Cycle 1
Health 2025-06-12 · Fire 2025-06-12
1 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
1 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cornwall, PA
Cornwall Manor
5-star overall rating with 5-star inspections with 1 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
Boyd Street, Cornwall, PA
(717) 273-2647
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
96
Certified beds
Average residents
74
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1967-03-13
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
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
0.88
Registered nurse staffing · state 0.78 · national 0.68
LPN hours / resident day
1.33
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
2.62
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
4.83
All reported nurse hours · state 3.89 · national 3.89
Licensed hours
2.21
RN + LPN hours · state 1.69 · national 1.54
Weekend hours
4.26
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.68
Weekend registered nurse coverage · state 0.55 · national 0.47
Physical therapist
0.05
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.94
CMS adjusted RN staffing hours
Adjusted total hours
5.11
CMS adjusted total nurse staffing hours
Case-mix index
1.29
Higher values indicate more complex resident acuity
RN turnover
14%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
32%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
904
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
62.23
Composite VBP score used to determine payment impact.
Payment multiplier
1.0172
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.97
Baseline 18.88% · Performance 20.06% · Measure score 2.97 · Achievement 2.97 · Improvement 0
Healthcare-associated infections
3.69
Baseline 6.05% · Performance 6.73% · Measure score 3.69 · Achievement 3.69 · Improvement 0
Total nurse turnover
8.24
Baseline 29.37% · Performance 30.00% · Measure score 8.24 · Achievement 8.24 · Improvement 0
Adjusted total nurse staffing
10
Baseline 5.45 hours · Performance 6.09 hours · Measure score 10 · Achievement 10 · Improvement 9
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.87% |
10.72%
0.9 pts better
|
No Different than the National Rate · Eligible stays 96 · Observed rate 7.29% · Lower 95% interval 7.01% |
| Discharge to community | 46.22% |
50.57%
4.4 pts worse
|
No Different than the National Rate · Eligible stays 81 · Observed rate 40.74% · Lower 95% interval 37.74% |
| Medicare spending per beneficiary | 0.71 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 98.15% |
95.27%
2.9 pts better
|
Numerator 53 · Denominator 54 |
| Falls with major injury | 1.85% |
0.77%
1.1 pts worse
|
Numerator 1 · Denominator 54 |
| Discharge self-care score | 50% |
53.69%
3.7 pts worse
|
Numerator 23 · Denominator 46 |
| Discharge mobility score | 47.83% |
50.94%
3.1 pts worse
|
Numerator 22 · Denominator 46 |
| Pressure ulcers or injuries, new or worsened | 5.56% |
2.29%
3.3 pts worse
|
Numerator 3 · Denominator 54 · Adjusted rate 5.09% |
| Healthcare-associated infections requiring hospitalization | 6.73% |
7.12%
0.4 pts better
|
No Different than the National Rate · Eligible stays 61 · Observed rate 4.92% · Lower 95% interval 3.88% |
| Staff COVID-19 vaccination coverage | 8.67% |
8.2%
0.5 pts better
|
Numerator 26 · Denominator 300 |
| Staff flu vaccination coverage | 62.81% |
42%
20.8 pts better
|
Numerator 179 · Denominator 285 |
| Discharge function score | 63.04% |
56.45%
6.6 pts better
|
Numerator 29 · Denominator 46 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 45.16% |
25.2%
20 pts better
|
Numerator 14 · Denominator 31 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.8 |
1.7
0.1 pts worse
|
1.9
0.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 1.5 · Expected 1.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.7 |
1.2
0.5 pts better
|
1.8
1.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.7 · Observed 0.6 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
86.9%
13.1 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| 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 | 4.5% |
3.2%
1.3 pts worse
|
3.3%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.9% · Q2 4.2% · Q3 1.4% · Q4 4.3% · 4Q avg 4.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 8.4% |
6.5%
1.9 pts worse
|
11.4%
3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.6% · Q2 4.8% · Q3 9.1% · Q4 9.0% · 4Q avg 8.4% |
| Percentage of long-stay residents who lose too much weight | 8.1% |
6.5%
1.6 pts worse
|
5.4%
2.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.8% · Q2 10.2% · Q3 8.9% · Q4 4.3% · 4Q avg 8.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 32.7% |
19.9%
12.8 pts worse
|
19.6%
13.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.0% · Q2 32.7% · Q3 34.8% · Q4 34.0% · 4Q avg 32.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 21.1% |
18.7%
2.4 pts worse
|
16.7%
4.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.7% · Q2 22.5% · Q3 20.0% · Q4 20.0% · 4Q avg 21.1% · 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 | 31.4% |
19.6%
11.8 pts worse
|
16.3%
15.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 31.2% · Q2 36.8% · Q3 30.1% · Q4 26.0% · 4Q avg 31.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 34.3% |
18.3%
16 pts worse
|
14.9%
19.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 38.2% · Q2 36.2% · Q3 30.8% · Q4 30.0% · 4Q avg 34.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.4% |
0.9%
0.5 pts better
|
1.0%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.4% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.1% |
1.7%
0.4 pts worse
|
1.7%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 4.3% · Q3 1.4% · Q4 0.0% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 32.4% |
26.4%
6 pts worse
|
19.8%
12.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.8% · Q2 35.6% · Q3 34.4% · Q4 30.0% · 4Q avg 32.4% |
| Percentage of long-stay residents with pressure ulcers | 2.5% |
5.3%
2.8 pts better
|
5.1%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.1% · Q3 4.0% · Q4 3.9% · 4Q avg 2.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.4% |
68.9%
29.5 pts better
|
81.7%
16.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 93.8% · 4Q avg 98.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.1% |
9.8%
0.3 pts worse
|
12.0%
1.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.1% · Observed 9.1% · 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% · Q3 0.0% · Q4 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 | 69.8% |
68.7%
1.1 pts better
|
79.7%
9.9 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 69.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.8% |
23.1%
0.7 pts worse
|
23.9%
0.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 23.8% · Observed 20.0% · Expected 20.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-08-01 · Fire 2024-08-01
1 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
4 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2023-07-28 · Fire 2023-07-28
5 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-06-12
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-07-14
E · Potential for more than minimal harm
2024-08-01
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-09-13
E · Potential for more than minimal harm
2024-08-01
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-09-13
E · Potential for more than minimal harm
2024-08-01
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-09-13
E · Potential for more than minimal harm
2024-08-01
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-09-13
E · Potential for more than minimal harm
2023-07-28
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-08-31
E · Potential for more than minimal harm
2023-07-28
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-08-31
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-06-12
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-07-15
D · Potential for more than minimal harm
2024-08-01
F740 · Quality of Life and Care Deficiencies
Health
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected 2024-08-31
E · Potential for more than minimal harm
2023-07-28
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 2023-08-31
D · Potential for more than minimal harm
2023-07-28
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2023-08-31
D · Potential for more than minimal harm
2023-07-28
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-08-31
D · Potential for more than minimal harm
2023-07-28
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2023-08-31
D · Potential for more than minimal harm
2023-07-28
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 2023-08-31
Penalties and ownership
What sits behind the stars
Ownership
Cornwall Manor
5% Or Greater Direct Ownership Interest · Organization
Arnold, Jeanne
Corporate Director · Individual
Brill, William
Corporate Director · Individual
Calvert, Michelle
Corporate Director · Individual
Davies, Kate
Operational/Managerial Control · Individual
Davies, Kate
Corporate Director · Individual
Davis, Glenn
Corporate Director · Individual
Deitzler, Vicki
Operational/Managerial Control · Individual
Deitzler, Vicki
Corporate Officer · Individual
Fogel, Brooke
Operational/Managerial Control · Individual
Fogel, Brooke
Corporate Officer · Individual
Griffiths, Diane
Corporate Director · Individual
Hoffman, Robert
Corporate Director · Individual
Margut, Jennifer
Operational/Managerial Control · Individual
Margut, Jennifer
Corporate Officer · Individual
Mcconnell, Harry
Operational/Managerial Control · Individual
Mcconnell, Harry
Corporate Officer · Individual
Olson, Mark
Corporate Director · Individual
Phillips, Lynn
Corporate Director · Individual
Siegel, Thomas
Corporate Director · Individual
Strickler, Minnie
Operational/Managerial Control · Individual
Strickler, Minnie
Corporate Officer · Individual
Tice, James
Corporate Director · Individual
Uzelac, Gary
Corporate Director · Individual
Weaber, Gregory
Operational/Managerial Control · Individual
Weaber, Gregory
Corporate Officer · Individual
Weidman, Paul
Operational/Managerial Control · Individual
Weidman, Paul
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Lebanon Skilled Nursing And Rehabilitation Center
Lebanon, PA
1-star overall rating with 2-star inspections with 16 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
Alpine Valley Post Acute and Healthcare Center
Lebanon, PA
4-star overall rating with 4-star inspections with 4 recent health deficiencies
#3
Cedar Haven Healthcare Center
Lebanon, PA
2-star overall rating with 2-star inspections with abuse icon flag with $78,888 in total fines with 8 recent health deficiencies
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