Cycle 1
Health 2024-09-20 · Fire 2024-09-20
1 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
3 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Ephrata, PA
Ephrata Manor
5-star overall rating with 4-star inspections with $13,845 in total fines with 1 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
99 Bethany Road, Ephrata, PA
(717) 738-4940
Overall
5 / 5
CMS overall stars
Health inspections
4 / 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
120
Certified beds
Average residents
112
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1991-08-07
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
0.76
Registered nurse staffing · state 0.78 · national 0.68
LPN hours / resident day
0.64
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
2.57
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.97
All reported nurse hours · state 3.89 · national 3.89
Licensed hours
1.40
RN + LPN hours · state 1.69 · national 1.54
Weekend hours
3.54
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.59
Weekend registered nurse coverage · state 0.55 · national 0.47
Physical therapist
0.04
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.82
CMS adjusted RN staffing hours
Adjusted total hours
4.26
CMS adjusted total nurse staffing hours
Case-mix index
1.28
Higher values indicate more complex resident acuity
RN turnover
17%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
29%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,654
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
43.28
Composite VBP score used to determine payment impact.
Payment multiplier
0.9963
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 19.44% · Performance 21.44% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
3.92
Baseline 6.15% · Performance 6.66% · Measure score 3.92 · Achievement 3.92 · Improvement 0
Total nurse turnover
7.54
Baseline 30.64% · Performance 32.87% · Measure score 7.54 · Achievement 7.54 · Improvement 0
Adjusted total nurse staffing
5.85
Baseline 4.49 hours · Performance 4.74 hours · Measure score 5.85 · Achievement 5.85 · Improvement 1.46
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.56% |
10.72%
0.8 pts worse
|
No Different than the National Rate · Eligible stays 166 · Observed rate 12.65% · Lower 95% interval 8.6% |
| Discharge to community | 43.99% |
50.57%
6.6 pts worse
|
No Different than the National Rate · Eligible stays 130 · Observed rate 37.69% · Lower 95% interval 35.85% |
| Medicare spending per beneficiary | 0.87 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 82.11% |
95.27%
13.2 pts worse
|
Numerator 78 · Denominator 95 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 95 |
| Discharge self-care score | 39.71% |
53.69%
14 pts worse
|
Numerator 27 · Denominator 68 |
| Discharge mobility score | 42.65% |
50.94%
8.3 pts worse
|
Numerator 29 · Denominator 68 |
| Pressure ulcers or injuries, new or worsened | 4.21% |
2.29%
1.9 pts worse
|
Numerator 4 · Denominator 95 · Adjusted rate 3.2% |
| Healthcare-associated infections requiring hospitalization | 6.66% |
7.12%
0.5 pts better
|
No Different than the National Rate · Eligible stays 87 · Observed rate 5.75% · Lower 95% interval 3.77% |
| Staff COVID-19 vaccination coverage | 2.17% |
8.2%
6 pts worse
|
Numerator 5 · Denominator 230 |
| Staff flu vaccination coverage | 18.7% |
42%
23.3 pts worse
|
Numerator 43 · Denominator 230 |
| Discharge function score | 51.47% |
56.45%
5 pts worse
|
Numerator 35 · Denominator 68 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 20 · Denominator 20 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 27 · Denominator 27 |
| Resident COVID-19 vaccinations up to date | 37.84% |
25.2%
12.6 pts better
|
Numerator 14 · Denominator 37 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.1 |
1.7
0.6 pts better
|
1.9
0.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 1.2 · Expected 2.1 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.6 |
1.2
0.6 pts better
|
1.8
1.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.6 · Observed 0.5 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 96.5% |
86.9%
9.6 pts better
|
93.4%
3.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 96.2% · Q2 94.6% · Q3 97.3% · Q4 98.1% · 4Q avg 96.5% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 94.0% |
93.5%
0.5 pts better
|
95.5%
1.5 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 94.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 6.9% |
3.2%
3.7 pts worse
|
3.3%
3.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.8% · Q2 5.4% · Q3 6.3% · Q4 10.3% · 4Q avg 6.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.8% |
6.5%
2.7 pts better
|
11.4%
7.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.1% · Q2 1.9% · Q3 7.0% · Q4 2.0% · 4Q avg 3.8% |
| Percentage of long-stay residents who lose too much weight | 6.7% |
6.5%
0.2 pts worse
|
5.4%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.5% · Q2 9.6% · Q3 8.9% · Q4 2.2% · 4Q avg 6.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 13.1% |
19.9%
6.8 pts better
|
19.6%
6.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.6% · Q2 13.5% · Q3 13.6% · Q4 12.8% · 4Q avg 13.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 6.8% |
18.7%
11.9 pts better
|
16.7%
9.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.4% · Q2 8.0% · Q3 7.2% · Q4 4.5% · 4Q avg 6.8% · 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 | 22.6% |
19.6%
3 pts worse
|
16.3%
6.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.0% · Q2 30.8% · Q3 24.9% · Q4 15.0% · 4Q avg 22.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 27.8% |
18.3%
9.5 pts worse
|
14.9%
12.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.1% · Q2 33.7% · Q3 24.5% · Q4 28.7% · 4Q avg 27.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 4.2% |
0.9%
3.3 pts worse
|
1.0%
3.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.6% · Q2 4.1% · Q3 5.9% · Q4 2.3% · 4Q avg 4.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.5% |
1.7%
1.8 pts worse
|
1.7%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 4.5% · Q3 2.8% · Q4 2.8% · 4Q avg 3.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 33.3% |
26.4%
6.9 pts worse
|
19.8%
13.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.6% · Q2 34.1% · Q3 34.0% · Q4 34.5% · 4Q avg 33.3% |
| Percentage of long-stay residents with pressure ulcers | 4.5% |
5.3%
0.8 pts better
|
5.1%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.9% · Q2 5.6% · Q3 4.4% · Q4 2.1% · 4Q avg 4.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 76.5% |
68.9%
7.6 pts better
|
81.7%
5.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 72.2% · Q2 82.1% · Q3 82.5% · Q4 72.2% · 4Q avg 76.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 6.6% |
9.8%
3.2 pts better
|
12.0%
5.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 6.6% · Observed 6.2% · Expected 10.4% · 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 | 74.4% |
68.7%
5.7 pts better
|
79.7%
5.3 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 74.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 26.5% |
23.1%
3.4 pts worse
|
23.9%
2.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 26.5% · Observed 24.6% · Expected 22.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-11-03 · Fire 2023-11-03
7 health deficiencies
Top issue: Nursing and Physician Services (2 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2022-12-16 · Fire 2022-12-16
2 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
3 fire-safety deficiencies
Top issue: Construction (1 deficiency)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2024-09-20
K325 · Smoke Deficiencies
Fire Safety
Have properly installed hallway dispensers for alcohol-based hand rub.
Corrected 2024-10-15
D · Potential for more than minimal harm
2024-09-20
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-10-15
D · Potential for more than minimal harm
2024-09-20
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-10-15
E · Potential for more than minimal harm
2023-11-03
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 2023-11-03
C · Minimal harm
2023-11-03
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-11-03
C · Minimal harm
2023-11-03
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-11-03
D · Potential for more than minimal harm
2022-12-16
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2023-01-31
D · Potential for more than minimal harm
2022-12-16
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-01-31
D · Potential for more than minimal harm
2022-12-16
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-01-31
Inspection history
Recent health citations
D · Potential for more than minimal harm
2024-09-20
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 2024-10-18
G · Actual harm
2023-11-03
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-11-30
D · Potential for more than minimal harm
2023-11-03
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 2023-11-30
D · Potential for more than minimal harm
2023-11-03
F638 · Resident Assessment and Care Planning Deficiencies
Health
Assure that each resident’s assessment is updated at least once every 3 months.
Corrected 2023-11-30
D · Potential for more than minimal harm
2023-11-03
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-11-30
D · Potential for more than minimal harm
2023-11-03
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2023-11-30
D · Potential for more than minimal harm
2023-11-03
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 2023-11-30
D · Potential for more than minimal harm
2023-11-03
F947 · Nursing and Physician Services Deficiencies
Health
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Corrected 2023-11-30
D · Potential for more than minimal harm
2022-12-16
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2023-01-30
D · Potential for more than minimal harm
2022-12-16
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 2023-01-30
Penalties and ownership
What sits behind the stars
$13,845
2023-11-03
Fine
Fine · fine $13,845
Fine
Ownership
United Church Of Christ Homes
5% Or Greater Direct Ownership Interest · Organization
Chmielewski, Jamie
Operational/Managerial Control · Individual
Cliftonlarsonallen Llp
Operational/Managerial Control · Organization
Connelly, Crystal
Operational/Managerial Control · Individual
Conrad Siegel Investment Advisors, Inc
Operational/Managerial Control · Organization
Costanzo, Amanda
Operational/Managerial Control · Individual
Dierolf, Lori
Operational/Managerial Control · Individual
Eyster, Sharon
Operational/Managerial Control · Individual
Eyster, Sharon
Corporate Officer · Individual
Fields, Meredith
Operational/Managerial Control · Individual
Fields, Meredith
Corporate Officer · Individual
Gagnon, Tempest
Operational/Managerial Control · Individual
Gourley, Ronald
Operational/Managerial Control · Individual
Gourley, Ronald
Corporate Officer · Individual
Harlan, Shaun
Operational/Managerial Control · Individual
Loretan, William
Operational/Managerial Control · Individual
Marsh And Mclennan Companies, Inc
Operational/Managerial Control · Organization
Pennsylvania Association Of Director Of Nursing Administration (Padona
Operational/Managerial Control · Organization
Shelly, Craig
Operational/Managerial Control · Individual
Troutman, Christopher
Operational/Managerial Control · Individual
Velez, Victoria
Operational/Managerial Control · Individual
Weiser, Neil
Operational/Managerial Control · Individual
Yoder, Jessica
Operational/Managerial Control · Individual
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#2
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5-star overall rating with 5-star inspections with 5 fire-safety deficiencies in the latest cycle
#3
Gardens At Stevens, The
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2-star overall rating with 2-star inspections with $55,807 in total fines with 17 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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