Cycle 1
Health 2025-03-21 · Fire 2025-03-21
1 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
2 fire-safety deficiencies
Top issue: Services (2 deficiencies)
Lancaster, PA
Brethren Village
3-star overall rating with 2-star inspections with abuse icon flag with $8,190 in total fines with 1 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
3001 Lititz Pike, Lancaster, PA
(717) 569-2657
Overall
3 / 5
CMS overall stars
Health inspections
2 / 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
120
Certified beds
Average residents
116
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1975-05-05
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
No
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.67
Registered nurse staffing · state 0.78 · national 0.68
LPN hours / resident day
1.10
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
3.09
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
4.87
All reported nurse hours · state 3.89 · national 3.89
Licensed hours
1.77
RN + LPN hours · state 1.69 · national 1.54
Weekend hours
4.45
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.48
Weekend registered nurse coverage · state 0.55 · national 0.47
Physical therapist
0.01
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.72
CMS adjusted RN staffing hours
Adjusted total hours
5.21
CMS adjusted total nurse staffing hours
Case-mix index
1.28
Higher values indicate more complex resident acuity
RN turnover
39%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
28%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,145
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
59.46
Composite VBP score used to determine payment impact.
Payment multiplier
1.0147
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
3.68
Baseline 5.75% · Performance 6.73% · Measure score 3.68 · Achievement 3.68 · Improvement 0
Total nurse turnover
8.08
Baseline 46.75% · Performance 30.66% · Measure score 8.08 · Achievement 8.08 · Improvement 6.85
Adjusted total nurse staffing
6.08
Baseline 5.19 hours · Performance 4.81 hours · Measure score 6.08 · Achievement 6.08 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.14% |
10.72%
1.6 pts better
|
No Different than the National Rate · Eligible stays 41 · Observed rate 0% · Lower 95% interval 5.39% |
| Discharge to community | 46.41% |
50.57%
4.2 pts worse
|
No Different than the National Rate · Eligible stays 32 · Observed rate 37.5% · Lower 95% interval 32.5% |
| Medicare spending per beneficiary | 0.81 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 95.83% |
95.27%
0.6 pts better
|
Numerator 23 · Denominator 24 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 24 |
| Discharge self-care score | 18.18% |
53.69%
35.5 pts worse
|
Numerator 4 · Denominator 22 |
| Discharge mobility score | 22.73% |
50.94%
28.2 pts worse
|
Numerator 5 · Denominator 22 |
| Pressure ulcers or injuries, new or worsened | 8.33% |
2.29%
6 pts worse
|
Numerator 2 · Denominator 24 · Adjusted rate 8.03% |
| Healthcare-associated infections requiring hospitalization | 6.73% |
7.12%
0.4 pts better
|
No Different than the National Rate · Eligible stays 25 · Observed rate 4% · Lower 95% interval 3.18% |
| Staff COVID-19 vaccination coverage | 1.68% |
8.2%
6.5 pts worse
|
Numerator 6 · Denominator 358 |
| Staff flu vaccination coverage | 51.64% |
42%
9.6 pts better
|
Numerator 267 · Denominator 517 |
| Discharge function score | 27.27% |
56.45%
29.2 pts worse
|
Numerator 6 · Denominator 22 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.5 |
1.7
1.2 pts better
|
1.9
1.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.5 · Observed 0.4 · Expected 1.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.4 |
1.2
0.8 pts better
|
1.8
1.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.4 · Observed 0.4 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 83.8% |
86.9%
3.1 pts worse
|
93.4%
9.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 93.5% · Q2 93.3% · Q3 80.4% · Q4 68.8% · 4Q avg 83.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 94.8% |
93.5%
1.3 pts better
|
95.5%
0.7 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 94.8% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.6% |
3.2%
0.6 pts better
|
3.3%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 1.9% · Q3 1.0% · Q4 3.6% · 4Q avg 2.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.6% |
6.5%
5.9 pts better
|
11.4%
10.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.4% · 4Q avg 0.6% |
| Percentage of long-stay residents who lose too much weight | 2.2% |
6.5%
4.3 pts better
|
5.4%
3.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 2.6% · Q3 2.5% · Q4 2.5% · 4Q avg 2.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 16.3% |
19.9%
3.6 pts better
|
19.6%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.5% · Q2 15.6% · Q3 17.3% · Q4 14.8% · 4Q avg 16.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 19.1% |
18.7%
0.4 pts worse
|
16.7%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.2% · Q2 20.3% · Q3 17.9% · Q4 16.2% · 4Q avg 19.1% · 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 | 25.4% |
19.6%
5.8 pts worse
|
16.3%
9.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.2% · Q2 26.6% · Q3 18.2% · Q4 33.8% · 4Q avg 25.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 28.4% |
18.3%
10.1 pts worse
|
14.9%
13.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 31.5% · Q2 23.3% · Q3 18.7% · Q4 40.0% · 4Q avg 28.4% · 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 | 0.5% |
1.7%
1.2 pts better
|
1.7%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 35.5% |
26.4%
9.1 pts worse
|
19.8%
15.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 37.1% · Q2 35.2% · Q3 34.7% · Q4 35.0% · 4Q avg 35.5% |
| Percentage of long-stay residents with pressure ulcers | 1.8% |
5.3%
3.5 pts better
|
5.1%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 1.9% · Q3 0.7% · Q4 1.6% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 38.7% |
68.9%
30.2 pts worse
|
81.7%
43 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 37.0% · Q2 50.0% · Q3 37.8% · Q4 25.0% · 4Q avg 38.7% |
| Percentage of short-stay residents who newly received an antipsychotic medication | 7.7% |
1.5%
6.2 pts worse
|
1.6%
6.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 7.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 80.9% |
68.7%
12.2 pts better
|
79.7%
1.2 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 80.9% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-02-23 · Fire 2024-02-23
3 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 2023-04-06 · Fire 2023-04-06
3 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
1 fire-safety deficiencies
Top issue: Services (1 deficiency)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-03-21
K531 · Services Deficiencies
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2025-04-04
E · Potential for more than minimal harm
2025-03-21
K541 · Services Deficiencies
Fire Safety
Install properly constructed and protected linen or trash chutes.
Corrected 2025-04-04
E · Potential for more than minimal harm
2024-02-23
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-03-18
E · Potential for more than minimal harm
2024-02-23
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-03-18
E · Potential for more than minimal harm
2023-04-06
K541 · Services Deficiencies
Fire Safety
Install properly constructed and protected linen or trash chutes.
Corrected 2023-05-12
Inspection history
Recent health citations
G · Actual harm
2025-08-26
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 2025-10-15
G · Actual harm
2025-02-06
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 2025-03-13
G · Actual harm
2025-02-06
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-03-13
D · Potential for more than minimal harm
2025-02-06
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-03-13
G · Actual harm
2023-04-06
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 2023-05-20
D · Potential for more than minimal harm
2023-04-06
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-05-20
D · Potential for more than minimal harm
2023-04-06
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 2023-05-20
Penalties and ownership
What sits behind the stars
$8,190
2023-04-06
Fine
Fine · fine $8,190
Fine
Ownership
Bellanca, Tina
Corporate Director · Individual
Boyd, Brian
Corporate Director · Individual
Brethren Village
Operational/Managerial Control · Organization
Covenant Alliance Rehab East LLC
Operational/Managerial Control · Organization
Dahl, Jeffrey
Corporate Director · Individual
Eshelman, Joanne
Corporate Director · Individual
Eshelman, Tyler
Corporate Director · Individual
Eshleman, Nancy
Operational/Managerial Control · Individual
Faus, Steven
Corporate Director · Individual
First National Bank Of Pennsylvania
5% Or Greater Mortgage Interest · Organization
Friends Services For The Aging
Operational/Managerial Control · Organization
Gibbel, John
Corporate Director · Individual
Horvath, Tara
Operational/Managerial Control · Individual
Martzall, Rodney
Operational/Managerial Control · Individual
Martzall, Rodney
Corporate Officer · Individual
Metzler, Connie
Corporate Director · Individual
Norris, Brad
Operational/Managerial Control · Individual
Riegen, Kathryn
Corporate Director · Individual
Scheid, Christopher
Operational/Managerial Control · Individual
Snader, John
Operational/Managerial Control · Individual
Snader, John
Corporate Officer · Individual
Tennis, Brett
Corporate Director · Individual
Upmc
Operational/Managerial Control · Organization
Weaver, Kimberly
Operational/Managerial Control · Individual
Wenzel, Stephen
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Rehabilitation Center At Brethren Village LLC
Lancaster, PA
5-star overall rating with 5-star inspections
#2
Neffsville Nursing And Rehabilitation
Lancaster, PA
2-star overall rating with 2-star inspections with 11 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
#3
Landis Homes
Lititz, PA
5-star overall rating with 4-star inspections with 1 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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