Souderton, PA
5-star overall rating with 4-star inspections with 4 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
207 West Summit Avenue, Souderton, PA
(215) 723-9881
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Beds
71
Certified beds
Average residents
69
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1984-04-01
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
1.28
Registered nurse staffing · state 0.78 · national 0.68
LPN hours / resident day
0.40
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
2.62
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
4.29
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
3.87
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
1.02
Weekend registered nurse coverage · state 0.55 · national 0.47
Physical therapist
0.04
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
1.40
CMS adjusted RN staffing hours
Adjusted total hours
4.73
CMS adjusted total nurse staffing hours
Case-mix index
1.24
Higher values indicate more complex resident acuity
RN turnover
15%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
22%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Program rank
1,664
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
54.91
Composite VBP score used to determine payment impact.
Payment multiplier
1.0099
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
5.59
Baseline 17.79% · Performance 18.84% · Measure score 5.59 · Achievement 5.59 · Improvement 0
Healthcare-associated infections
6.87
Baseline 4.59% · Performance 5.78% · Measure score 6.87 · Achievement 6.87 · Improvement 0
Total nurse turnover
5.93
Baseline 34.29% · Performance 39.44% · Measure score 5.93 · Achievement 5.93 · Improvement 0
Adjusted total nurse staffing
3.58
Baseline 4.27 hours · Performance 4.10 hours · Measure score 3.58 · Achievement 3.58 · Improvement 0
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.29% |
10.72%
1.4 pts better
|
No Different than the National Rate · Eligible stays 176 · Observed rate 6.82% · Lower 95% interval 6.18% |
| Discharge to community | 35.25% |
50.57%
15.3 pts worse
|
Worse than the National Rate · Eligible stays 151 · Observed rate 29.8% · Lower 95% interval 29.32% |
| Medicare spending per beneficiary | 0.74 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 95.71% |
95.27%
0.4 pts better
|
Numerator 67 · Denominator 70 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 70 |
| Discharge self-care score | 57.89% |
53.69%
4.2 pts better
|
Numerator 33 · Denominator 57 |
| Discharge mobility score | 63.16% |
50.94%
12.2 pts better
|
Numerator 36 · Denominator 57 |
| Pressure ulcers or injuries, new or worsened | 2.86% |
2.29%
0.6 pts worse
|
Numerator 2 · Denominator 70 · Adjusted rate 2.99% |
| Healthcare-associated infections requiring hospitalization | 5.78% |
7.12%
1.3 pts better
|
No Different than the National Rate · Eligible stays 101 · Observed rate 2.97% · Lower 95% interval 3.08% |
| Staff COVID-19 vaccination coverage | 6.44% |
8.2%
1.8 pts worse
|
Numerator 13 · Denominator 202 |
| Staff flu vaccination coverage | 77.33% |
42%
35.3 pts better
|
Numerator 116 · Denominator 150 |
| Discharge function score | 75.44% |
56.45%
19 pts better
|
Numerator 43 · Denominator 57 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 33 · Denominator 33 |
| Resident COVID-19 vaccinations up to date | 60% |
25.2%
34.8 pts better
|
Numerator 18 · Denominator 30 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.0 |
1.7
0.7 pts better
|
1.9
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 0.8 · Expected 1.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.6 |
1.2
0.6 pts better
|
1.8
1.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.6 · Observed 0.5 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.2% |
86.9%
12.3 pts better
|
93.4%
5.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.3% · Q2 98.3% · Q3 100.0% · Q4 100.0% · 4Q avg 99.2% |
| 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 | 2.0% |
3.2%
1.2 pts better
|
3.3%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 3.2% · Q4 4.5% · 4Q avg 2.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.2% |
6.5%
5.3 pts better
|
11.4%
10.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 0.0% · Q3 0.0% · Q4 3.1% · 4Q avg 1.2% |
| Percentage of long-stay residents who lose too much weight | 5.5% |
6.5%
1 pts better
|
5.4%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 6.1% · Q3 10.2% · Q4 3.9% · 4Q avg 5.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 35.9% |
19.9%
16 pts worse
|
19.6%
16.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 31.4% · Q2 34.0% · Q3 36.5% · Q4 41.5% · 4Q avg 35.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 16.9% |
18.7%
1.8 pts better
|
16.7%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.3% · Q2 15.8% · Q3 16.7% · Q4 18.6% · 4Q avg 16.9% · 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 | 17.2% |
19.6%
2.4 pts better
|
16.3%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 30.3% · Q3 8.4% · Q4 22.9% · 4Q avg 17.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 22.6% |
18.3%
4.3 pts worse
|
14.9%
7.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.3% · Q2 33.3% · Q3 18.4% · Q4 30.0% · 4Q avg 22.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.4% |
0.9%
0.5 pts better
|
1.0%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 4.5% |
1.7%
2.8 pts worse
|
1.7%
2.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.5% · Q2 3.4% · Q3 1.7% · Q4 4.7% · 4Q avg 4.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 29.6% |
26.4%
3.2 pts worse
|
19.8%
9.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.2% · Q2 27.9% · Q3 31.6% · Q4 31.5% · 4Q avg 29.6% |
| Percentage of long-stay residents with pressure ulcers | 2.3% |
5.3%
3 pts better
|
5.1%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.3% · Q3 3.6% · Q4 4.1% · 4Q avg 2.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 89.7% |
68.9%
20.8 pts better
|
81.7%
8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 65.7% · Q2 91.1% · Q3 100.0% · Q4 100.0% · 4Q avg 89.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 2.7% |
9.8%
7.1 pts better
|
12.0%
9.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 2.7% · Observed 2.3% · Expected 9.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.5%
1.5 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 95.6% |
68.7%
26.9 pts better
|
79.7%
15.9 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 95.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 19.5% |
23.1%
3.6 pts better
|
23.9%
4.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 19.5% · Observed 18.2% · Expected 22.3% · Used in QM five-star |
Survey summary
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Top issue: Quality of Life and Care (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Top issue: Quality of Life and Care (1 deficiency)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire Safety
Install a two-hour-resistant firewall separation.
Corrected 2025-05-01
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2025-05-01
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-05-01
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2023-07-11
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-07-11
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-07-11
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2023-07-11
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-07-11
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-07-11
Inspection history
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-12-15
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-04-15
Health
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
Corrected 2025-04-15
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2025-04-15
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-05-27
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 2024-05-27
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-05-27
Health
Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency.
Corrected 2024-05-27
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-06-27
Penalties and ownership
Corporate Director · Individual
Operational/Managerial Control · Individual
Corporate Director · Individual
Corporate Director · Individual
Operational/Managerial Control · Individual
Corporate Director · Individual
Corporate Director · Individual
Operational/Managerial Control · Organization
Corporate Director · Individual
Operational/Managerial Control · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
Operational/Managerial Control · Organization
Operational/Managerial Control · Organization
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Corporate Director · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Organization
Corporate Director · Individual
Operational/Managerial Control · Individual
Corporate Director · Individual
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