West Chester, PA

West Chester Rehabilitation And Healthcare Center

2-star overall rating with 2-star inspections with $83,889 in total fines with 6 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle

800 West Miner Street, West Chester, PA

(610) 696-3120

Compare this facility

Overall

2 / 5

CMS overall stars

Health inspections

2 / 5

Survey and complaint cycles

Staffing

2 / 5

RN + nurse staffing

Quality measures

4 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

180

Certified beds

Average residents

171

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Marquis Health Services

Operator or chain grouping

Approved since

1987-07-31

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

81 facilities

Chain averages 3 overall / 3 health / 2 staffing / 4 quality stars

Changed ownership

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

0.41

Registered nurse staffing · state 0.78 · national 0.68

LPN hours / resident day

0.87

Licensed practical nurse staffing · state 0.91 · national 0.87

Aide hours / resident day

2.06

Nurse aide staffing · state 2.20 · national 2.35

Total nurse hours

3.33

All reported nurse hours · state 3.89 · national 3.89

Licensed hours

1.28

RN + LPN hours · state 1.69 · national 1.54

Weekend hours

3.18

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

0.03

Reported PT staffing · state 0.10 · national 0.07

Adjusted RN hours

0.41

CMS adjusted RN staffing hours

Adjusted total hours

3.37

CMS adjusted total nurse staffing hours

Case-mix index

1.35

Higher values indicate more complex resident acuity

RN turnover

36%

Annual RN turnover · state 43% · national 45%

Total nurse turnover

46%

Annual nurse turnover · state 47% · national 46%

SNF VBP

Value-based purchasing

Program rank

11,445

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

16.74

Composite VBP score used to determine payment impact.

Payment multiplier

0.9817

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

Baseline 16.94% · Performance 22.28% · Measure score 0 · Achievement 0 · Improvement 0

Healthcare-associated infections

Baseline 4.78% · Performance 9.54% · Measure score 0 · Achievement 0 · Improvement 0

Total nurse turnover

5.42

Baseline 71.88% · Performance 44.06% · Measure score 5.42 · Achievement 4.80 · Improvement 5.42

Adjusted total nurse staffing

1.28

Baseline 3.68 hours · Performance 3.44 hours · Measure score 1.28 · Achievement 1.28 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	9.73%	10.72% 1 pts better	No Different than the National Rate · Eligible stays 204 · Observed rate 10.78% · Lower 95% interval 7.55%
Discharge to community	54.02%	50.57% 3.5 pts better	No Different than the National Rate · Eligible stays 190 · Observed rate 43.16% · Lower 95% interval 45.97%
Medicare spending per beneficiary	1.08	1.02 0.1 pts worse
Drug regimen review with follow-up	99.42%	95.27% 4.2 pts better	Numerator 172 · Denominator 173
Falls with major injury	0.58%	0.77% 0.2 pts better	Numerator 1 · Denominator 173
Discharge self-care score	82.73%	53.69% 29 pts better	Numerator 91 · Denominator 110
Discharge mobility score	51.82%	50.94% 0.9 pts better	Numerator 57 · Denominator 110
Pressure ulcers or injuries, new or worsened	4.62%	2.29% 2.3 pts worse	Numerator 8 · Denominator 173 · Adjusted rate 3.95%
Healthcare-associated infections requiring hospitalization	9.54%	7.12% 2.4 pts worse	No Different than the National Rate · Eligible stays 139 · Observed rate 12.95% · Lower 95% interval 5.8%
Staff COVID-19 vaccination coverage	40.22%	8.2% 32 pts better	Numerator 74 · Denominator 184
Staff flu vaccination coverage	50.2%	42% 8.2 pts better	Numerator 125 · Denominator 249
Discharge function score	78.18%	56.45% 21.7 pts better	Numerator 86 · Denominator 110
Transfer of health information to provider	100%	95.95% 4 pts better	Numerator 49 · Denominator 49
Transfer of health information to patient	100%	96.28% 3.7 pts better	Numerator 61 · Denominator 61
Resident COVID-19 vaccinations up to date	15.58%	25.2% 9.6 pts worse	Numerator 12 · Denominator 77

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 3.4 · Expected 2.8 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	1.6	1.2 0.4 pts worse	1.8 0.2 pts better	Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 1.9 · Expected 2.1 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	86.2%	86.9% 0.7 pts worse	93.4% 7.2 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 74.3% · Q2 86.2% · Q3 91.2% · Q4 93.1% · 4Q avg 86.2%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	94.1%	93.5% 0.6 pts better	95.5% 1.4 pts worse	Long Stay · 2024Q3-2025Q2 · 4Q avg 94.1%
Percentage of long-stay residents experiencing one or more falls with major injury	4.2%	3.2% 1 pts worse	3.3% 0.9 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 3.6% · Q3 5.4% · Q4 4.8% · 4Q avg 4.2% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	7.9%	6.5% 1.4 pts worse	11.4% 3.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 5.2% · Q2 3.9% · Q3 6.1% · Q4 16.9% · 4Q avg 7.9%
Percentage of long-stay residents who lose too much weight	6.2%	6.5% 0.3 pts better	5.4% 0.8 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 8.1% · Q2 6.7% · Q3 4.5% · Q4 5.9% · 4Q avg 6.2%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	17.9%	19.9% 2 pts better	19.6% 1.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 18.2% · Q2 19.5% · Q3 17.5% · Q4 16.4% · 4Q avg 17.9%
Percentage of long-stay residents who received an antipsychotic medication	16.1%	18.7% 2.6 pts better	16.7% 0.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 16.7% · Q2 18.9% · Q3 17.6% · Q4 11.4% · 4Q avg 16.1% · 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	1.7%	19.6% 17.9 pts better	16.3% 14.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 1.9% · Q3 1.6% · Q4 0.0% · 4Q avg 1.7% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	3.4%	18.3% 14.9 pts better	14.9% 11.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 7.0% · Q2 5.6% · Q3 0.0% · Q4 1.5% · 4Q avg 3.4% · 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 0.7% · 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	32.6%	26.4% 6.2 pts worse	19.8% 12.8 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 29.6% · Q2 44.9% · Q3 24.3% · Q4 32.1% · 4Q avg 32.6%
Percentage of long-stay residents with pressure ulcers	3.8%	5.3% 1.5 pts better	5.1% 1.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 3.6% · Q3 4.9% · Q4 4.6% · 4Q avg 3.8% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	40.0%	68.9% 28.9 pts worse	81.7% 41.7 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 34.1% · Q2 36.0% · Q3 40.0% · Q4 50.0% · 4Q avg 40.0%
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 10.4% · Expected 12.8% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	1.9%	1.5% 0.4 pts worse	1.6% 0.3 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 1.0% · Q3 2.2% · Q4 2.4% · 4Q avg 1.9% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	34.3%	68.7% 34.4 pts worse	79.7% 45.4 pts worse	Short Stay · 2024Q3-2025Q2 · 4Q avg 34.3%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	24.2%	23.1% 1.1 pts worse	23.9% 0.3 pts worse	Short Stay · 20240701-20250630 · Adjusted 24.2% · Observed 28.8% · Expected 28.4% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2024-10-03 · Fire 2024-10-03

6 health deficiencies

Top issue: Pharmacy Service (2 deficiencies)

1 fire-safety deficiencies

Top issue: Miscellaneous (1 deficiency)

Cycle 2 Health 2024-05-06 · Fire 2024-05-06

12 health deficiencies

Top issue: Quality of Life and Care (4 deficiencies)

5 fire-safety deficiencies

Top issue: Smoke (2 deficiencies)

Cycle 3 Health 2023-06-16 · Fire 2023-06-16

22 health deficiencies

Top issue: Quality of Life and Care (11 deficiencies)

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Fire safety

Fire-safety citations

C · Minimal harm 2024-10-03

K761 · Miscellaneous Deficiencies

Fire Safety

To conduct inspection, testing and maintenance of fire doors by qualified individuals.

Corrected 2024-10-06

F · Potential for more than minimal harm 2024-05-06

K291 · Egress Deficiencies

Fire Safety

Install emergency lighting that can last at least 1 1/2 hours.

Corrected 2024-05-05

F · Potential for more than minimal harm 2024-05-06

K932 · Smoke Deficiencies

Fire Safety

Meet other general requirements.

Corrected 2024-05-05

C · Minimal harm 2024-05-06

K100 · Construction Deficiencies

Fire Safety

Meet other general requirements.

Corrected 2024-05-05

C · Minimal harm 2024-05-06

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2024-05-05

C · Minimal harm 2024-05-06

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2024-05-05

Inspection history

Recent health citations

E · Potential for more than minimal harm 2025-02-27

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 2025-03-25

E · Potential for more than minimal harm 2024-10-03

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 2024-11-05

E · Potential for more than minimal harm 2024-10-03

F947 · Nursing and Physician Services Deficiencies

Health

Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.

Corrected 2024-11-05

D · Potential for more than minimal harm 2024-10-03

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 2024-11-05

D · Potential for more than minimal harm 2024-10-03

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2024-11-05

D · Potential for more than minimal harm 2024-10-03

F757 · Pharmacy Service Deficiencies

Health

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Corrected 2024-11-05

D · Potential for more than minimal harm 2024-10-03

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 2024-11-05

G · Actual harm 2024-08-15

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 2024-09-03

J · Immediate jeopardy 2024-05-06

F678 · Quality of Life and Care Deficiencies

Health

Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.

Corrected 2024-06-11

E · Potential for more than minimal harm 2024-05-06

F698 · Quality of Life and Care Deficiencies

Health

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Corrected 2024-06-11

E · Potential for more than minimal harm 2024-05-06

F835 · Administration Deficiencies

Health

Administer the facility in a manner that enables it to use its resources effectively and efficiently.

Corrected 2024-06-11

D · Potential for more than minimal harm 2024-05-06

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 2024-06-11

D · Potential for more than minimal harm 2024-05-06

F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Respond appropriately to all alleged violations.

Corrected 2024-06-11

D · Potential for more than minimal harm 2024-05-06

F623 · Resident Rights Deficiencies

Health

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Corrected 2024-06-11

D · Potential for more than minimal harm 2024-05-06

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 2024-06-11

D · Potential for more than minimal harm 2024-05-06

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2024-06-11

D · Potential for more than minimal harm 2024-05-06

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 2024-06-11

E · Potential for more than minimal harm 2024-03-26

F692 · Quality of Life and Care Deficiencies

Health

Provide enough food/fluids to maintain a resident's health.

Corrected 2024-04-17

D · Potential for more than minimal harm 2024-02-28

F686 · Quality of Life and Care Deficiencies

Health

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected 2024-03-26

D · Potential for more than minimal harm 2024-02-28

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 2024-03-26

D · Potential for more than minimal harm 2024-01-17

F558 · Resident Rights Deficiencies

Health

Reasonably accommodate the needs and preferences of each resident.

Corrected 2024-02-12

D · Potential for more than minimal harm 2024-01-17

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 2024-02-12

D · Potential for more than minimal harm 2023-09-05

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 2023-08-29

J · Immediate jeopardy 2023-06-16

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 2023-05-16

G · Actual harm 2023-06-16

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2023-07-17

E · Potential for more than minimal harm 2023-06-16

F698 · Quality of Life and Care Deficiencies

Health

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Corrected 2023-07-17

E · Potential for more than minimal harm 2023-06-16

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 2023-07-17

E · Potential for more than minimal harm 2023-06-16

F809 · Nutrition and Dietary Deficiencies

Health

Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.

Corrected 2023-07-17