Cycle 1
Health 2026-01-16 · Fire 2024-12-04
0 health deficiencies
No concentrated health issue counts in this cycle.
1 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Willow Street, PA
Lakeside At Willow Valley
5-star overall rating with 5-star inspections with 1 fire-safety deficiencies in the latest cycle
300 Willow Valley Lakes Drive, Willow Street, PA
(717) 464-9542
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
80
Certified beds
Average residents
48
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1989-01-01
CMS approved date
Coverage
Medicare
Participation flags
Staffing
Hours and turnover
RN hours / resident day
1.27
Registered nurse staffing
LPN hours / resident day
0.81
Licensed practical nurse staffing
Aide hours / resident day
2.63
Nurse aide staffing
Weekend hours
4.28
Weekend nurse staffing
RN turnover
38%
Annual RN turnover
Total nurse turnover
58%
Annual nurse turnover
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 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.2 |
1.2
1 pts better
|
1.8
1.6 pts better
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.2% |
86.9%
12.3 pts better
|
93.4%
5.8 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 96.7% |
93.5%
3.2 pts better
|
95.5%
1.2 pts better
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 8.1% |
3.2%
4.9 pts worse
|
3.3%
4.8 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 2.6% |
6.5%
3.9 pts better
|
11.4%
8.8 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 0.0% |
6.5%
6.5 pts better
|
5.4%
5.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 33.3% |
19.9%
13.4 pts worse
|
19.6%
13.7 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 16.9% |
18.7%
1.8 pts better
|
16.7%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents whose ability to walk independently worsened | 21.1% |
19.6%
1.5 pts worse
|
16.3%
4.8 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 23.5% |
18.3%
5.2 pts worse
|
14.9%
8.6 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents with a urinary tract infection | 1.6% |
1.7%
0.1 pts better
|
1.7%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 26.3% |
26.4%
0.1 pts better
|
19.8%
6.5 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 3.7% |
5.3%
1.6 pts better
|
5.1%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 91.4% |
68.9%
22.5 pts better
|
81.7%
9.7 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 3.5% |
1.5%
2 pts worse
|
1.6%
1.9 pts worse
|
Short Stay · 2024Q4-2025Q3 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-12-04 · Fire 2024-01-05
1 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Cycle 3
Health 2024-01-05 · Fire 2023-03-17
0 health deficiencies
No concentrated health issue counts in this cycle.
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Fire safety
Fire-safety citations
C · Minimal harm
2024-12-04
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2025-01-31
E · Potential for more than minimal harm
2024-01-05
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-03-07
E · Potential for more than minimal harm
2023-03-17
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-05-01
Inspection history
Recent health citations
E · Potential for more than minimal harm
2024-12-04
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-01-29
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
Gerner, Elric
Corporate Officer · Individual
Gilbert, Jill
Corporate Officer · Individual
Grant, Gerald
Corporate Officer · Individual
Kemrer, John
Corporate Director · Individual
Loose, Kristen
W-2 Managing Employee · Individual
Mashner, Marvin
Corporate Officer · Individual
Nearby options
Other facilities in reach
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Glen At Willow Valley
Lancaster, PA
5-star overall rating with 5-star inspections with 3 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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