Cycle 1
Health 2025-03-20 · Fire 2025-03-20
4 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Philadelphia, PA
Transitional Care Unit At Nazareth Hospital
5-star overall rating with 4-star inspections with 4 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
2601 Holme Avenue, Philadelphia, PA
(215) 335-6367
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
28
Certified beds
Average residents
10
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Trinity Health
Operator or chain grouping
Approved since
1996-08-02
CMS approved date
Coverage
Medicare
Participation flags
Chain footprint
20 facilities
Chain averages 3 overall / 3 health / 4 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
No
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Hospital-based
Yes
CMS reports the provider resides in a hospital
Staffing
Hours and turnover
RN hours / resident day
4.51
Registered nurse staffing · state 0.78 · national 0.68
LPN hours / resident day
0.00
Licensed practical nurse staffing
Aide hours / resident day
2.83
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
7.34
All reported nurse hours · state 3.89 · national 3.89
Licensed hours
4.51
RN + LPN hours · state 1.69 · national 1.54
Weekend hours
6.89
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
3.87
Weekend registered nurse coverage · state 0.55 · national 0.47
Physical therapist
0.51
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
4.96
CMS adjusted RN staffing hours
Adjusted total hours
8.07
CMS adjusted total nurse staffing hours
Case-mix index
1.24
Higher values indicate more complex resident acuity
RN turnover
8%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
21%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
2,087
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
51.87
Composite VBP score used to determine payment impact.
Payment multiplier
1.0063
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 19.75% · Performance 23.65% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
5.56
Baseline 5.24% · Performance 6.17% · Measure score 5.56 · Achievement 5.56 · Improvement 0
Total nurse turnover
10
Baseline 32.00% · Performance 16.67% · Measure score 10 · Achievement 10 · Improvement 9
Adjusted total nurse staffing
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 14.42% |
10.72%
3.7 pts worse
|
Worse than the National Rate · Eligible stays 303 · Observed rate 17.49% · Lower 95% interval 10.76% |
| Discharge to community | 71.86% |
50.57%
21.3 pts better
|
Better than the National Rate · Eligible stays 288 · Observed rate 68.75% · Lower 95% interval 66.26% |
| Medicare spending per beneficiary | 0.67 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 97.56% |
95.27%
2.3 pts better
|
Numerator 160 · Denominator 164 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 164 |
| Discharge self-care score | 47.3% |
53.69%
6.4 pts worse
|
Numerator 70 · Denominator 148 |
| Discharge mobility score | 36.49% |
50.94%
14.4 pts worse
|
Numerator 54 · Denominator 148 |
| Pressure ulcers or injuries, new or worsened | 1.22% |
2.29%
1.1 pts better
|
Numerator 2 · Denominator 164 · Adjusted rate 2.27% |
| Healthcare-associated infections requiring hospitalization | 6.17% |
7.12%
1 pts better
|
No Different than the National Rate · Eligible stays 150 · Observed rate 4.67% · Lower 95% interval 3.9% |
| Staff COVID-19 vaccination coverage | 2.38% |
8.2%
5.8 pts worse
|
Numerator 1 · Denominator 42 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 31.76% |
56.45%
24.7 pts worse
|
Numerator 47 · Denominator 148 |
| Transfer of health information to provider | 96.67% |
95.95%
0.7 pts better
|
Numerator 145 · Denominator 150 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 12.86% |
25.2%
12.3 pts worse
|
Numerator 9 · Denominator 70 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.9% |
68.9%
30 pts better
|
81.7%
17.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 98.6% · Q2 99.5% · Q3 99.0% · Q4 98.4% · 4Q avg 98.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 6.9% |
9.8%
2.9 pts better
|
12.0%
5.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 6.9% · Observed 6.6% · Expected 10.7% · 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 | 100.0% |
68.7%
31.3 pts better
|
79.7%
20.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| 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 25.7% · Expected 21.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-05-16 · Fire 2024-05-16
0 health deficiencies
No concentrated health issue counts in this cycle.
4 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cycle 3
Health 2023-07-27 · Fire 2023-07-27
6 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
1 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-03-20
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-04-07
E · Potential for more than minimal harm
2024-05-16
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-07-26
E · Potential for more than minimal harm
2024-05-16
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-07-26
E · Potential for more than minimal harm
2024-05-16
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-07-26
E · Potential for more than minimal harm
2024-05-16
K907 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure medical gas and vacuum systems have documented maintenance programs.
Corrected 2024-07-26
C · Minimal harm
2023-07-27
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-08-03
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-03-20
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2025-05-16
D · Potential for more than minimal harm
2025-03-20
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-05-16
D · Potential for more than minimal harm
2025-03-20
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2025-05-16
D · Potential for more than minimal harm
2025-03-20
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-05-16
E · Potential for more than minimal harm
2023-07-27
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 2023-09-25
D · Potential for more than minimal harm
2023-07-27
F622 · Resident Rights Deficiencies
Health
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Corrected 2023-09-25
D · Potential for more than minimal harm
2023-07-27
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-09-25
D · Potential for more than minimal harm
2023-07-27
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-09-25
D · Potential for more than minimal harm
2023-07-27
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 2023-09-25
D · Potential for more than minimal harm
2023-07-27
F836 · Administration Deficiencies
Health
Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards.
Corrected 2023-09-25
Penalties and ownership
What sits behind the stars
$0
2023-07-27
Payment Denial
Payment Denial · denial start 2023-10-27 · 50 days
50 day denial
Ownership
Bromberg, Talyana
Corporate Director · Individual
Brucker, Mark
Corporate Director · Individual
Buckley, Barbara
Corporate Director · Individual
Calope, Michelle
Corporate Director · Individual
Cummings, Kimberly
Corporate Officer · Individual
Deignan, Martina
Corporate Director · Individual
Fontanilla, Hiral
Corporate Director · Individual
Gordon, Vincent
Corporate Director · Individual
Gordon, Vincent
Corporate Officer · Individual
Grace, Marianne
Corporate Director · Individual
Johnson, Rebecca
Corporate Director · Individual
Kapur, Shaila
Corporate Director · Individual
Kapur, Shaila
Corporate Officer · Individual
Keegan, Julia
Corporate Director · Individual
Kilpinen, Stuart
Operational/Managerial Control · Individual
Magro, Michael
Corporate Officer · Individual
Mikus, Catherine
Corporate Officer · Individual
Monihan, James
Corporate Director · Individual
Trinity Health Corporation
5% Or Greater Indirect Ownership Interest · Organization
Trinity Health Of The Mid-Atlantic Region
5% Or Greater Indirect Ownership Interest · Organization
Wajda, David
W-2 Managing Employee · Individual
Washington, Julie
Corporate Director · Individual
Woodward, James
Corporate Director · Individual
Woodward, James
Corporate Officer · Individual
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#3
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