Cycle 1
Health 2025-04-04 · Fire 2025-04-04
3 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Newtown Square, PA
William Hood Dunwoody Care Ctr
5-star overall rating with 4-star inspections with 3 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
3500 West Chester Pike, Newtown Square, PA
(215) 359-4401
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
81
Certified beds
Average residents
68
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1975-07-08
CMS approved date
Coverage
Medicare
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
1.80
Registered nurse staffing · state 0.78 · national 0.68
LPN hours / resident day
0.92
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
3.16
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
5.88
All reported nurse hours · state 3.89 · national 3.89
Licensed hours
2.72
RN + LPN hours · state 1.69 · national 1.54
Weekend hours
5.44
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
1.22
Weekend registered nurse coverage · state 0.55 · national 0.47
Physical therapist
0.19
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
1.83
CMS adjusted RN staffing hours
Adjusted total hours
5.99
CMS adjusted total nurse staffing hours
Case-mix index
1.34
Higher values indicate more complex resident acuity
RN turnover
23%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
33%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
261
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
75.36
Composite VBP score used to determine payment impact.
Payment multiplier
1.0246
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.27
Baseline 21.32% · Performance 18.99% · Measure score 5.27 · Achievement 5.27 · Improvement 4.92
Healthcare-associated infections
7.83
Baseline 5.34% · Performance 5.50% · Measure score 7.83 · Achievement 7.83 · Improvement 0
Total nurse turnover
7.05
Baseline 28.28% · Performance 34.86% · Measure score 7.05 · Achievement 7.05 · Improvement 0
Adjusted total nurse staffing
10
Baseline 5.97 hours · Performance 5.9 hours · Measure score 10 · Achievement 10 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 7.66% |
10.72%
3.1 pts better
|
Better than the National Rate · Eligible stays 755 · Observed rate 5.17% · Lower 95% interval 6.12% |
| Discharge to community | 58.47% |
50.57%
7.9 pts better
|
Better than the National Rate · Eligible stays 791 · Observed rate 59.54% · Lower 95% interval 55.32% |
| Medicare spending per beneficiary | 0.88 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 99.8% |
95.27%
4.5 pts better
|
Numerator 487 · Denominator 488 |
| Falls with major injury | 0.82% |
0.77%
About the same
|
Numerator 4 · Denominator 488 |
| Discharge self-care score | 71.84% |
53.69%
18.2 pts better
|
Numerator 227 · Denominator 316 |
| Discharge mobility score | 66.46% |
50.94%
15.5 pts better
|
Numerator 210 · Denominator 316 |
| Pressure ulcers or injuries, new or worsened | 3.07% |
2.29%
0.8 pts worse
|
Numerator 15 · Denominator 488 · Adjusted rate 3.55% |
| Healthcare-associated infections requiring hospitalization | 5.5% |
7.12%
1.6 pts better
|
No Different than the National Rate · Eligible stays 455 · Observed rate 3.52% · Lower 95% interval 3.82% |
| Staff COVID-19 vaccination coverage | 3.28% |
8.2%
4.9 pts worse
|
Numerator 6 · Denominator 183 |
| Staff flu vaccination coverage | 82% |
42%
40 pts better
|
Numerator 451 · Denominator 550 |
| Discharge function score | 70.25% |
56.45%
13.8 pts better
|
Numerator 222 · Denominator 316 |
| Transfer of health information to provider | 99.36% |
95.95%
3.4 pts better
|
Numerator 311 · Denominator 313 |
| Transfer of health information to patient | 97.52% |
96.28%
1.2 pts better
|
Numerator 118 · Denominator 121 |
| Resident COVID-19 vaccinations up to date | 24.89% |
25.2%
0.3 pts worse
|
Numerator 59 · Denominator 237 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.5 |
1.7
0.8 pts worse
|
1.9
0.6 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.5 · Observed 2.3 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.9 |
1.2
0.7 pts worse
|
1.8
0.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 1.7 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 67.7% |
86.9%
19.2 pts worse
|
93.4%
25.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 81.2% · Q3 43.8% · Q4 41.4% · 4Q avg 67.7% |
| 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 | 7.9% |
3.2%
4.7 pts worse
|
3.3%
4.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.9% · Q2 9.4% · Q3 9.4% · Q4 6.9% · 4Q avg 7.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
6.5%
6.5 pts better
|
11.4%
11.4 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 who lose too much weight | 12.8% |
6.5%
6.3 pts worse
|
5.4%
7.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.2% · Q2 4.5% · Q3 13.6% · Q4 14.3% · 4Q avg 12.8% |
| 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 10.0% · Q2 16.0% · Q3 20.0% · Q4 22.7% · 4Q avg 16.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 7.1% |
18.7%
11.6 pts better
|
16.7%
9.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.5% · Q2 7.4% · Q3 8.3% · Q4 0.0% · 4Q avg 7.1% · 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 | 5.8% |
19.6%
13.8 pts better
|
16.3%
10.5 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 5.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 14.0% |
18.3%
4.3 pts better
|
14.9%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.8% · Q2 17.4% · Q3 17.4% · Q4 5.0% · 4Q avg 14.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.9%
0.9 pts better
|
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% · 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 | 21.9% |
26.4%
4.5 pts better
|
19.8%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.5% · Q2 15.3% · Q3 23.0% · Q4 29.5% · 4Q avg 21.9% |
| 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 6.3% · Q2 5.4% · Q3 2.7% · Q4 5.6% · 4Q avg 5.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 91.9% |
68.9%
23 pts better
|
81.7%
10.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 96.1% · Q2 94.0% · Q3 89.3% · Q4 88.6% · 4Q avg 91.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.5% |
9.8%
1.7 pts worse
|
12.0%
0.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.5% · Observed 10.0% · Expected 9.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.2% |
1.5%
1.3 pts better
|
1.6%
1.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.5% · Q3 0.5% · Q4 0.0% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 91.7% |
68.7%
23 pts better
|
79.7%
12 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 91.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.5% |
23.1%
0.4 pts worse
|
23.9%
0.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 23.5% · Observed 18.8% · Expected 19.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-05-03 · Fire 2024-05-03
2 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2023-06-23 · Fire 2023-06-23
0 health deficiencies
No concentrated health issue counts in this cycle.
5 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-04-04
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-06-16
F · Potential for more than minimal harm
2025-04-04
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-06-16
F · Potential for more than minimal harm
2025-04-04
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-06-16
E · Potential for more than minimal harm
2025-04-04
K131 · Construction Deficiencies
Fire Safety
Meet requirements for sections of health care facilities separated by fire resistive construction.
Corrected 2025-06-16
E · Potential for more than minimal harm
2025-04-04
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2025-06-16
E · Potential for more than minimal harm
2025-04-04
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-06-16
E · Potential for more than minimal harm
2025-04-04
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2025-06-16
F · Potential for more than minimal harm
2024-05-03
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-07-12
F · Potential for more than minimal harm
2024-05-03
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 2024-07-12
E · Potential for more than minimal harm
2024-05-03
K133 · Construction Deficiencies
Fire Safety
Install a two-hour-resistant firewall separation.
Corrected 2024-07-12
E · Potential for more than minimal harm
2024-05-03
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 2024-07-12
E · Potential for more than minimal harm
2024-05-03
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-07-12
E · Potential for more than minimal harm
2024-05-03
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-07-12
E · Potential for more than minimal harm
2023-06-23
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2023-07-14
E · Potential for more than minimal harm
2023-06-23
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2023-07-14
E · Potential for more than minimal harm
2023-06-23
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-07-14
E · Potential for more than minimal harm
2023-06-23
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-07-14
E · Potential for more than minimal harm
2023-06-23
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-07-14
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-04-04
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 2025-04-25
D · Potential for more than minimal harm
2025-04-04
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-04-25
D · Potential for more than minimal harm
2025-04-04
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-04-25
D · Potential for more than minimal harm
2024-05-03
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
2024-05-03
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 2024-06-11
Penalties and ownership
What sits behind the stars
Ownership
Casey, Maureen
Corporate Director · Individual
Casey, Maureen
Corporate Officer · Individual
Casey, Maureen
W-2 Managing Employee · Individual
Mccullough, Kelly
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
#1
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
#2
Broomall Manor
Broomall, PA
5-star overall rating with 5-star inspections with 1 recent health deficiencies
#3
Wesley Enhanced Living Main Line Rehab And Skd Nsg
Media, PA
4-star overall rating with 3-star inspections with $151,457 in total fines with 4 fire-safety deficiencies in the latest cycle
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