Cycle 1
Health 2024-12-19 · Fire 2024-12-19
0 health deficiencies
No concentrated health issue counts in this cycle.
4 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Media, PA
Wesley Enhanced Living Main Line Rehab And Skd Nsg
4-star overall rating with 3-star inspections with $151,457 in total fines with 4 fire-safety deficiencies in the latest cycle
100 Halcyon Drive, Media, PA
(610) 353-7660
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
60
Certified beds
Average residents
56
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1981-01-12
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
Hours and turnover
RN hours / resident day
1.18
Registered nurse staffing · state 0.78 · national 0.68
LPN hours / resident day
0.85
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
2.42
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
4.45
All reported nurse hours · state 3.89 · national 3.89
Licensed hours
2.03
RN + LPN hours · state 1.69 · national 1.54
Weekend hours
4.24
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.95
Weekend registered nurse coverage · state 0.55 · national 0.47
Physical therapist
0.10
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
1.20
CMS adjusted RN staffing hours
Adjusted total hours
4.54
CMS adjusted total nurse staffing hours
Case-mix index
1.34
Higher values indicate more complex resident acuity
RN turnover
33%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
25%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,525
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
55.98
Composite VBP score used to determine payment impact.
Payment multiplier
1.0110
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.44
Baseline 20.44% · Performance 19.38% · Measure score 4.44 · Achievement 4.44 · Improvement 2.63
Healthcare-associated infections
6.04
Baseline 5.48% · Performance 6.03% · Measure score 6.04 · Achievement 6.04 · Improvement 0
Total nurse turnover
7.30
Baseline 32.81% · Performance 33.82% · Measure score 7.30 · Achievement 7.30 · Improvement 0
Adjusted total nurse staffing
4.61
Baseline 3.88 hours · Performance 4.39 hours · Measure score 4.61 · Achievement 4.61 · Improvement 2.17
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.69% |
10.72%
2 pts worse
|
No Different than the National Rate · Eligible stays 163 · Observed rate 14.11% · Lower 95% interval 8.91% |
| Discharge to community | 57.66% |
50.57%
7.1 pts better
|
No Different than the National Rate · Eligible stays 146 · Observed rate 54.11% · Lower 95% interval 48.99% |
| Medicare spending per beneficiary | 0.65 |
1.02
0.4 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 92 · Denominator 92 |
| Falls with major injury | 2.17% |
0.77%
1.4 pts worse
|
Numerator 2 · Denominator 92 |
| Discharge self-care score | 61.33% |
53.69%
7.6 pts better
|
Numerator 46 · Denominator 75 |
| Discharge mobility score | 53.33% |
50.94%
2.4 pts better
|
Numerator 40 · Denominator 75 |
| Pressure ulcers or injuries, new or worsened | 1.09% |
2.29%
1.2 pts better
|
Numerator 1 · Denominator 92 · Adjusted rate 1% |
| Healthcare-associated infections requiring hospitalization | 6.03% |
7.12%
1.1 pts better
|
No Different than the National Rate · Eligible stays 90 · Observed rate 3.33% · Lower 95% interval 3.67% |
| Staff COVID-19 vaccination coverage | 2.05% |
8.2%
6.1 pts worse
|
Numerator 3 · Denominator 146 |
| Staff flu vaccination coverage | 98.81% |
42%
56.8 pts better
|
Numerator 499 · Denominator 505 |
| Discharge function score | 62.67% |
56.45%
6.2 pts better
|
Numerator 47 · Denominator 75 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 59 · Denominator 59 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 36.59% |
25.2%
11.4 pts better
|
Numerator 15 · Denominator 41 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.3 |
1.7
0.6 pts worse
|
1.9
0.4 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.3 · Observed 2.0 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.8 |
1.2
0.4 pts better
|
1.8
1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.8 · Observed 0.7 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
86.9%
13.1 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.2% |
93.5%
4.7 pts better
|
95.5%
2.7 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.2% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 6.0% |
3.2%
2.8 pts worse
|
3.3%
2.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.1% · Q2 4.3% · Q3 3.9% · Q4 9.6% · 4Q avg 6.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.3% |
6.5%
3.2 pts better
|
11.4%
8.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.9% · Q2 0.0% · Q3 4.2% · Q4 4.1% · 4Q avg 3.3% |
| Percentage of long-stay residents who lose too much weight | 2.5% |
6.5%
4 pts better
|
5.4%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.4% · Q3 7.3% · Q4 0.0% · 4Q avg 2.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 8.9% |
19.9%
11 pts better
|
19.6%
10.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.1% · Q2 7.3% · Q3 9.3% · Q4 11.9% · 4Q avg 8.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 3.4% |
18.7%
15.3 pts better
|
16.7%
13.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 5.4% · Q3 2.4% · Q4 2.8% · 4Q avg 3.4% · 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 | 51.8% |
19.6%
32.2 pts worse
|
16.3%
35.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 51.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 28.0% |
18.3%
9.7 pts worse
|
14.9%
13.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 33.3% · Q2 24.4% · Q3 31.0% · Q4 23.1% · 4Q avg 28.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.3% |
0.9%
0.4 pts worse
|
1.0%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.3% · Q3 1.6% · Q4 1.4% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.1% |
1.7%
0.6 pts better
|
1.7%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 4.1% · Q4 0.0% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 21.3% |
26.4%
5.1 pts better
|
19.8%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.3% · Q2 16.0% · Q3 21.2% · Q4 18.7% · 4Q avg 21.3% |
| Percentage of long-stay residents with pressure ulcers | 8.6% |
5.3%
3.3 pts worse
|
5.1%
3.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.1% · Q2 13.9% · Q3 4.6% · Q4 6.8% · 4Q avg 8.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 96.2% |
68.9%
27.3 pts better
|
81.7%
14.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 94.6% · Q2 98.1% · Q3 98.1% · Q4 93.6% · 4Q avg 96.2% |
| 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 8.1% · Expected 10.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.9% |
1.5%
0.6 pts better
|
1.6%
0.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 3.7% · Q4 0.0% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 85.7% |
68.7%
17 pts better
|
79.7%
6 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 85.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.7% |
23.1%
0.6 pts worse
|
23.9%
0.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 23.7% · Observed 20.3% · Expected 20.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-01-11 · Fire 2024-01-11
4 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
4 fire-safety deficiencies
Top issue: Construction (1 deficiency)
Cycle 3
Health 2023-01-13 · Fire 2023-01-13
5 health deficiencies
Top issue: Administration (1 deficiency)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-12-19
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2025-01-18
E · Potential for more than minimal harm
2024-12-19
K912 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2025-01-18
E · Potential for more than minimal harm
2024-12-19
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-01-18
E · Potential for more than minimal harm
2024-12-19
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-01-18
F · Potential for more than minimal harm
2024-01-11
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-02-13
E · Potential for more than minimal harm
2024-01-11
K100 · Construction Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2024-02-13
E · Potential for more than minimal harm
2024-01-11
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-02-13
E · Potential for more than minimal harm
2024-01-11
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 2024-02-13
F · Potential for more than minimal harm
2023-01-13
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-03-01
F · Potential for more than minimal harm
2023-01-13
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-03-01
E · Potential for more than minimal harm
2023-01-13
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-03-01
D · Potential for more than minimal harm
2023-01-13
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-03-01
C · Minimal harm
2023-01-13
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-03-01
C · Minimal harm
2023-01-13
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-03-01
Inspection history
Recent health citations
L · Immediate jeopardy
2024-07-31
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-07-31
E · Potential for more than minimal harm
2024-07-31
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2024-07-31
E · Potential for more than minimal harm
2024-01-11
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-01-26
D · Potential for more than minimal harm
2024-01-11
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-01-22
D · Potential for more than minimal harm
2023-01-13
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 2023-02-02
D · Potential for more than minimal harm
2023-01-13
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 2023-02-02
D · Potential for more than minimal harm
2023-01-13
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-02-02
D · Potential for more than minimal harm
2023-01-13
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2023-02-02
D · Potential for more than minimal harm
2023-01-13
F770 · Administration Deficiencies
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2023-02-02
Penalties and ownership
What sits behind the stars
$151,457
2024-07-31
Fine
Fine · fine $151,457
Fine
Ownership
Martins Run
5% Or Greater Direct Ownership Interest · Organization
Conner, Ronnie
Corporate Director · Individual
Hood, Daniel
Operational/Managerial Control · Individual
Martins Run
Operational/Managerial Control · Organization
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Newtown Square, PA
5-star overall rating with 4-star inspections with 3 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#2
Pine View Healthcare And Rehabilitation Center
Broomall, PA
3-star overall rating with 3-star inspections with 14 recent health deficiencies with 14 fire-safety deficiencies in the latest cycle
#3
Broomall Manor
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5-star overall rating with 5-star inspections with 1 recent health deficiencies
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