Palmyra, PA

Lebanon Valley Brethren Home

5-star overall rating with 5-star inspections

1200 Grubb Street, Palmyra, PA

(717) 838-5406

Compare this facility

Overall

5 / 5

CMS overall stars

Health inspections

5 / 5

Survey and complaint cycles

Staffing

4 / 5

RN + nurse staffing

Quality measures

5 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

88

Certified beds

Average residents

59

Average occupied residents

Ownership

Non-Profit

Publicly displayed owner type

Chain

No chain reported

Operator or chain grouping

Approved since

1979-02-23

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

0.92

Registered nurse staffing · state 0.78 · national 0.68

LPN hours / resident day

1.21

Licensed practical nurse staffing · state 0.91 · national 0.87

Aide hours / resident day

2.86

Nurse aide staffing · state 2.20 · national 2.35

Total nurse hours

4.99

All reported nurse hours · state 3.89 · national 3.89

Licensed hours

2.13

RN + LPN hours · state 1.69 · national 1.54

Weekend hours

4.37

Weekend nurse staffing · state 3.51 · national 3.43

Weekend RN hours

0.47

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

1.07

CMS adjusted RN staffing hours

Adjusted total hours

5.81

CMS adjusted total nurse staffing hours

Case-mix index

1.17

Higher values indicate more complex resident acuity

RN turnover

100%

Annual RN turnover · state 43% · national 45%

Total nurse turnover

98%

Annual nurse turnover · state 47% · national 46%

SNF VBP

Value-based purchasing

Program rank

576

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

67.18

Composite VBP score used to determine payment impact.

Payment multiplier

1.0208

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

Not reported

This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.

Healthcare-associated infections

4.95

Performance 6.35% · Measure score 4.95 · Achievement 4.95 · This facility did not have sufficient data to calculate a baseline period measure result.

Total nurse turnover

7.80

Baseline 41.28% · Performance 31.82% · Measure score 7.80 · Achievement 7.80 · Improvement 5.26

Adjusted total nurse staffing

7.40

Baseline 4.90 hours · Performance 5.18 hours · Measure score 7.40 · Achievement 7.40 · Improvement 2.71

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	10.26%	10.72% 0.5 pts better	No Different than the National Rate · Eligible stays 59 · Observed rate 6.78% · Lower 95% interval 6.48%
Discharge to community	49.12%	50.57% 1.5 pts worse	No Different than the National Rate · Eligible stays 57 · Observed rate 45.61% · Lower 95% interval 37.94%
Medicare spending per beneficiary	0.71	1.02 0.3 pts better
Drug regimen review with follow-up	97.3%	95.27% 2 pts better	Numerator 36 · Denominator 37
Falls with major injury	0%	0.77% 0.8 pts better	Numerator 0 · Denominator 37
Discharge self-care score	64.52%	53.69% 10.8 pts better	Numerator 20 · Denominator 31
Discharge mobility score	80.65%	50.94% 29.7 pts better	Numerator 25 · Denominator 31
Pressure ulcers or injuries, new or worsened	0%	2.29% 2.3 pts better	Numerator 0 · Denominator 37 · Adjusted rate 0%
Healthcare-associated infections requiring hospitalization	6.35%	7.12% 0.8 pts better	No Different than the National Rate · Eligible stays 27 · Observed rate 0% · Lower 95% interval 3.43%
Staff COVID-19 vaccination coverage	2.44%	8.2% 5.8 pts worse	Numerator 5 · Denominator 205
Staff flu vaccination coverage	23.34%	42% 18.7 pts worse	Numerator 74 · Denominator 317
Discharge function score	83.87%	56.45% 27.4 pts better	Numerator 26 · Denominator 31
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly.
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date	53.85%	25.2% 28.7 pts better	Numerator 14 · Denominator 26

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	0.2	1.7 1.5 pts better	1.9 1.7 pts better	Long Stay · 20240701-20250630 · Adjusted 0.2 · Observed 0.2 · Expected 1.4 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	0.4	1.2 0.8 pts better	1.8 1.4 pts better	Long Stay · 20240701-20250630 · Adjusted 0.4 · Observed 0.3 · Expected 1.4 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	99.6%	86.9% 12.7 pts better	93.4% 6.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 98.3% · 4Q avg 99.6%
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	3.7%	3.2% 0.5 pts worse	3.3% 0.4 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 6.6% · Q2 5.2% · Q3 1.6% · Q4 1.7% · 4Q avg 3.7% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	0.0%	6.5% 6.5 pts better	11.4% 11.4 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 who lose too much weight	2.0%	6.5% 4.5 pts better	5.4% 3.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 2.1% · Q3 1.9% · Q4 2.0% · 4Q avg 2.0%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	16.7%	19.9% 3.2 pts better	19.6% 2.9 pts better	Long Stay · 2024Q4-2025Q3 · Q1 14.0% · Q2 15.1% · Q3 17.9% · Q4 20.0% · 4Q avg 16.7%
Percentage of long-stay residents who received an antipsychotic medication	18.7%	18.7% About the same	16.7% 2 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 20.4% · Q2 17.8% · Q3 17.3% · Q4 19.1% · 4Q avg 18.7% · 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	30.0%	19.6% 10.4 pts worse	16.3% 13.7 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 37.2% · Q2 29.4% · Q3 29.0% · Q4 24.0% · 4Q avg 30.0% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	25.0%	18.3% 6.7 pts worse	14.9% 10.1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 27.3% · Q2 21.2% · Q3 24.1% · Q4 27.5% · 4Q avg 25.0% · Used in QM five-star
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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	1.2%	1.7% 0.5 pts better	1.7% 0.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.8% · Q3 1.6% · Q4 1.7% · 4Q avg 1.2% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	27.6%	26.4% 1.2 pts worse	19.8% 7.8 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 28.6% · Q2 25.9% · Q3 17.3% · Q4 38.4% · 4Q avg 27.6%
Percentage of long-stay residents with pressure ulcers	1.2%	5.3% 4.1 pts better	5.1% 3.9 pts better	Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 1.8% · Q3 0.0% · Q4 1.3% · 4Q avg 1.2% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	93.4%	68.9% 24.5 pts better	81.7% 11.7 pts better	Short Stay · 2024Q4-2025Q3 · Q1 93.9% · Q2 96.3% · Q3 92.5% · Q4 88.0% · 4Q avg 93.4%
Percentage of short-stay residents who had an outpatient emergency department visit	7.6%	9.8% 2.2 pts better	12.0% 4.4 pts better	Short Stay · 20240701-20250630 · Adjusted 7.6% · Observed 7.1% · Expected 10.5% · 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 · Q2 0.0% · Q3 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	92.5%	68.7% 23.8 pts better	79.7% 12.8 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 92.5%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	19.0%	23.1% 4.1 pts better	23.9% 4.9 pts better	Short Stay · 20240701-20250630 · Adjusted 19.0% · Observed 17.9% · Expected 22.4% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-01-23 · Fire 2025-01-23

0 health deficiencies

No concentrated health issue counts in this cycle.

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Cycle 2 Health 2024-01-11 · Fire 2024-01-11

1 health deficiencies

Top issue: Quality of Life and Care (1 deficiency)

2 fire-safety deficiencies

Top issue: Construction (1 deficiency)

Cycle 3 Health 2023-02-09 · Fire 2023-02-09

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

E · Potential for more than minimal harm 2024-01-11

K161 · Construction Deficiencies

Fire Safety

Use approved construction type or materials.

Corrected 2024-02-16

E · Potential for more than minimal harm 2024-01-11

K223 · Egress Deficiencies

Fire Safety

Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.

Corrected 2024-02-16

E · Potential for more than minimal harm 2023-02-09

K372 · Smoke Deficiencies

Fire Safety

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Corrected 2023-03-13

E · Potential for more than minimal harm 2023-02-09

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2023-03-13

Inspection history

Recent health citations

D · Potential for more than minimal harm 2024-01-11

F697 · Quality of Life and Care Deficiencies

Health

Provide safe, appropriate pain management for a resident who requires such services.

Corrected 2024-02-02

Penalties and ownership

What sits behind the stars

Ownership

Brubaker, Henry

Corporate Officer · Individual

0% 1 facilities 2017-06-01

Flagg, Raymond