Cycle 1
Health 2024-11-07 · Fire 2024-11-07
4 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
10 fire-safety deficiencies
Top issue: Emergency Preparedness (4 deficiencies)
Havertown, PA
Westgate Hills Rehabilitation And Nursing Ctr
3-star overall rating with 3-star inspections with $52,764 in total fines with 4 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
2050 Old West Chester Pike, Havertown, PA
(610) 449-8600
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
110
Certified beds
Average residents
104
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Prestige Healthcare Administrative Services
Operator or chain grouping
Approved since
1972-02-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
15 facilities
Chain averages 3 overall / 3 health / 3 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
0.55
Registered nurse staffing · state 0.78 · national 0.68
LPN hours / resident day
0.91
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
1.97
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.43
All reported nurse hours · state 3.89 · national 3.89
Licensed hours
1.46
RN + LPN hours · state 1.69 · national 1.54
Weekend hours
3.13
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.38
Weekend registered nurse coverage · state 0.55 · national 0.47
Physical therapist
0.08
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.56
CMS adjusted RN staffing hours
Adjusted total hours
3.50
CMS adjusted total nurse staffing hours
Case-mix index
1.34
Higher values indicate more complex resident acuity
RN turnover
61%
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
4,410
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
40.1
Composite VBP score used to determine payment impact.
Payment multiplier
0.9930
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.56
Baseline 19.43% · Performance 18.86% · Measure score 5.56 · Achievement 5.56 · Improvement 1.88
Healthcare-associated infections
4.99
Baseline 11.37% · Performance 7.87% · Measure score 4.99 · Achievement 0 · Improvement 4.99
Total nurse turnover
2.70
Baseline 47.42% · Performance 52.63% · Measure score 2.70 · Achievement 2.70 · Improvement 0
Adjusted total nurse staffing
2.79
Baseline 3.51 hours · Performance 3.87 hours · Measure score 2.79 · Achievement 2.79 · Improvement 1.08
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 14.16% |
10.72%
3.4 pts worse
|
Worse than the National Rate · Eligible stays 177 · Observed rate 18.64% · Lower 95% interval 11.26% |
| Discharge to community | 49.71% |
50.57%
0.9 pts worse
|
No Different than the National Rate · Eligible stays 139 · Observed rate 40.29% · Lower 95% interval 41.56% |
| Medicare spending per beneficiary | 1.05 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 169 · Denominator 169 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 169 |
| Discharge self-care score | 44.83% |
53.69%
8.9 pts worse
|
Numerator 52 · Denominator 116 |
| Discharge mobility score | 49.14% |
50.94%
1.8 pts worse
|
Numerator 57 · Denominator 116 |
| Pressure ulcers or injuries, new or worsened | 2.96% |
2.29%
0.7 pts worse
|
Numerator 5 · Denominator 169 · Adjusted rate 2.52% |
| Healthcare-associated infections requiring hospitalization | 7.87% |
7.12%
0.8 pts worse
|
No Different than the National Rate · Eligible stays 99 · Observed rate 10.1% · Lower 95% interval 4.74% |
| Staff COVID-19 vaccination coverage | 3.49% |
8.2%
4.7 pts worse
|
Numerator 6 · Denominator 172 |
| Staff flu vaccination coverage | 60.91% |
42%
18.9 pts better
|
Numerator 120 · Denominator 197 |
| Discharge function score | 47.41% |
56.45%
9 pts worse
|
Numerator 55 · Denominator 116 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 48 · Denominator 48 |
| Transfer of health information to patient | 95.45% |
96.28%
0.8 pts worse
|
Numerator 63 · Denominator 66 |
| Resident COVID-19 vaccinations up to date | 21.65% |
25.2%
3.6 pts worse
|
Numerator 21 · Denominator 97 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.6 |
1.7
0.9 pts worse
|
1.9
0.7 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.6 · Observed 2.4 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.5 |
1.2
0.3 pts worse
|
1.8
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.3 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 62.6% |
86.9%
24.3 pts worse
|
93.4%
30.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 55.4% · Q2 64.2% · Q3 64.1% · Q4 67.1% · 4Q avg 62.6% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
93.5%
6.5 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.6% |
3.2%
2.6 pts better
|
3.3%
2.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.3% · Q4 1.3% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 20.8% |
6.5%
14.3 pts worse
|
11.4%
9.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.6% · Q2 25.7% · Q3 30.1% · Q4 20.8% · 4Q avg 20.8% |
| Percentage of long-stay residents who lose too much weight | 5.4% |
6.5%
1.1 pts better
|
5.4%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 7.0% · Q2 2.8% · Q3 8.8% · Q4 3.0% · 4Q avg 5.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 16.7% |
19.9%
3.2 pts better
|
19.6%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 23.4% · Q2 17.1% · Q3 12.5% · Q4 13.5% · 4Q avg 16.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 15.6% |
18.7%
3.1 pts better
|
16.7%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.0% · Q2 14.8% · Q3 13.6% · Q4 16.1% · 4Q avg 15.6% · 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 | 9.9% |
19.6%
9.7 pts better
|
16.3%
6.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 11.7% · Q3 10.4% · Q4 15.7% · 4Q avg 9.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 9.8% |
18.3%
8.5 pts better
|
14.9%
5.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.1% · Q2 8.3% · Q3 8.7% · Q4 11.1% · 4Q avg 9.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.8% |
0.9%
0.9 pts worse
|
1.0%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 2.5% · Q3 2.4% · Q4 1.2% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.3% |
1.7%
0.4 pts better
|
1.7%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 0.0% · Q3 1.4% · Q4 2.8% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 22.2% |
26.4%
4.2 pts better
|
19.8%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.9% · Q2 22.5% · Q3 24.0% · Q4 14.6% · 4Q avg 22.2% |
| Percentage of long-stay residents with pressure ulcers | 5.0% |
5.3%
0.3 pts better
|
5.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 4.4% · Q3 7.3% · Q4 4.7% · 4Q avg 5.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 45.9% |
68.9%
23 pts worse
|
81.7%
35.8 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 44.5% · Q2 51.2% · Q3 48.8% · Q4 39.6% · 4Q avg 45.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.2% |
9.8%
1.6 pts better
|
12.0%
3.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.2% · Observed 7.9% · Expected 10.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.2% |
1.5%
0.3 pts better
|
1.6%
0.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.1% · Q3 1.9% · Q4 1.7% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 59.5% |
68.7%
9.2 pts worse
|
79.7%
20.2 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 59.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 25.2% |
23.1%
2.1 pts worse
|
23.9%
1.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.2% · Observed 26.2% · Expected 24.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-12-14 · Fire 2023-12-14
7 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Cycle 3
Health 2023-02-17 · Fire 2023-02-17
3 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
9 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-11-07
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-02-08
E · Potential for more than minimal harm
2024-11-07
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 2025-02-08
E · Potential for more than minimal harm
2024-11-07
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-02-08
E · Potential for more than minimal harm
2024-11-07
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-12-06
E · Potential for more than minimal harm
2024-11-07
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-12-06
C · Minimal harm
2024-11-07
E26 · Emergency Preparedness Deficiencies
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2025-02-08
C · Minimal harm
2024-11-07
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2025-02-08
C · Minimal harm
2024-11-07
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2025-02-08
C · Minimal harm
2024-11-07
E7 · Emergency Preparedness Deficiencies
Fire Safety
Address patient/client population and determine types of services needed.
Corrected 2025-02-08
C · Minimal harm
2024-11-07
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-02-08
E · Potential for more than minimal harm
2023-12-14
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2024-03-10
E · Potential for more than minimal harm
2023-12-14
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-03-10
E · Potential for more than minimal harm
2023-12-14
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-03-10
E · Potential for more than minimal harm
2023-12-14
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-03-10
E · Potential for more than minimal harm
2023-12-14
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-03-10
E · Potential for more than minimal harm
2023-12-14
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2024-03-10
E · Potential for more than minimal harm
2023-12-14
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-03-10
F · Potential for more than minimal harm
2023-02-17
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-04-11
F · Potential for more than minimal harm
2023-02-17
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-04-11
F · Potential for more than minimal harm
2023-02-17
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2023-04-11
E · Potential for more than minimal harm
2023-02-17
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 2023-05-11
E · Potential for more than minimal harm
2023-02-17
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-04-11
E · Potential for more than minimal harm
2023-02-17
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-04-11
E · Potential for more than minimal harm
2023-02-17
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-04-11
E · Potential for more than minimal harm
2023-02-17
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2023-04-11
E · Potential for more than minimal harm
2023-02-17
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-04-11
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-11-21
F910 · Environmental Deficiencies
Health
Ensure resident rooms meet each resident's needs.
Corrected 2025-12-04
D · Potential for more than minimal harm
2024-11-07
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-12-11
D · Potential for more than minimal harm
2024-11-07
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-12-11
D · Potential for more than minimal harm
2024-11-07
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 2024-12-11
K · Immediate jeopardy
2023-12-14
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-01-23
E · Potential for more than minimal harm
2023-12-14
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2024-01-23
E · Potential for more than minimal harm
2023-12-14
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2024-01-23
D · Potential for more than minimal harm
2023-12-14
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-01-23
D · Potential for more than minimal harm
2023-12-14
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 2024-01-23
D · Potential for more than minimal harm
2023-12-14
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-01-23
D · Potential for more than minimal harm
2023-12-14
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 2024-01-23
G · Actual harm
2023-02-17
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 2023-04-14
F · Potential for more than minimal harm
2023-02-17
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 2023-04-14
E · Potential for more than minimal harm
2023-02-17
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-04-14
Penalties and ownership
What sits behind the stars
$10,256
2024-01-22
Fine
Fine · fine $10,256
Fine
$6,480
2023-12-26
Fine
Fine · fine $6,480
Fine
$32,854
2023-12-14
Fine
Fine · fine $32,854
Fine
$0
2023-12-14
Payment Denial
Payment Denial · denial start 2024-01-18 · 5 days
5 day denial
$3,174
2023-07-31
Fine
Fine · fine $3,174
Fine
Ownership
Karmel, Jacob
5% Or Greater Direct Ownership Interest · Individual
Phwh Holdings LLC
5% Or Greater Direct Ownership Interest · Organization
Karmel, Jacob
Corporate Director · Individual
Tornari, Catherine
W-2 Managing Employee · Individual
Nearby options
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#2
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5-star overall rating with 4-star inspections with 3 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Bryn Mawr Village
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3-star overall rating with 2-star inspections with $15,902 in total fines with 13 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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