Above average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Hrh Transitional Care Unit(a D/b/a Entity Of Hrhs) during CMS and state inspections, most recent first.
Failure to assess and obtain consent for bed rail use. Four residents were observed with two side rails upright, but the record lacked documentation of a side rail assessment, review of risks and benefits, and informed consent from the resident or RP. The residents had diagnoses including arthritis, fractures, and deconditioning, and the Unit Mgr confirmed there was no evidence that alternative bed mobility methods were attempted or that consent was obtained before the rails were used.
Failure to Provide Required Transfer and Discharge Notifications: The facility did not send written transfer notices, including the reasons for transfer, to the responsible parties or legal representatives of three residents who were sent to the hospital after a change in condition. The facility also did not provide copies of written discharge notices to the Office of the State LTC Ombudsman for three discharged residents. The Unit Manager confirmed the missing notifications during interview.
The facility failed to maintain its fire alarm system in operable condition, affecting the entire facility. A fire alarm report listed eight deficiencies with no verification of repair. The LTC location was not separately zoned or monitored, and the fire alarm annunciator panel indicated several trouble conditions.
The facility did not maintain emergency lighting as per NFPA 101 standards. A battery back-up light in the ground floor Sprinkler Room failed to illuminate during a test, as confirmed by the Director of Maintenance and Assistant Director.
The facility failed to transmit encoded MDS data to CMS within the required 14 days for two residents who had been discharged. Discharge MDS assessments were completed but not exported by the required deadline. An RN confirmed the delay in transmission.
Failure to Assess and Obtain Consent for Bed Rail Use
Penalty
Summary
The facility failed to assess residents for side rail use, review the risks and benefits of side rail use, and obtain informed consent from the resident or responsible party before using side rails for four sampled residents. Resident 4 was admitted with arthritis and abnormalities of gait and mobility, had no memory impairment, and required moderate assistance with bed mobility; the resident was observed in bed with two side rails upright, but there was no documented evidence of a side rail assessment, review of risks and benefits, or informed consent. Resident 36 was admitted with a right hip fracture, had no memory impairment, and required supervisory assistance for bed mobility; the resident was observed in bed with two side rails upright on two occasions, with no documented evidence of assessment, risk/benefit review, or informed consent. Resident 37 was admitted with a right thigh fracture, had no memory impairment, and required supervisory assistance for bed mobility; the resident was observed in bed with two side rails upright, and there was no documented evidence of assessment, risk/benefit review, or informed consent. Resident 38 was admitted with deconditioning, had no memory impairment, and was independent for bed mobility; the resident was observed in bed with two side rails upright on two occasions, and there was no documented evidence of assessment, risk/benefit review, or informed consent. During interview, the Unit Manager confirmed there was no documented evidence that alternative bed mobility methods were attempted, that the residents were assessed for bed rail use, or that informed consent discussing risks and benefits was obtained before bed rail use.
Failure to Provide Required Transfer and Discharge Notifications
Penalty
Summary
The facility failed to notify resident representatives in writing of transfers, including the reasons for the moves, for three residents who were transferred out of the facility. Resident 1 was transferred to the hospital on February 11, 2026 after a change in condition, Resident 5 was transferred to the hospital on December 5, 2025 after a change in condition, and Resident 29 was transferred to the hospital on January 26, 2026 after a change in condition. For each of these residents, there was no documented evidence that the resident's responsible party or legal representative received written information regarding the transfer. The facility also failed to provide copies of written discharge notices to a representative of the Office of the State Long-Term Care Ombudsman for three residents who were discharged from the facility. Resident 2 was discharged on February 5, 2026, Resident 3 was discharged on January 30, 2026, and Resident 31 was discharged on January 23, 2026. During an interview on February 19, 2026 at 9:50 a.m., the Unit Manager confirmed that the transfer notifications were not sent for the noted resident representatives and that the written copies of the discharge notices were not sent to the Office of the State Long-Term Care Ombudsman.
Fire Alarm System Deficiencies
Penalty
Summary
The facility failed to maintain its fire alarm system components in operable condition, affecting the entire facility. During a document review on January 23, 2025, it was found that a fire alarm report dated December 27, 2024, listed eight deficiencies, and there was no verification of repair available at the time of the survey. An exit interview with the Director of Maintenance and Assistant Director confirmed that the facility's LTC location was not separately zoned or monitored, and the building fire alarm deficiencies remained uncorrected. Additionally, an observation on January 23, 2025, revealed that the fire alarm annunciator panel inside the electrical room on the third floor indicated several trouble conditions. This was confirmed during the exit interview with the Director of Maintenance and Assistant Director.
Plan Of Correction
The fire alarm system is a combined system with the Hospital and the (3) components of the St. Joseph's Manor campus. At the time of the inspection, we had identified the troubles listed on the fire alarm report that we had received two weeks earlier and had already scheduled the contractor to resolve the issues. The contractor had been scheduled for the following Monday and has since been here and cleared the troubles. We will be monitoring the fire panel daily to insure that any troubles are reported and resolved in a more timely fashion. The Director of Maintenance will be responsible for insuring the troubles are monitored and the contractors are trained on the alternative fire notification procedures while they have devices off-line.
Failure to Maintain Emergency Lighting
Penalty
Summary
The facility failed to maintain emergency lighting as required by NFPA 101 standards. During an observation on January 23, 2025, at 11:50 a.m., it was noted that the battery back-up light in the Sprinkler Room on the ground floor did not illuminate when tested. This deficiency was confirmed during an exit interview with the Director of Maintenance and Assistant Director at 12:00 p.m. on the same day.
Plan Of Correction
This unit passed the 30 second test the prior month, but did not light during survey. The light has been replaced. We have retested all the battery operated lights to insure they are operating and during our Annual 90 minute test we will be re-verifying that all the lights are operational and that the batteries are sufficient. The Director of Maintenance will be responsible for maintaining compliance of this inspection.
Failure to Transmit MDS Data Timely
Penalty
Summary
The facility failed to electronically transmit encoded Minimum Data Set (MDS) data to the Centers for Medicare & Medicaid Services (CMS) within the required 14 days after completing the resident assessments. This deficiency was identified for two residents who had been discharged from the facility. Specifically, a discharge MDS assessment for one resident was completed on December 4, 2024, but had not been exported by January 15, 2025. Similarly, another resident's discharge MDS assessment was completed on December 11, 2024, and also had not been exported by January 15, 2025. During an interview on January 15, 2025, a registered nurse (RN1) confirmed that the discharge MDS assessments had not been exported and transmitted to the CMS system in a timely manner.
Plan Of Correction
The assessment for the two of two residents who had been discharged from the Facility have been completed and transmitted. (Residents 1, 3) Holy Redeemer TCU facility will assess all records in the system to assure all residents data is now completed and electronically transmitted to the Centers for Medicare & Medicaid Services (CMS) immediately. The facility RNAC will electronically transmit encoded Minimum Data Set (MDS) data to the Centers for Medicare & Medicaid Services (CMS) within 14 days after residents are discharged from the facility. The nurse manager and NHA or their designee will monitor MDS transmissions weekly to assure compliance. We complete this audit by running the MDS in progress list from PCC weekly to assure they are all up to date and submitted. We will also run all admissions and discharges list from the EHR and reconcile the two reports to assure no one is missed each week. The RNAC and the Unit Manager have been in serviced on the requirement and how to comply. MDS transmission compliance reports will be added to QAPI quarterly for next 6 months.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Meadowbrook
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| St Joseph's Manor | 0.1 mi | ★★★★★ | 9 | 0 |
| Rydal Park Of Philadelphia Presbytery Homes, Inc | 1.7 mi | ★★★★★ | 0 | 0 |
| Lafayette-redeemer, The | 2 mi | ★★★★★ | 0 | 0 |
| Chapel Manor | 2.2 mi | ★★★★★ | 21 | 0 |
| Pennypack Rehab And Care Center | 2.7 mi | ★★★★★ | 6 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.