worse
|
23.9%
17.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 41.7% · Observed 41.0% · Expected 23.4% · Used in QM five-star |
Survey summary
Top issue: Pharmacy Service (4 deficiencies)
6 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Top issue: Quality of Life and Care (5 deficiencies)
2 fire-safety deficiencies
Top issue: Construction (1 deficiency)
Top issue: Quality of Life and Care (5 deficiencies)
4 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Fire safety
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 2025-01-24
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2025-03-05
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-01-24
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-01-24
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-01-24
Fire Safety
Conduct testing and exercise requirements.
Corrected 2025-01-24
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-04-10
Fire Safety
Install a two-hour-resistant firewall separation.
Corrected 2024-04-06
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-07-07
Fire Safety
Conduct testing and exercise requirements.
Corrected 2023-07-07
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-07-07
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-08-08
Inspection history
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-08-01
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-04-24
Health
Keep all essential equipment working safely.
Corrected 2025-02-05
Health
Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
Corrected 2025-02-05
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-02-05
Health
Plan the resident's discharge to meet the resident's goals and needs.
Corrected 2025-02-05
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2025-02-05
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-02-05
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-02-05
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 2025-02-05
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-02-05
Health
Provide and implement an infection prevention and control program.
Corrected 2025-02-05
Health
Implement a program that monitors antibiotic use.
Corrected 2025-02-05
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2025-02-05
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-04-01
Health
Dispose of garbage and refuse properly.
Corrected 2024-04-01
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2024-04-01
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 2024-04-01
Health
Implement a program that monitors antibiotic use.
Corrected 2024-04-01
Health
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Corrected 2024-04-01
Health
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Corrected 2024-04-01
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-04-01
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2024-04-01
Health
Assure that each resident’s assessment is updated at least once every 3 months.
Corrected 2024-04-01
Health
Notify the appropriate authorities when residents with MD or ID services has a significant change in condition.
Corrected 2024-04-01
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-04-01
Health
Provide appropriate foot care.
Corrected 2024-04-01
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-04-01
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2024-04-01
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2024-04-01
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-04-01
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2024-04-01
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-04-01
Health
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Corrected 2024-04-01
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-03-01
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-03-01
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-12-08
Health
Have a plan that describes the process for conducting QAPI and QAA activities.
Corrected 2023-06-22
Health
Provide and implement an infection prevention and control program.
Corrected 2023-06-22
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-06-22
Health
Ensure residents have reasonable access to and privacy in their use of communication methods.
Corrected 2023-06-22
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-06-22
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2023-06-22
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 2023-06-22
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2023-06-22
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2023-06-22
Health
Provide or obtain dental services for each resident.
Corrected 2023-06-22
Health
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Corrected 2023-06-22
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2023-06-22
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2023-06-22
Health
Keep all essential equipment working safely.
Corrected 2023-06-22
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-04-14
Penalties and ownership
5% Or Greater Direct Ownership Interest · Individual
5% Or Greater Direct Ownership Interest · Individual
5% Or Greater Direct Ownership Interest · Individual
5% Or Greater Direct Ownership Interest · Individual
W-2 Managing Employee · Individual
Operational/Managerial Control · Individual
Corporate Officer · Individual
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