Cycle 1
Health 2025-07-02 · Fire 2025-07-02
0 health deficiencies
No concentrated health issue counts in this cycle.
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Ephrata, PA
Fairmount Homes
5-star overall rating with 5-star inspections with 5 fire-safety deficiencies in the latest cycle
333 Wheat Ridge Drive, Ephrata, PA
(717) 354-1800
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
114
Certified beds
Average residents
98
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1989-10-01
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
0.70
Registered nurse staffing · state 0.78 · national 0.68
LPN hours / resident day
1.01
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
2.64
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
4.35
All reported nurse hours · state 3.89 · national 3.89
Licensed hours
1.71
RN + LPN hours · state 1.69 · national 1.54
Weekend hours
3.79
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.44
Weekend registered nurse coverage · state 0.55 · national 0.47
Physical therapist
0.03
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.75
CMS adjusted RN staffing hours
Adjusted total hours
4.67
CMS adjusted total nurse staffing hours
Case-mix index
1.27
Higher values indicate more complex resident acuity
RN turnover
30%
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
1,358
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
57.26
Composite VBP score used to determine payment impact.
Payment multiplier
1.0124
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
6.97
Baseline 18.18% · Performance 18.20% · Measure score 6.97 · Achievement 6.97 · Improvement 0
Healthcare-associated infections
2.09
Baseline 5.15% · Performance 7.21% · Measure score 2.09 · Achievement 2.09 · Improvement 0
Total nurse turnover
8.89
Baseline 31.36% · Performance 27.35% · Measure score 8.89 · Achievement 8.89 · Improvement 5.66
Adjusted total nurse staffing
4.96
Baseline 4.07 hours · Performance 4.49 hours · Measure score 4.96 · Achievement 4.96 · Improvement 1.92
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 8.3% |
10.72%
2.4 pts better
|
No Different than the National Rate · Eligible stays 87 · Observed rate 1.15% · Lower 95% interval 5.67% |
| Discharge to community | 57.79% |
50.57%
7.2 pts better
|
No Different than the National Rate · Eligible stays 90 · Observed rate 54.44% · Lower 95% interval 46.95% |
| Medicare spending per beneficiary | 0.87 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 89.36% |
95.27%
5.9 pts worse
|
Numerator 42 · Denominator 47 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 47 |
| Discharge self-care score | 57.14% |
53.69%
3.5 pts better
|
Numerator 24 · Denominator 42 |
| Discharge mobility score | 40.48% |
50.94%
10.5 pts worse
|
Numerator 17 · Denominator 42 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 47 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 7.21% |
7.12%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 45 · Observed rate 6.67% · Lower 95% interval 3.76% |
| Staff COVID-19 vaccination coverage | 2.35% |
8.2%
5.8 pts worse
|
Numerator 8 · Denominator 341 |
| Staff flu vaccination coverage | 73.17% |
42%
31.2 pts better
|
Numerator 270 · Denominator 369 |
| Discharge function score | 66.67% |
56.45%
10.2 pts better
|
Numerator 28 · Denominator 42 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 28 · Denominator 28 |
| Resident COVID-19 vaccinations up to date | 26.92% |
25.2%
1.7 pts better
|
Numerator 7 · Denominator 26 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.2 |
1.7
0.5 pts better
|
1.9
0.7 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.0 · 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 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.5% |
86.9%
11.6 pts better
|
93.4%
5.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 97.7% · Q2 97.6% · Q3 98.8% · Q4 100.0% · 4Q avg 98.5% |
| 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 | 1.7% |
3.2%
1.5 pts better
|
3.3%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 2.4% · Q3 1.2% · Q4 1.1% · 4Q avg 1.7% · 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 1.4% · Q3 1.3% · Q4 0.0% · 4Q avg 0.6% |
| Percentage of long-stay residents who lose too much weight | 5.1% |
6.5%
1.4 pts better
|
5.4%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.0% · Q2 8.2% · Q3 3.9% · Q4 3.7% · 4Q avg 5.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 22.0% |
19.9%
2.1 pts worse
|
19.6%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.8% · Q2 21.6% · Q3 19.0% · Q4 23.5% · 4Q avg 22.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 18.8% |
18.7%
0.1 pts worse
|
16.7%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.3% · Q2 13.7% · Q3 16.7% · Q4 22.6% · 4Q avg 18.8% · 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 | 36.0% |
19.6%
16.4 pts worse
|
16.3%
19.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 47.7% · Q2 43.2% · Q3 21.7% · Q4 35.7% · 4Q avg 36.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 36.4% |
18.3%
18.1 pts worse
|
14.9%
21.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 41.2% · Q2 34.0% · Q3 38.6% · Q4 32.2% · 4Q avg 36.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.3% |
0.9%
0.6 pts better
|
1.0%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.3% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.3% |
1.7%
1.4 pts better
|
1.7%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.1% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 29.1% |
26.4%
2.7 pts worse
|
19.8%
9.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.1% · Q2 39.7% · Q3 20.7% · Q4 28.3% · 4Q avg 29.1% |
| Percentage of long-stay residents with pressure ulcers | 3.0% |
5.3%
2.3 pts better
|
5.1%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 2.6% · Q3 3.7% · Q4 2.2% · 4Q avg 3.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 96.8% |
68.9%
27.9 pts better
|
81.7%
15.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 91.5% · Q2 100.0% · Q3 97.6% · Q4 97.0% · 4Q avg 96.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 4.9% |
9.8%
4.9 pts better
|
12.0%
7.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 4.9% · Observed 4.4% · Expected 10.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.7% |
1.5%
0.8 pts better
|
1.6%
0.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.4% · Q4 0.0% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 91.4% |
68.7%
22.7 pts better
|
79.7%
11.7 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 91.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 11.6% |
23.1%
11.5 pts better
|
23.9%
12.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.6% · Observed 8.9% · Expected 18.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-08-07 · Fire 2024-08-07
0 health deficiencies
No concentrated health issue counts in this cycle.
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2023-09-15 · Fire 2023-09-15
0 health deficiencies
No concentrated health issue counts in this cycle.
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-07-02
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2025-09-12
F · Potential for more than minimal harm
2025-07-02
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-09-12
E · Potential for more than minimal harm
2025-07-02
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 2025-09-12
C · Minimal harm
2025-07-02
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2025-09-12
C · Minimal harm
2025-07-02
K343 · Smoke Deficiencies
Fire Safety
Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire.
Corrected 2025-09-12
E · Potential for more than minimal harm
2024-08-07
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-10-18
C · Minimal harm
2024-08-07
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-10-18
E · Potential for more than minimal harm
2023-09-15
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2023-11-15
E · Potential for more than minimal harm
2023-09-15
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-11-15
Inspection history
Recent health citations
Penalties and ownership
What sits behind the stars
Ownership
Driver, Kay
Operational/Managerial Control · Individual
Friends Services For The Aging
Operational/Managerial Control · Organization
Kimmet, Katie
Operational/Managerial Control · Individual
Lile, Jerry
Operational/Managerial Control · Individual
Richard, Kent
Operational/Managerial Control · Individual
Univest Bank And Trust
Operational/Managerial Control · Organization
Zimmerman, Pauline
Operational/Managerial Control · Individual
Nearby options
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#2
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5-star overall rating with 4-star inspections with 4 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Garden Spot Village
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5-star overall rating with 4-star inspections with $8,018 in total fines with 1 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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