Cycle 1
Health 2025-12-18 · Fire 2025-12-18
4 health deficiencies
Top issue: Nutrition and Dietary (3 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Mechanicsburg, PA
Bethany Village Retirement Center
5-star overall rating with 4-star inspections with 4 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
5225 Wilson Lane, Mechanicsburg, PA
(717) 766-0279
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
69
Certified beds
Average residents
65
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Asbury Communities
Operator or chain grouping
Approved since
1977-11-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
7 facilities
Chain averages 4 overall / 4 health / 3 staffing / 5 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
0.62
Registered nurse staffing · state 0.78 · national 0.68
LPN hours / resident day
1.19
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
2.39
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
4.20
All reported nurse hours · state 3.89 · national 3.89
Licensed hours
1.81
RN + LPN hours · state 1.69 · national 1.54
Weekend hours
3.88
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
0.64
CMS adjusted RN staffing hours
Adjusted total hours
4.32
CMS adjusted total nurse staffing hours
Case-mix index
1.33
Higher values indicate more complex resident acuity
RN turnover
18%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
24%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
983
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
61.37
Composite VBP score used to determine payment impact.
Payment multiplier
1.0164
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
7.57
Baseline 21.41% · Performance 17.92% · Measure score 7.57 · Achievement 7.57 · Improvement 7.46
Healthcare-associated infections
4.15
Baseline 5.37% · Performance 6.59% · Measure score 4.15 · Achievement 4.15 · Improvement 0
Total nurse turnover
8.27
Baseline 25.81% · Performance 29.87% · Measure score 8.27 · Achievement 8.27 · Improvement 0
Adjusted total nurse staffing
4.55
Baseline 3.56 hours · Performance 4.37 hours · Measure score 4.55 · Achievement 4.55 · Improvement 3.17
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.15% |
10.72%
0.6 pts better
|
No Different than the National Rate · Eligible stays 104 · Observed rate 7.69% · Lower 95% interval 7.45% |
| Discharge to community | 47.55% |
50.57%
3 pts worse
|
No Different than the National Rate · Eligible stays 96 · Observed rate 42.71% · Lower 95% interval 37.75% |
| Medicare spending per beneficiary | 0.7 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 96.49% |
95.27%
1.2 pts better
|
Numerator 55 · Denominator 57 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 57 |
| Discharge self-care score | 40.38% |
53.69%
13.3 pts worse
|
Numerator 21 · Denominator 52 |
| Discharge mobility score | 50% |
50.94%
0.9 pts worse
|
Numerator 26 · Denominator 52 |
| Pressure ulcers or injuries, new or worsened | 5.26% |
2.29%
3 pts worse
|
Numerator 3 · Denominator 57 · Adjusted rate 5.07% |
| Healthcare-associated infections requiring hospitalization | 6.59% |
7.12%
0.5 pts better
|
No Different than the National Rate · Eligible stays 49 · Observed rate 4.08% · Lower 95% interval 3.36% |
| Staff COVID-19 vaccination coverage | 25.18% |
8.2%
17 pts better
|
Numerator 35 · Denominator 139 |
| Staff flu vaccination coverage | 97% |
42%
55 pts better
|
Numerator 226 · Denominator 233 |
| Discharge function score | 40.38% |
56.45%
16.1 pts worse
|
Numerator 21 · Denominator 52 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 17.24% |
25.2%
8 pts worse
|
Numerator 5 · Denominator 29 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.4 |
1.7
1.3 pts better
|
1.9
1.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.4 · Observed 0.3 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.3 |
1.2
0.9 pts better
|
1.8
1.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.3 · Observed 0.2 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.7% |
86.9%
11.8 pts better
|
93.4%
5.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 98.3% · Q3 98.4% · Q4 98.3% · 4Q avg 98.7% |
| 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 | 0.8% |
3.2%
2.4 pts better
|
3.3%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 0.0% · Q3 0.0% · Q4 1.7% · 4Q avg 0.8% · 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 | 5.4% |
6.5%
1.1 pts better
|
5.4%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 7.5% · Q2 5.6% · Q3 5.1% · Q4 3.6% · 4Q avg 5.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 33.5% |
19.9%
13.6 pts worse
|
19.6%
13.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.9% · Q2 37.0% · Q3 33.9% · Q4 36.8% · 4Q avg 33.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 21.9% |
18.7%
3.2 pts worse
|
16.7%
5.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.3% · Q2 21.1% · Q3 19.6% · Q4 21.1% · 4Q avg 21.9% · 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 | 15.5% |
19.6%
4.1 pts better
|
16.3%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 15.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 14.7% |
18.3%
3.6 pts better
|
14.9%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 26.1% · Q2 11.6% · Q3 5.8% · Q4 16.3% · 4Q avg 14.7% · 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 | 1.7% |
1.7%
About the same
|
1.7%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 1.7% · Q3 0.0% · Q4 1.7% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 32.3% |
26.4%
5.9 pts worse
|
19.8%
12.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 31.0% · Q2 28.4% · Q3 31.3% · Q4 38.8% · 4Q avg 32.3% |
| Percentage of long-stay residents with pressure ulcers | 3.5% |
5.3%
1.8 pts better
|
5.1%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.2% · Q2 4.0% · Q3 2.7% · Q4 2.4% · 4Q avg 3.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.1% |
68.9%
29.2 pts better
|
81.7%
16.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 93.8% · Q4 97.7% · 4Q avg 98.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 0.0% |
9.8%
9.8 pts better
|
12.0%
12 pts better
|
Short Stay · 20240701-20250630 · Adjusted 0.0% · Observed 0.0% · Expected 10.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.5%
1.5 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 97.6% |
68.7%
28.9 pts better
|
79.7%
17.9 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 97.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 17.5% |
23.1%
5.6 pts better
|
23.9%
6.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 17.5% · Observed 15.6% · Expected 21.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-11-14 · Fire 2024-11-14
4 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2024-01-11 · Fire 2024-01-11
4 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-12-18
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Not marked corrected
E · Potential for more than minimal harm
2025-12-18
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Not marked corrected
E · Potential for more than minimal harm
2025-12-18
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Not marked corrected
E · Potential for more than minimal harm
2024-11-14
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-01-10
E · Potential for more than minimal harm
2024-11-14
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2025-01-10
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-12-18
F810 · Nutrition and Dietary Deficiencies
Health
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
Corrected 2026-02-06
E · Potential for more than minimal harm
2025-12-18
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 2026-02-06
D · Potential for more than minimal harm
2025-12-18
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 2026-02-06
D · Potential for more than minimal harm
2025-12-18
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2026-02-06
E · Potential for more than minimal harm
2024-11-14
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-01-03
E · Potential for more than minimal harm
2024-11-14
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2025-01-03
D · Potential for more than minimal harm
2024-11-14
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 2025-01-03
D · Potential for more than minimal harm
2024-11-14
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2025-01-03
E · Potential for more than minimal harm
2024-01-11
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 2024-02-29
D · Potential for more than minimal harm
2024-01-11
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-02-29
D · Potential for more than minimal harm
2024-01-11
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-02-29
D · Potential for more than minimal harm
2024-01-11
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2024-02-29
Penalties and ownership
What sits behind the stars
Ownership
Asbury Communities Inc
5% Or Greater Direct Ownership Interest · Organization
Andrews, Todd
Corporate Director · Individual
Andrews, Todd
Corporate Officer · Individual
Harbison, Barbara
Corporate Director · Individual
Hill-Milbourne, Veronica
Corporate Director · Individual
Jeanneret, Andrew
Corporate Officer · Individual
Joseph, Andrew
Corporate Officer · Individual
Lively, Henri
Operational/Managerial Control · Individual
Shuman, Richard
Corporate Director · Individual
Sproles, Efonda
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Fox Subacute At Mechanicsburg
Mechanicsburg, PA
4-star overall rating with 3-star inspections with $14,886 in total fines with 9 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#2
Vibra Rehabilitation Center
Mechanicsburg, PA
3-star overall rating with 2-star inspections with 10 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Messiah Lifeways At Messiah Village
Mechanicsburg, PA
5-star overall rating with 4-star inspections with $8,018 in total fines with 2 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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