Cycle 1
Health 2025-12-04 · Fire 2025-12-04
0 health deficiencies
No concentrated health issue counts in this cycle.
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Lancaster, PA
Glen At Willow Valley
5-star overall rating with 5-star inspections with 3 fire-safety deficiencies in the latest cycle
675 Willow Valley Square, Lancaster, PA
(717) 464-6161
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
262
Certified beds
Average residents
217
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1995-07-20
CMS approved date
Coverage
Medicare
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
0.78
Registered nurse staffing · state 0.78 · national 0.68
LPN hours / resident day
1.09
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
2.66
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
4.53
All reported nurse hours · state 3.89 · national 3.89
Licensed hours
1.87
RN + LPN hours · state 1.69 · national 1.54
Weekend hours
4.12
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.46
Weekend registered nurse coverage · state 0.55 · national 0.47
Physical therapist
0.07
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
1.01
CMS adjusted RN staffing hours
Adjusted total hours
5.83
CMS adjusted total nurse staffing hours
Case-mix index
1.06
Higher values indicate more complex resident acuity
RN turnover
23%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
31%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
42
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
93.80
Composite VBP score used to determine payment impact.
Payment multiplier
1.0275
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
10
Baseline 16.80% · Performance 16.91% · Measure score 10 · Achievement 10 · Improvement 0
Healthcare-associated infections
10
Baseline 5.87% · Performance 4.97% · Measure score 10 · Achievement 10 · Improvement 9
Total nurse turnover
8.68
Baseline 26.67% · Performance 28.19% · Measure score 8.68 · Achievement 8.68 · Improvement 0
Adjusted total nurse staffing
8.84
Baseline 5.09 hours · Performance 5.59 hours · Measure score 8.84 · Achievement 8.84 · Improvement 6.75
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 7% |
10.72%
3.7 pts better
|
Better than the National Rate · Eligible stays 189 · Observed rate 1.06% · Lower 95% interval 4.68% |
| Discharge to community | 46.73% |
50.57%
3.8 pts worse
|
No Different than the National Rate · Eligible stays 157 · Observed rate 45.22% · Lower 95% interval 40.37% |
| Medicare spending per beneficiary | 0.73 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 98.08% |
95.27%
2.8 pts better
|
Numerator 153 · Denominator 156 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 156 |
| Discharge self-care score | 56.43% |
53.69%
2.7 pts better
|
Numerator 79 · Denominator 140 |
| Discharge mobility score | 33.57% |
50.94%
17.4 pts worse
|
Numerator 47 · Denominator 140 |
| Pressure ulcers or injuries, new or worsened | 1.94% |
2.29%
0.4 pts better
|
Numerator 3 · Denominator 155 · Adjusted rate 2.59% |
| Healthcare-associated infections requiring hospitalization | 4.97% |
7.12%
2.2 pts better
|
No Different than the National Rate · Eligible stays 123 · Observed rate 0.81% · Lower 95% interval 2.94% |
| Staff COVID-19 vaccination coverage | 15.73% |
8.2%
7.5 pts better
|
Numerator 81 · Denominator 515 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 67.14% |
56.45%
10.7 pts better
|
Numerator 94 · Denominator 140 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 98.41% |
96.28%
2.1 pts better
|
Numerator 62 · Denominator 63 |
| Resident COVID-19 vaccinations up to date | 54.95% |
25.2%
29.8 pts better
|
Numerator 50 · Denominator 91 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.7 |
1.7
1 pts better
|
1.9
1.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.7 · Observed 0.5 · Expected 1.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.8 |
1.2
0.4 pts better
|
1.8
1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.8 · Observed 0.7 · Expected 1.3 · 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 98.6% · Q2 98.2% · Q3 98.6% · Q4 99.5% · 4Q avg 98.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.3% |
93.5%
4.8 pts better
|
95.5%
2.8 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 6.1% |
3.2%
2.9 pts worse
|
3.3%
2.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.5% · Q2 5.4% · Q3 5.4% · Q4 7.3% · 4Q avg 6.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.1% |
6.5%
6.4 pts better
|
11.4%
11.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.5% · Q3 0.0% · Q4 0.0% · 4Q avg 0.1% |
| Percentage of long-stay residents who lose too much weight | 3.7% |
6.5%
2.8 pts better
|
5.4%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 4.5% · Q3 3.1% · Q4 3.4% · 4Q avg 3.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 15.1% |
19.9%
4.8 pts better
|
19.6%
4.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.6% · Q2 13.8% · Q3 15.8% · Q4 15.3% · 4Q avg 15.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 14.0% |
18.7%
4.7 pts better
|
16.7%
2.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.7% · Q2 15.4% · Q3 13.8% · Q4 14.1% · 4Q avg 14.0% · 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 | 11.8% |
19.6%
7.8 pts better
|
16.3%
4.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.0% · Q2 11.7% · Q3 12.4% · Q4 12.8% · 4Q avg 11.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 18.5% |
18.3%
0.2 pts worse
|
14.9%
3.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.6% · Q2 17.3% · Q3 19.8% · Q4 20.5% · 4Q avg 18.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.2% |
0.9%
0.7 pts better
|
1.0%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.9% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.6% |
1.7%
1.1 pts better
|
1.7%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.5% · Q2 0.9% · Q3 0.9% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 23.4% |
26.4%
3 pts better
|
19.8%
3.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.3% · Q2 25.6% · Q3 22.3% · Q4 22.4% · 4Q avg 23.4% |
| Percentage of long-stay residents with pressure ulcers | 3.4% |
5.3%
1.9 pts better
|
5.1%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 5.5% · Q3 2.3% · Q4 2.3% · 4Q avg 3.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 91.9% |
68.9%
23 pts better
|
81.7%
10.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 90.0% · Q2 92.9% · Q3 93.8% · Q4 90.8% · 4Q avg 91.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 6.5% |
9.8%
3.3 pts better
|
12.0%
5.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 6.5% · Observed 5.7% · Expected 9.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.6% |
1.5%
0.9 pts better
|
1.6%
1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.0% · Q3 1.1% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 83.9% |
68.7%
15.2 pts better
|
79.7%
4.2 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 83.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 13.2% |
23.1%
9.9 pts better
|
23.9%
10.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 13.2% · Observed 9.5% · Expected 17.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-10-18 · Fire 2024-10-18
0 health deficiencies
No concentrated health issue counts in this cycle.
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2023-11-17 · Fire 2023-11-17
1 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2025-12-04
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Not marked corrected
D · Potential for more than minimal harm
2025-12-04
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Not marked corrected
D · Potential for more than minimal harm
2025-12-04
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
2024-10-18
K133 · Construction Deficiencies
Fire Safety
Install a two-hour-resistant firewall separation.
Corrected 2024-12-29
E · Potential for more than minimal harm
2024-10-18
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2024-12-29
E · Potential for more than minimal harm
2024-10-18
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 2024-12-29
E · Potential for more than minimal harm
2024-10-18
K325 · Smoke Deficiencies
Fire Safety
Have properly installed hallway dispensers for alcohol-based hand rub.
Corrected 2024-12-29
E · Potential for more than minimal harm
2024-10-18
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-12-29
E · Potential for more than minimal harm
2023-11-17
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2024-01-23
E · Potential for more than minimal harm
2023-11-17
K531 · Services Deficiencies
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2024-01-23
Inspection history
Recent health citations
E · Potential for more than minimal harm
2023-11-17
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-01-16
Penalties and ownership
What sits behind the stars
Ownership
Willow Valley Communities
5% Or Greater Direct Ownership Interest · Organization
Allmond, Susan
Corporate Director · Individual
Barley, Jane
Corporate Officer · Individual
Brant, Leslie
Corporate Officer · Individual
Donegan, Margaret
W-2 Managing Employee · Individual
Gerner, Elric
Corporate Officer · Individual
Gilbert, Jill
Corporate Officer · Individual
Grant, Gerald
Corporate Officer · Individual
Hunsicker, Kendall
W-2 Managing Employee · Individual
Kemrer, John
Corporate Director · Individual
Mashner, Marvin
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Lakeside At Willow Valley
Willow Street, PA
5-star overall rating with 5-star inspections with 1 fire-safety deficiencies in the latest cycle
#2
Lancaster Nursing And Rehabilitation Center
Lancaster, PA
2-star overall rating with 2-star inspections with 16 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#3
Hamilton Arms Center
Lancaster, PA
3-star overall rating with 3-star inspections with $9,009 in total fines with 6 recent health deficiencies
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