Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record

WEST CHESTER REHABILITATION AND HEALTHCARE CENTER

WEST CHESTER, PA · 180 certified beds · Last Life Safety survey October 3, 2024

CMS Certification Number 395740 · first certified July 1987

Ownership

Operated by MARQUIS HEALTH SERVICES · For profit - Limited Liability company

  • Ownership changed October 7, 2022 (change of ownership)from 800 WEST MINER STREET OPERATIONS LLC
6
Citations on file
Rolling three-year window
3
Life Safety surveys
In the same window
0
Tags cited more than once
Across separate surveys
4
Inspection & testing records
Of the citations on file

Position within PA

6 citations — more than 29% of the 656 certified nursing homes in PA. Compared within PA rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated

Improvingfewer citations at the latest survey than at its earlier surveys in the window.

The latest survey found 1 citation; the earlier surveys in the window averaged 2.5. With 3 surveys on file this is a direction of travel, not a conclusion.

When is the next survey likely?

Well past the typical window (August 2025 to October 2025), and past the point by which nine in ten PA facilities have been surveyed. This facility’s last Life Safety survey was October 2024. Facilities in PA are typically surveyed 10–12 months after the last one (median 11), measured over 1,113 consecutive surveys in the last two years of CMS records.

A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured

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Which alerts

Physical environment (health survey)

2 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 6 Life Safety citations above. The Physical Environment Index

  • F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

How that compares

Citations on file over three years

Compared with the median facility in PA, and nationally. Surveyors differ markedly between states, so the PA figure is the meaningful one.

This facility6PA median10National median11
Citations on file over three years, compared
MeasureCitations
This facility6
Median facility in PA10
Median facility nationally11

Survey history

Citations at each Life Safety survey
02023-0652024-0512024-10
Citations at each Life Safety survey
Survey dateCitations
June 16, 20230
May 6, 20245
October 3, 20241

Most-cited tags

Most-cited tags at this facility
K-01001K-03531K-09321K-02911K-07611K-09181
Most-cited tags at this facility
TagWhat the surveyor checksTimes citedLast cited
K-0100Meet other general requirements.12024-05-06
K-0353Inspect, test, and maintain automatic sprinkler systems.12024-05-06
K-0932Meet other general requirements.12024-05-06
K-0291Install emergency lighting that can last at least 1 1/2 hours.12024-05-06
K-0761To conduct inspection, testing and maintenance of fire doors by qualified individuals.12024-10-03
K-0918Have generator or other power source capable of supplying service within 10 seconds.12024-05-06

What the citations cover

Citations by CMS category
  • Smoke Deficiencies 2
  • Egress Deficiencies 1
  • Gas, Vacuum, and Electrical Systems Deficiencies 1
  • Miscellaneous Deficiencies 1
  • Other 1
Citations by CMS category
CategoryCitations
Smoke Deficiencies2
Egress Deficiencies1
Gas, Vacuum, and Electrical Systems Deficiencies1
Miscellaneous Deficiencies1
Construction Deficiencies1

Every citation on file

As published by CMS, newest survey first. Descriptions are CMS’s own wording.

October 3, 2024 — 1 citation

Citations issued on October 3, 2024
TagWhat the surveyor checksStatus
K-0761To conduct inspection, testing and maintenance of fire doors by qualified individuals.Deficient, Provider has date of correction (October 6, 2024)

May 6, 2024 — 5 citations

Citations issued on May 6, 2024
TagWhat the surveyor checksStatus
K-0100Meet other general requirements.Deficient, Provider has date of correction (May 5, 2024)
K-0291Install emergency lighting that can last at least 1 1/2 hours.Deficient, Provider has date of correction (May 5, 2024)
K-0353Inspect, test, and maintain automatic sprinkler systems.Deficient, Provider has date of correction (May 5, 2024)
K-0918Have generator or other power source capable of supplying service within 10 seconds.Deficient, Provider has date of correction (May 5, 2024)
K-0932Meet other general requirements.Deficient, Provider has date of correction (May 5, 2024)

Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.