Cycle 1
Health 2026-01-08 · Fire 2025-02-21
1 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
3 fire-safety deficiencies
Top issue: Construction (1 deficiency)
Downingtown, PA
St Martha Center For Rehabilitation & Healthcare
3-star overall rating with 4-star inspections with 1 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
470 Manor Ave, Downingtown, PA
(610) 873-8490
Overall
3 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
120
Certified beds
Average residents
107
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Center Management Group
Operator or chain grouping
Approved since
1989-12-19
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
0.38
Registered nurse staffing · state 0.78 · national 0.68
LPN hours / resident day
0.99
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
2.09
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.47
All reported nurse hours · state 3.89 · national 3.89
Licensed hours
1.37
RN + LPN hours · state 1.69 · national 1.54
Weekend hours
3.24
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
0.12
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.35
CMS adjusted RN staffing hours
Adjusted total hours
3.21
CMS adjusted total nurse staffing hours
Case-mix index
1.48
Higher values indicate more complex resident acuity
RN turnover
46%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
55%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
12,329
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
12.85
Composite VBP score used to determine payment impact.
Payment multiplier
0.9811
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 21.74% · Performance 21.85% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
2.41
Baseline 6.31% · Performance 7.12% · Measure score 2.41 · Achievement 2.41 · Improvement 0
Total nurse turnover
1.72
Baseline 65.87% · Performance 56.76% · Measure score 1.72 · Achievement 1.69 · Improvement 1.72
Adjusted total nurse staffing
1.01
Baseline 3.84 hours · Performance 3.37 hours · Measure score 1.01 · Achievement 1.01 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.11% |
10.72%
0.6 pts better
|
No Different than the National Rate · Eligible stays 154 · Observed rate 9.09% · Lower 95% interval 7.21% |
| Discharge to community | 32.91% |
50.57%
17.7 pts worse
|
Worse than the National Rate · Eligible stays 133 · Observed rate 26.32% · Lower 95% interval 26.08% |
| Medicare spending per beneficiary | 1.38 |
1.02
0.4 pts worse
|
|
| Drug regimen review with follow-up | 93.08% |
95.27%
2.2 pts worse
|
Numerator 148 · Denominator 159 |
| Falls with major injury | 0.63% |
0.77%
0.1 pts better
|
Numerator 1 · Denominator 159 |
| Discharge self-care score | 49.48% |
53.69%
4.2 pts worse
|
Numerator 48 · Denominator 97 |
| Discharge mobility score | 50.52% |
50.94%
0.4 pts worse
|
Numerator 49 · Denominator 97 |
| Pressure ulcers or injuries, new or worsened | 4.43% |
2.29%
2.1 pts worse
|
Numerator 7 · Denominator 158 · Adjusted rate 3.97% |
| Healthcare-associated infections requiring hospitalization | 7.11% |
7.12%
About the same
|
No Different than the National Rate · Eligible stays 120 · Observed rate 6.67% · Lower 95% interval 4.35% |
| Staff COVID-19 vaccination coverage | 1.94% |
8.2%
6.3 pts worse
|
Numerator 3 · Denominator 155 |
| Staff flu vaccination coverage | 76.29% |
42%
34.3 pts better
|
Numerator 148 · Denominator 194 |
| Discharge function score | 56.7% |
56.45%
0.2 pts better
|
Numerator 55 · Denominator 97 |
| Transfer of health information to provider | 96.15% |
95.95%
0.2 pts better
|
Numerator 50 · Denominator 52 |
| Transfer of health information to patient | 96.67% |
96.28%
0.4 pts better
|
Numerator 58 · Denominator 60 |
| Resident COVID-19 vaccinations up to date | 11.34% |
25.2%
13.9 pts worse
|
Numerator 11 · Denominator 97 |
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 1.8 · Expected 1.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.4 |
1.2
0.2 pts worse
|
1.8
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.2 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 59.5% |
86.9%
27.4 pts worse
|
93.4%
33.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 62.4% · Q2 53.8% · Q3 60.4% · Q4 61.4% · 4Q avg 59.5% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.0% |
93.5%
4.5 pts better
|
95.5%
2.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.7% |
3.2%
0.5 pts better
|
3.3%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.4% · Q2 3.2% · Q3 1.1% · Q4 1.1% · 4Q avg 2.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 44.0% |
6.5%
37.5 pts worse
|
11.4%
32.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 44.4% · Q2 43.3% · Q3 50.0% · Q4 37.8% · 4Q avg 44.0% |
| Percentage of long-stay residents who lose too much weight | 9.7% |
6.5%
3.2 pts worse
|
5.4%
4.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 11.1% · Q2 8.5% · Q3 13.9% · Q4 5.1% · 4Q avg 9.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 19.4% |
19.9%
0.5 pts better
|
19.6%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 20.9% · Q2 18.0% · Q3 20.9% · Q4 17.6% · 4Q avg 19.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 18.0% |
18.7%
0.7 pts better
|
16.7%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.3% · Q2 17.9% · Q3 17.1% · Q4 19.7% · 4Q avg 18.0% · 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 | 10.3% |
19.6%
9.3 pts better
|
16.3%
6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.3% · Q2 25.4% · Q3 2.5% · Q4 5.3% · 4Q avg 10.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 11.8% |
18.3%
6.5 pts better
|
14.9%
3.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.3% · Q2 22.6% · Q3 3.8% · Q4 13.0% · 4Q avg 11.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.2% |
0.9%
0.7 pts better
|
1.0%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.9% · Q4 0.0% · 4Q avg 0.2% · 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 | 33.4% |
26.4%
7 pts worse
|
19.8%
13.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.3% · Q2 39.2% · Q3 29.1% · Q4 37.1% · 4Q avg 33.4% |
| Percentage of long-stay residents with pressure ulcers | 3.3% |
5.3%
2 pts better
|
5.1%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 2.1% · Q3 3.2% · Q4 5.0% · 4Q avg 3.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 28.0% |
68.9%
40.9 pts worse
|
81.7%
53.7 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 29.9% · Q2 31.1% · Q3 22.0% · Q4 28.9% · 4Q avg 28.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.0% |
9.8%
1.2 pts worse
|
12.0%
1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.0% · Observed 9.2% · Expected 9.4% · 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% · Q4 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 | 43.7% |
68.7%
25 pts worse
|
79.7%
36 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 43.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 20.9% |
23.1%
2.2 pts better
|
23.9%
3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 20.9% · Observed 19.2% · Expected 22.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2025-02-21 · Fire 2024-01-12
2 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
4 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Cycle 3
Health 2024-01-12 · Fire 2023-03-10
11 health deficiencies
Top issue: Resident Assessment and Care Planning (4 deficiencies)
3 fire-safety deficiencies
Top issue: Construction (1 deficiency)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-02-21
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-03-21
D · Potential for more than minimal harm
2025-02-21
K133 · Construction Deficiencies
Fire Safety
Install a two-hour-resistant firewall separation.
Corrected 2025-03-21
D · Potential for more than minimal harm
2025-02-21
K754 · Miscellaneous Deficiencies
Fire Safety
Provide properly sized and located linen or trash receptacles.
Corrected 2025-03-21
D · Potential for more than minimal harm
2024-01-12
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-02-23
D · Potential for more than minimal harm
2024-01-12
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-02-23
D · Potential for more than minimal harm
2024-01-12
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-02-23
C · Minimal harm
2024-01-12
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 2024-02-23
E · Potential for more than minimal harm
2023-03-10
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-04-24
D · Potential for more than minimal harm
2023-03-10
K131 · Construction Deficiencies
Fire Safety
Meet requirements for sections of health care facilities separated by fire resistive construction.
Corrected 2023-04-24
D · Potential for more than minimal harm
2023-03-10
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-04-24
Inspection history
Recent health citations
D · Potential for more than minimal harm
2026-01-08
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Not marked corrected
D · Potential for more than minimal harm
2025-02-21
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-03-21
D · Potential for more than minimal harm
2025-02-21
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 2025-03-21
E · Potential for more than minimal harm
2024-01-12
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-02-23
D · Potential for more than minimal harm
2024-01-12
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 2024-02-23
D · Potential for more than minimal harm
2024-01-12
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 2024-02-23
D · Potential for more than minimal harm
2024-01-12
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-02-23
D · Potential for more than minimal harm
2024-01-12
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 2024-02-23
D · Potential for more than minimal harm
2024-01-12
F770 · Administration Deficiencies
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2024-02-23
F · Potential for more than minimal harm
2023-08-29
F802 · Nutrition and Dietary Deficiencies
Health
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Corrected 2023-10-01
D · Potential for more than minimal harm
2023-04-27
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-05-12
D · Potential for more than minimal harm
2023-04-27
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 2023-05-12
E · Potential for more than minimal harm
2023-03-10
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2023-04-24
D · Potential for more than minimal harm
2023-03-10
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 2023-04-24
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
Blackwood, Rohan
Operational/Managerial Control · Individual
Greystone Funding Company LLC
5% Or Greater Mortgage Interest · Organization
Kataria, Vinod
Operational/Managerial Control · Individual
Klein, Baruch
Operational/Managerial Control · Individual
Levi, Shlomo
Operational/Managerial Control · Individual
Marino, Brandie
Operational/Managerial Control · Individual
Petroski, Edward
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Exton Post Acute
Exton, PA
3-star overall rating with 3-star inspections with $120,174 in total fines with 3 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#2
Inn At Freedom Village,the
West Brandywine, PA
5-star overall rating with 4-star inspections with 2 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#3
Park Lane Post Acute LLC
West Chester, PA
4-star overall rating with 3-star inspections with 9 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
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