Average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
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 St Francis Center For Rehabilitation & Healthcare during CMS and state inspections, most recent first.
The facility did not provide food that accommodated resident allergies, intolerances, and preferences, nor did it ensure appealing meal options. This resulted in residents not consistently receiving meals tailored to their individual dietary requirements.
A nurse left medications, including inhalers and a bottle of MiraLAX, unattended on top of the medication cart while administering medications to residents in their rooms. The nurse confirmed leaving the medications unattended, which was not in accordance with the facility's medication storage policy.
A resident with hypothyroidism did not receive a physician-ordered TSH lab test within the specified timeframe. Review of clinical records and staff interviews confirmed that the test was not completed as ordered, despite ongoing monitoring noted in the physician's progress notes.
The facility failed to treat residents with dignity and respect by not serving meals simultaneously to all residents at a table in the Fourth Floor Main dining room. Two residents received their lunch trays early, while others at the same table waited an hour longer. Staff interviews confirmed the delay, highlighting a breach in resident rights.
A facility failed to develop a baseline care plan for a resident's oxygen therapy within 48 hours of admission. The resident, with chronic obstructive pulmonary disease and other conditions, had a physician's order for continuous oxygen, but the care plan lacked a focus area for this therapy. An interview with a nurse confirmed the absence of a care plan for the resident's oxygen needs.
The facility failed to update care plans for several residents, leading to deficiencies in addressing bed rail use, bed positioning, oxygen therapy, and dietary needs. A paraplegic resident's request for bed rails was not documented, and another resident's oxygen therapy was not included in their care plan. Additionally, two residents had their beds positioned against the wall without care plan updates, and a resident's diet order was not reflected in their care plan.
A resident with multiple health issues experienced a decline in mobility due to inconsistent restorative therapy. The facility's practice of reassigning restorative aides to other duties during understaffing resulted in the resident receiving only six days of therapy over a month, contrary to the care plan. The DON confirmed this staffing issue, which affected the resident's ability to maintain or improve walking distance.
The facility failed to administer medications timely for two residents, with medications given hours later than prescribed. A resident reported receiving medications late, affecting those needing to be taken with meals. The pharmacist and DON confirmed inappropriate timing, particularly for Apixaban, which requires an 8-hour interval.
A facility failed to follow physician orders for a resident with COPD, administering oxygen at 3L/min instead of the prescribed 2L/min. This discrepancy was confirmed by a nurse, indicating non-compliance with the facility's oxygen administration policy.
A resident with an anxiety disorder did not receive prescribed Ativan gel due to repeated delays in pharmacy delivery. Despite the facility's policy requiring timely medication provision, nursing notes from January to June 2024 documented ongoing unavailability of the medication, highlighting a failure in the facility's pharmacy services.
The facility failed to implement proper infection control during dining services on the Fourth Floor Main unit. Observations showed that five employees served lunch to 14 residents without performing hand hygiene. Despite the presence of hand sanitizer units, staff did not use them, and residents, many with cognitive impairments, were not assisted with hygiene. The Unit Manager confirmed the lack of hand hygiene practices.
The facility failed to maintain an effective antibiotic stewardship program over four months, lacking protocols and a system to monitor antibiotic usage. Documentation revealed multiple infections treated with antibiotics without adequate surveillance tools, missing stop dates, therapy duration, outcomes, and adverse events. The Infection Preventionist confirmed the absence of necessary protocols and monitoring systems.
The facility failed to maintain safe handrails in the corridors on the Fourth Floor Main. Observations showed that several handrails were loose, detached, or missing near resident rooms and other areas. The Maintenance Director confirmed these deficiencies.
An aide mistakenly believed a resident needed her brief changed and removed the covers without asking for permission, leading the resident to feel violated. The resident clarified that the aide did not touch her and should have asked before proceeding.
The facility failed to maintain complete and accurate medical records for eight residents, with multiple instances of unsigned medical orders and treatments. An interview with the Nursing Home Administrator and the Director of Nursing confirmed the expectation that all treatments be signed out at the time they are provided.
Failure to Accommodate Dietary Needs and Preferences
Penalty
Summary
The facility failed to ensure that each resident received food that accommodated their allergies, intolerances, and preferences, and did not provide appealing options. This deficiency was identified based on observations and findings that the facility did not consistently provide meals tailored to individual dietary needs and preferences, as required.
Medications Left Unattended on Medication Cart During Administration
Penalty
Summary
Facility staff failed to ensure that medications were stored in a safe and secure manner during medication administration. During observation, a zip-lock bag containing Spiriva (oral inhalation spray) and Fluticasone Propionate (nasal spray), both labeled for a specific resident, was found left unattended on top of the medication cart. The licensed nurse responsible for administering medications confirmed that she left these medications unattended while she went into a resident's room to administer other medications. Upon returning, she put the medications away. A further observation revealed that a bottle of MiraLAX was also left unattended on top of the medication cart while the same nurse went to administer medication to another resident. The nurse confirmed during interview that she left the MiraLAX unattended while she was away from the cart. These actions were not in accordance with the facility's medication storage policy, which requires all drugs and biologicals to be stored in a safe, secure, and orderly manner, and that only authorized personnel have access to medications.
Failure to Complete Ordered Laboratory Test for Hypothyroid Resident
Penalty
Summary
The facility failed to obtain laboratory services as ordered for a resident diagnosed with hypothyroidism. Clinical records showed that a physician ordered a thyroid stimulating hormone (TSH) test to be completed in five weeks. However, review of the resident's records and staff interviews revealed that there was no documentation that the TSH test was completed as ordered. The Unit Manager and an LPN confirmed during interviews that the physician's progress notes indicated continued monitoring, but the specific order for the TSH test from May was not carried out.
Failure to Serve Meals Timely in Dining Room
Penalty
Summary
The facility failed to ensure that residents were treated with dignity and respect in the Fourth Floor Main dining room. On September 25, 2024, observations revealed that 14 residents were present in the dining room during lunchtime. Two residents at a table were served their lunch trays early, around 11:30 a.m., and finished eating by 12:30 p.m., while the remaining five residents at the same table were not served until an hour later. The cart with trays for the other residents arrived at 12:32 p.m., and meals were served by 12:35 p.m., leaving one resident without a tray until 12:40 p.m. Interviews with staff confirmed the delay in serving meals to residents at the same table, with Employee E8, a nurse aide, and Employee E9, the unit manager, acknowledging the discrepancy in meal service times. This inconsistency in meal service timing led to a failure in maintaining the residents' right to a dignified existence and self-determination, as outlined in 28 Pa. Code: 201.29(j) Resident rights.
Failure to Develop Baseline Care Plan for Oxygen Therapy
Penalty
Summary
The facility failed to develop a baseline care plan within 48 hours of admission for Resident R99, specifically regarding oxygen administration. Resident R99 was admitted with diagnoses including chronic obstructive pulmonary disease, congestive heart failure, and hypertension. Despite having a physician's order for continuous oxygen therapy at 2 liters via nasal cannula dated August 20, 2024, the baseline care plan did not include a focus area for oxygen therapy. An observation on September 24, 2024, confirmed that Resident R99 was receiving oxygen while resting in bed. However, an interview with a licensed nurse, Employee E3, on September 25, 2024, revealed that there was no current care plan in place for the resident's oxygen therapy, despite the resident having been on oxygen since admission. This oversight was identified as a deficiency in the facility's adherence to its care planning policy.
Care Plan Deficiencies in Resident Safety and Treatment
Penalty
Summary
The facility failed to ensure that care plans were revised for five residents concerning bed rails, bed positioning, oxygen therapy, and diet. Resident R106, who is paraplegic, requested bed side rails for assistance and safety, but her care plan lacked any goals or interventions related to bedrail use despite an evaluation indicating their necessity. Resident R42, who was receiving oxygen therapy, did not have a care plan addressing this treatment, as confirmed by the Director of Nursing. Additionally, Resident R96's care plan was outdated, reflecting a renal diet, while the current physician's order indicated a regular diet. Further deficiencies were noted with Residents R125 and R574, whose beds were positioned against the wall without corresponding care plans. Resident R125, admitted to hospice care, had her bed against the wall, confirmed by a registered nurse, but this was not documented in her care plan. Similarly, Resident R574's bed was moved against the wall after a fall, as per her request, but this change was not reflected in her care plan. The Director of Nursing confirmed these omissions, indicating a failure to update care plans to reflect residents' current needs and preferences.
Inconsistent Restorative Therapy Leads to Decline in Resident Mobility
Penalty
Summary
The facility failed to provide necessary care and services to ensure that a resident's ability to perform activities of daily living was maintained. The resident, identified as R141, was admitted with multiple diagnoses including chronic pain syndrome, muscle wasting and atrophy, muscle weakness, osteoarthritis, and morbid obesity. Despite having a care plan initiated to address impaired walking ability, the resident reported a significant reduction in restorative therapy sessions, which were intended to maintain or improve his walking distance. The resident expressed that when the facility was short-staffed, restorative nurses were reassigned to other duties, resulting in a lack of consistent therapy. The clinical record review revealed that the resident's restorative nursing program was not consistently implemented, with documentation showing only six days of therapy over a 30-day period. The Director of Nursing confirmed that restorative aides were reassigned as nursing aides during understaffing, impacting the delivery of the restorative program. This inconsistency in providing restorative therapy contributed to the resident's diminished ability to walk, as he noted a decline in his mobility since the reduction in therapy sessions.
Medication Administration Timing Deficiency
Penalty
Summary
The facility failed to administer medications in a timely manner as ordered by the physician and according to professional standards of practice for two residents. Resident R147 reported receiving medications late, including those that needed to be taken with or before meals. The review of the physician's orders for Resident R147 showed multiple medications, including Apixaban, Cymbalta, Farxiga, Furosemide, Metoprolol Succinate, Mometasone Furoate Inhalation, and Sacubitril-Valsartan, were not administered at the prescribed times. For instance, Apixaban, which should be taken twice daily, was given only 5.5 hours apart, and morning medications were administered around noon instead of before 9 a.m. Similarly, Resident R179's medication administration was not timely. The resident was prescribed Baclofen and Gabapentin to be taken three times a day, with the morning dose scheduled for 9:00 a.m. However, these medications were administered at 11:27 a.m. and 2:19 p.m., less than three hours apart. Interviews with the pharmacist and the Director of Nursing confirmed that the timing of medication administration was inappropriate, with specific reference to Apixaban needing at least an 8-hour interval between doses.
Failure to Follow Physician Orders for Oxygen Administration
Penalty
Summary
The facility failed to ensure that physician orders for oxygen administration were followed for a resident diagnosed with chronic obstructive pulmonary disease. The facility's policy on oxygen administration, revised in December 2022, outlines specific steps for safe oxygen delivery, including starting the flow at the rate ordered by the physician. However, during an observation on September 24, 2024, it was noted that the resident was receiving oxygen at a rate of 3 liters per minute, contrary to the physician's order of 2 liters per minute via nasal cannula. Further review on September 25, 2025, confirmed that the oxygen level remained at 3 liters, which was acknowledged as incorrect by a licensed nurse. This discrepancy indicates a failure to adhere to the prescribed oxygen administration guidelines, as outlined in the facility's policy and the physician's orders. The deficiency was identified under the Pennsylvania Code sections related to resident care policies and nursing services.
Failure to Provide Timely Medication Delivery
Penalty
Summary
The facility failed to ensure the timely availability of medication for a resident diagnosed with an anxiety disorder. According to the facility's policy on Pharmacy Services, effective March 2020, the facility is required to provide or obtain pharmacy services, including routine and emergency medication, and employ a licensed pharmacist. However, the facility did not adhere to this policy for one resident, as evidenced by the repeated unavailability of Ativan gel, a medication prescribed to be applied three times daily. The clinical record review revealed multiple instances where the Ativan gel was not administered due to delays in pharmacy delivery. Nursing notes from January to June 2024 consistently documented that the medication was either awaiting delivery or pending from the pharmacy. Despite communication with the pharmacy, the medication remained unavailable, indicating a failure in the facility's pharmacy services to meet the resident's needs as per the physician's orders.
Inadequate Infection Control During Dining Services
Penalty
Summary
The facility failed to implement an effective infection prevention and control program during dining services on the Fourth Floor Main nursing unit. Observations on September 25, 2024, revealed that five employees were serving lunch to 14 residents in the dining room without performing hand hygiene. Employee E8, a Nurse Aide, was seen passing trays, setting up utensils, and assisting residents without washing hands between tasks. Similarly, Employee E12 collected finished trays and delivered new ones without any hand hygiene. None of the five employees assisting with meal trays performed hand hygiene before or during the meal service. The residents in the dining room, many of whom were cognitively impaired or had dementia, were observed touching their clothes, tables, and wheelchairs without any hand hygiene before receiving their meal trays. One resident was seen eating with her hands. Despite the presence of two wall-mounted hand sanitizer units in the dining room, they were not utilized by staff or residents. An interview with Employee E9, the Unit Manager, confirmed the lack of hand hygiene practices during meal services, acknowledging the residents' need for assistance with hygiene.
Deficient Antibiotic Stewardship Program
Penalty
Summary
The facility failed to maintain an effective antibiotic stewardship program over a four-month period, as evidenced by a lack of antibiotic use protocols and a system to effectively monitor antibiotic usage. The review of facility documentation from May to August 2024 revealed that the facility did not have a comprehensive surveillance tool that included essential elements such as stop dates, total days of therapy, outcomes, and adverse events related to antibiotic use. Additionally, there was no antibiotic review conducted to determine the appropriateness of the antibiotic usage during this period. Throughout the months reviewed, the facility documented multiple cases of urinary tract infections (UTIs) and other infections such as skin, respiratory, intestinal, and wound infections, all treated with antibiotics. However, the facility's surveillance tool was inadequate, lacking critical information necessary for effective monitoring and evaluation of antibiotic use. This deficiency was confirmed through an interview with the Infection Preventionist, who acknowledged the absence of use protocols and a system for reviewing antibiotic orders to ensure their appropriateness. The report highlights that the facility did not integrate dispensing and consultant pharmacists into the clinical care team as key partners in supporting antibiotic stewardship. This integration is crucial for ensuring antibiotics are ordered appropriately and for developing antibiotic monitoring and infection management guidance. The lack of adherence to CDC guidelines and the absence of a structured antibiotic stewardship program contributed to the facility's failure to optimize antibiotic use and reduce the threat of antibiotic resistance.
Deficient Corridor Handrails
Penalty
Summary
The facility failed to equip corridors with safe handrails on each side, specifically on the Fourth Floor Main. Observations revealed that several corridor handrails were loose or not secured properly near multiple resident rooms. Additionally, some handrails were found detached from the wall next to the attic access wall towards the nurses' station, next to elevator B, and near another room. There was also a missing handrail next to the attic access wall. During an interview, the Maintenance Director confirmed the issues with the handrails, acknowledging that they were broken, detached, or missing.
Failure to Respect Resident's Dignity During Care
Penalty
Summary
The facility failed to ensure that a resident was treated with dignity and respect during a care interaction. An incident occurred where an aide on the night shift mistakenly believed that a resident needed her brief changed. Without asking for permission, the aide removed the covers from the resident's bed. The resident, identified as R322, expressed feeling violated by this action, as the aide did not ask before pulling the sheets off. The resident clarified that the aide did not touch her and mistakenly thought she wore a brief, emphasizing that the aide should have asked before proceeding.
Incomplete and Inaccurate Medical Records
Penalty
Summary
The facility did not maintain complete and accurate medical records for eight out of ten residents reviewed. Specifically, the Treatment Administration Records (TAR) for multiple residents showed that various medical orders were not signed off as completed. For instance, Resident R2's order to check the placement of a wearable tracking device was not signed off on multiple shifts in April 2024. Similarly, Resident R3's order for Silvadene External Cream was not signed off on April 8, 2024, and Resident R4's order for suprapubic catheter care was not signed off on the evening shift of April 9, 2024. Other residents, including R5, R6, R7, R8, and R10, also had missing sign-offs for their respective medical treatments and checks on various dates in April 2024 and March 2024. An interview with the Nursing Home Administrator and the Director of Nursing confirmed that it is the facility's expectation that all medications and treatments be signed out at the time they are provided to the resident. The review and interview revealed that these treatments had not been signed as appropriate, indicating a failure to maintain complete and accurate medical records as required by the facility's standards and regulations.
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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 Darby
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Providence Rehab And Hlthcare Ctratmercyfitzgerald | 0.4 mi | ★★★★★ | 8 | 0 |
| Little Flower Manor | 0.4 mi | ★★★★★ | 1 | 0 |
| Edenbrook Of Yeadon | 0.8 mi | ★★★★★ | 1 | 0 |
| Holy Family Home | 2.6 mi | ★★★★★ | 8 | 0 |
| Care Pavilion Nursing And Rehabilitation Center | 2.7 mi | ★★★★★ | 51 | 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.