Cycle 1
Health 2025-07-18 · Fire 2024-09-26
3 health deficiencies
Top issue: Administration (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Darby, PA
St Francis Center For Rehabilitation & Healthcare
4-star overall rating with 4-star inspections with 3 recent health deficiencies
1412 Lansdowne Avenue, Darby, PA
(610) 461-6510
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
0 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
273
Certified beds
Average residents
228
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Center Management Group
Operator or chain grouping
Approved since
1976-11-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
17 facilities
Chain averages 3 overall / 3 health / 2 staffing / 4 quality stars
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
0.40
Registered nurse staffing · state 0.78 · national 0.68
LPN hours / resident day
1.21
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
2.03
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.64
All reported nurse hours · state 3.89 · national 3.89
Licensed hours
1.61
RN + LPN hours · state 1.69 · national 1.54
Weekend hours
3.27
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.31
Weekend registered nurse coverage · state 0.55 · national 0.47
Physical therapist
0.06
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.37
CMS adjusted RN staffing hours
Adjusted total hours
3.35
CMS adjusted total nurse staffing hours
Case-mix index
1.49
Higher values indicate more complex resident acuity
RN turnover
33%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
57%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
5,235
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
36.91
Composite VBP score used to determine payment impact.
Payment multiplier
0.9902
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
6.63
Baseline 21.66% · Performance 18.36% · Measure score 6.63 · Achievement 6.63 · Improvement 6.63
Healthcare-associated infections
5.10
Baseline 7.27% · Performance 6.31% · Measure score 5.10 · Achievement 5.10 · Improvement 3.72
Total nurse turnover
0.74
Baseline 42.69% · Performance 60.67% · Measure score 0.74 · Achievement 0.74 · Improvement 0
Adjusted total nurse staffing
2.30
Baseline 4.04 hours · Performance 3.73 hours · Measure score 2.30 · Achievement 2.30 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.2% |
10.72%
0.5 pts worse
|
No Different than the National Rate · Eligible stays 162 · Observed rate 12.96% · Lower 95% interval 7.81% |
| Discharge to community | 47.48% |
50.57%
3.1 pts worse
|
No Different than the National Rate · Eligible stays 121 · Observed rate 38.02% · Lower 95% interval 40.39% |
| Medicare spending per beneficiary | 1.23 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 98.24% |
95.27%
3 pts better
|
Numerator 279 · Denominator 284 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 284 |
| Discharge self-care score | 61.59% |
53.69%
7.9 pts better
|
Numerator 85 · Denominator 138 |
| Discharge mobility score | 55.8% |
50.94%
4.9 pts better
|
Numerator 77 · Denominator 138 |
| Pressure ulcers or injuries, new or worsened | 1.76% |
2.29%
0.5 pts better
|
Numerator 5 · Denominator 284 · Adjusted rate 1.69% |
| Healthcare-associated infections requiring hospitalization | 6.31% |
7.12%
0.8 pts better
|
No Different than the National Rate · Eligible stays 122 · Observed rate 5.74% · Lower 95% interval 4.02% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 297 |
| Staff flu vaccination coverage | 91.47% |
42%
49.5 pts better
|
Numerator 268 · Denominator 293 |
| Discharge function score | 62.32% |
56.45%
5.9 pts better
|
Numerator 86 · Denominator 138 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 84 · Denominator 84 |
| Transfer of health information to patient | 96.8% |
96.28%
0.5 pts better
|
Numerator 121 · Denominator 125 |
| Resident COVID-19 vaccinations up to date | 3.51% |
25.2%
21.7 pts worse
|
Numerator 6 · Denominator 171 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.2 |
1.7
0.5 pts worse
|
1.9
0.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.2 · Observed 2.2 · Expected 1.9 · 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 1.2 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 94.4% |
86.9%
7.5 pts better
|
93.4%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.9% · Q2 92.9% · Q3 92.9% · Q4 92.8% · 4Q avg 94.4% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 95.5% |
93.5%
2 pts better
|
95.5%
About the same
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 95.5% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.4% |
3.2%
2.8 pts better
|
3.3%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 31.7% |
6.5%
25.2 pts worse
|
11.4%
20.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.7% · Q2 30.5% · Q3 32.4% · Q4 35.3% · 4Q avg 31.7% |
| Percentage of long-stay residents who lose too much weight | 5.9% |
6.5%
0.6 pts better
|
5.4%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 4.1% · Q3 7.1% · Q4 9.2% · 4Q avg 5.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 13.7% |
19.9%
6.2 pts better
|
19.6%
5.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.5% · Q2 11.8% · Q3 15.1% · Q4 12.4% · 4Q avg 13.7% |
| 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 | 7.2% |
19.6%
12.4 pts better
|
16.3%
9.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.3% · Q2 9.2% · Q3 5.1% · Q4 5.0% · 4Q avg 7.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 6.3% |
18.3%
12 pts better
|
14.9%
8.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.3% · Q2 5.4% · Q3 3.6% · Q4 6.1% · 4Q avg 6.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.1% |
0.9%
0.8 pts better
|
1.0%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.4% · 4Q avg 0.1% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.4% |
1.7%
1.3 pts better
|
1.7%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.1% · Q3 0.0% · Q4 0.6% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 31.0% |
26.4%
4.6 pts worse
|
19.8%
11.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.2% · Q2 34.5% · Q3 31.2% · Q4 29.7% · 4Q avg 31.0% |
| Percentage of long-stay residents with pressure ulcers | 4.4% |
5.3%
0.9 pts better
|
5.1%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 3.6% · Q3 4.6% · Q4 5.3% · 4Q avg 4.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 58.2% |
68.9%
10.7 pts worse
|
81.7%
23.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 49.4% · Q2 51.0% · Q3 58.1% · Q4 72.9% · 4Q avg 58.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.1% |
9.8%
0.7 pts better
|
12.0%
2.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.1% · Observed 8.9% · Expected 11.0% · 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 1.4% · Q2 2.2% · Q3 1.7% · Q4 0.6% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 56.4% |
68.7%
12.3 pts worse
|
79.7%
23.3 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 56.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.4% |
23.1%
1.3 pts worse
|
23.9%
0.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.4% · Observed 26.2% · Expected 25.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-09-26 · Fire 2023-12-01
12 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2023-12-01 · Fire 2023-02-02
10 health deficiencies
Top issue: Nutrition and Dietary (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-07-18
F806 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2025-09-04
D · Potential for more than minimal harm
2025-07-18
F761 · Pharmacy Service Deficiencies
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 2025-09-04
D · Potential for more than minimal harm
2025-07-18
F770 · Administration Deficiencies
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2025-09-04
D · Potential for more than minimal harm
2024-09-26
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-11-20
D · Potential for more than minimal harm
2024-09-26
F557 · Resident Rights Deficiencies
Health
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Corrected 2024-11-20
D · Potential for more than minimal harm
2024-09-26
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2024-11-20
D · Potential for more than minimal harm
2024-09-26
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-11-20
D · Potential for more than minimal harm
2024-09-26
F676 · Quality of Life and Care Deficiencies
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2024-11-20
D · Potential for more than minimal harm
2024-09-26
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-11-20
D · Potential for more than minimal harm
2024-09-26
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-11-20
D · Potential for more than minimal harm
2024-09-26
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 2024-11-20
D · Potential for more than minimal harm
2024-09-26
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-11-20
D · Potential for more than minimal harm
2024-09-26
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2024-11-20
D · Potential for more than minimal harm
2024-09-26
F924 · Environmental Deficiencies
Health
Put firmly secured handrails on each side of hallways.
Corrected 2024-11-20
E · Potential for more than minimal harm
2024-04-24
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 2024-06-12
D · Potential for more than minimal harm
2024-01-09
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 2024-01-30
E · Potential for more than minimal harm
2023-12-01
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2024-01-09
D · Potential for more than minimal harm
2023-12-01
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-01-09
D · Potential for more than minimal harm
2023-12-01
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-01-09
D · Potential for more than minimal harm
2023-12-01
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-01-09
D · Potential for more than minimal harm
2023-12-01
F801 · Nutrition and Dietary Deficiencies
Health
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Corrected 2024-01-09
D · Potential for more than minimal harm
2023-12-01
F806 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2024-01-09
D · Potential for more than minimal harm
2023-12-01
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2024-01-09
D · Potential for more than minimal harm
2023-06-29
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2023-07-31
D · Potential for more than minimal harm
2023-03-23
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-04-18
Penalties and ownership
What sits behind the stars
Ownership
Gros, Charles-Edouard
5% Or Greater Direct Ownership Interest · Individual
Boehm, Caroline
5% Or Greater Direct Ownership Interest · Individual
Allen, Daniel
Operational/Managerial Control · Individual
Bauer, John
Operational/Managerial Control · Individual
Greystone Funding Company LLC
5% Or Greater Mortgage Interest · Organization
Klein, Baruch
Operational/Managerial Control · Individual
Levi, Shlomo
Operational/Managerial Control · Individual
Marasco-Kennedy, Elizabeth
Operational/Managerial Control · Individual
Pearlstein, Robert
Operational/Managerial Control · Individual
Petroski, Edward
Operational/Managerial Control · Individual
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