Cycle 1
Health 2024-11-15 · Fire 2024-11-15
2 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
2 fire-safety deficiencies
Top issue: Construction (1 deficiency)
Lititz, PA
Luther Acres Manor
4-star overall rating with 4-star inspections with 2 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
400 Saint Luke Dr, Lititz, PA
(717) 626-6884
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
106
Certified beds
Average residents
81
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1978-07-01
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
0.47
Registered nurse staffing · state 0.78 · national 0.68
LPN hours / resident day
1.28
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
2.17
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.93
All reported nurse hours · state 3.89 · national 3.89
Licensed hours
1.75
RN + LPN hours · state 1.69 · national 1.54
Weekend hours
3.69
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.30
Weekend registered nurse coverage · state 0.55 · national 0.47
Physical therapist
0.06
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.50
CMS adjusted RN staffing hours
Adjusted total hours
4.19
CMS adjusted total nurse staffing hours
Case-mix index
1.28
Higher values indicate more complex resident acuity
RN turnover
77%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
52%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
6,711
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
31.95
Composite VBP score used to determine payment impact.
Payment multiplier
0.9868
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.15
Performance 20.44% · Measure score 2.15 · Achievement 2.15 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
3.38
Performance 6.82% · Measure score 3.38 · Achievement 3.38 · This facility did not have sufficient data to calculate a baseline period measure result.
Total nurse turnover
3.22
Baseline 63.64% · Performance 50.54% · Measure score 3.22 · Achievement 3.22 · Improvement 2.88
Adjusted total nurse staffing
4.03
Baseline 4.14 hours · Performance 4.23 hours · Measure score 4.03 · Achievement 4.03 · Improvement 0.03
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.81% |
10.72%
0.9 pts better
|
No Different than the National Rate · Eligible stays 139 · Observed rate 7.19% · Lower 95% interval 6.63% |
| Discharge to community | 36.64% |
50.57%
13.9 pts worse
|
Worse than the National Rate · Eligible stays 150 · Observed rate 32% · Lower 95% interval 28.66% |
| Medicare spending per beneficiary | 0.92 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 85.61% |
95.27%
9.7 pts worse
|
Numerator 113 · Denominator 132 |
| Falls with major injury | 0.76% |
0.77%
About the same
|
Numerator 1 · Denominator 132 |
| Discharge self-care score | 48.57% |
53.69%
5.1 pts worse
|
Numerator 51 · Denominator 105 |
| Discharge mobility score | 50.48% |
50.94%
0.5 pts worse
|
Numerator 53 · Denominator 105 |
| Pressure ulcers or injuries, new or worsened | 1.52% |
2.29%
0.8 pts better
|
Numerator 2 · Denominator 132 · Adjusted rate 1.91% |
| Healthcare-associated infections requiring hospitalization | 6.82% |
7.12%
0.3 pts better
|
No Different than the National Rate · Eligible stays 99 · Observed rate 6.06% · Lower 95% interval 4.18% |
| Staff COVID-19 vaccination coverage | 0.55% |
8.2%
7.6 pts worse
|
Numerator 1 · Denominator 183 |
| Staff flu vaccination coverage | 58.59% |
42%
16.6 pts better
|
Numerator 58 · Denominator 99 |
| Discharge function score | 60% |
56.45%
3.5 pts better
|
Numerator 63 · Denominator 105 |
| Transfer of health information to provider | 95.83% |
95.95%
0.1 pts worse
|
Numerator 23 · Denominator 24 |
| Transfer of health information to patient | 98.67% |
96.28%
2.4 pts better
|
Numerator 74 · Denominator 75 |
| Resident COVID-19 vaccinations up to date | 17.57% |
25.2%
7.6 pts worse
|
Numerator 13 · Denominator 74 |
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 1.1 · Expected 1.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.0 |
1.2
0.2 pts better
|
1.8
0.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 1.0 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 95.8% |
86.9%
8.9 pts better
|
93.4%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 92.8% · Q2 95.2% · Q3 98.5% · Q4 97.0% · 4Q avg 95.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 95.8% |
93.5%
2.3 pts better
|
95.5%
0.3 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 95.8% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.6% |
3.2%
0.6 pts better
|
3.3%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 3.2% · Q3 3.0% · Q4 1.5% · 4Q avg 2.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.5% |
6.5%
4 pts better
|
11.4%
8.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 1.9% · Q3 4.2% · Q4 0.0% · 4Q avg 2.5% |
| Percentage of long-stay residents who lose too much weight | 4.1% |
6.5%
2.4 pts better
|
5.4%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.5% · Q2 1.8% · Q3 1.8% · Q4 2.0% · 4Q avg 4.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 38.1% |
19.9%
18.2 pts worse
|
19.6%
18.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 39.7% · Q2 35.1% · Q3 40.4% · Q4 37.0% · 4Q avg 38.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 22.3% |
18.7%
3.6 pts worse
|
16.7%
5.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.4% · Q2 20.0% · Q3 28.3% · Q4 22.2% · 4Q avg 22.3% · 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 | 40.5% |
19.6%
20.9 pts worse
|
16.3%
24.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 32.7% · Q2 56.4% · Q3 30.6% · Q4 40.2% · 4Q avg 40.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 38.7% |
18.3%
20.4 pts worse
|
14.9%
23.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 35.8% · Q2 55.6% · Q3 32.7% · Q4 29.2% · 4Q avg 38.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.0% |
0.9%
1.1 pts worse
|
1.0%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 2.7% · Q3 1.2% · Q4 2.5% · 4Q avg 2.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.8% |
1.7%
0.9 pts better
|
1.7%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 1.6% · Q3 0.0% · Q4 0.0% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 33.4% |
26.4%
7 pts worse
|
19.8%
13.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.4% · Q2 35.2% · Q3 35.5% · Q4 32.7% · 4Q avg 33.4% |
| Percentage of long-stay residents with pressure ulcers | 4.2% |
5.3%
1.1 pts better
|
5.1%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.1% · Q2 3.5% · Q3 4.6% · Q4 2.5% · 4Q avg 4.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 73.0% |
68.9%
4.1 pts better
|
81.7%
8.7 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 68.8% · Q2 61.6% · Q3 77.4% · Q4 84.2% · 4Q avg 73.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 17.1% |
9.8%
7.3 pts worse
|
12.0%
5.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 17.1% · Observed 16.0% · Expected 10.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 3.1% |
1.5%
1.6 pts worse
|
1.6%
1.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 4.3% · Q3 2.6% · Q4 3.2% · 4Q avg 3.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 44.1% |
68.7%
24.6 pts worse
|
79.7%
35.6 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 44.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 27.5% |
23.1%
4.4 pts worse
|
23.9%
3.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 27.5% · Observed 22.7% · Expected 19.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-12-14 · Fire 2023-12-14
4 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2023-02-24 · Fire 2023-02-24
1 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
1 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
2024-11-15
K133 · Construction Deficiencies
Fire Safety
Install a two-hour-resistant firewall separation.
Corrected 2025-01-02
E · Potential for more than minimal harm
2024-11-15
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-01-02
E · Potential for more than minimal harm
2023-12-14
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2024-02-17
E · Potential for more than minimal harm
2023-12-14
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 2024-02-17
E · Potential for more than minimal harm
2023-12-14
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-02-17
E · Potential for more than minimal harm
2023-12-14
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-02-17
E · Potential for more than minimal harm
2023-12-14
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-02-17
C · Minimal harm
2023-12-14
K100 · Construction Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2024-02-17
C · Minimal harm
2023-12-14
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-02-17
E · Potential for more than minimal harm
2023-02-24
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-03-09
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-08-07
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-09-29
E · Potential for more than minimal harm
2025-08-07
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-10-29
D · Potential for more than minimal harm
2024-05-29
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2024-07-08
D · Potential for more than minimal harm
2023-12-14
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2024-01-30
D · Potential for more than minimal harm
2023-12-14
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-01-30
D · Potential for more than minimal harm
2023-12-14
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-01-30
D · Potential for more than minimal harm
2023-02-24
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-04-11
Penalties and ownership
What sits behind the stars
Ownership
Boyer, Keith
Corporate Director · Individual
Bradbury, David
Corporate Director · Individual
Deitzel, Daniel
Operational/Managerial Control · Individual
Deitzel, Daniel
Corporate Director · Individual
Deluca, Oneida
Corporate Director · Individual
Fisher, David
Corporate Director · Individual
Fritz, Stephen
Corporate Director · Individual
Harrold, Joan
Corporate Director · Individual
Lapine, Bernard
Corporate Director · Individual
Lecas, Megan
Corporate Director · Individual
Mckee, Thomas
Corporate Director · Individual
Millen, Raymond
Corporate Director · Individual
Murray, Donald
Corporate Director · Individual
Picchini, Marissa
Operational/Managerial Control · Individual
Picchini, Marissa
Corporate Officer · Individual
Saenz, Lindsay
Corporate Officer · Individual
Smarilli, James
Corporate Director · Individual
Smith, Stuart
Corporate Director · Individual
Stoudt, David
Corporate Director · Individual
Walko, James
Operational/Managerial Control · Individual
Walko, James
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Kadima Rehabilitation & Nursing At Lititz
Lititz, PA
1-star overall rating with 1-star inspections with 25 recent health deficiencies with 15 fire-safety deficiencies in the latest cycle
#2
Moravian Manor
Lititz, PA
3-star overall rating with 4-star inspections with 2 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Landis Homes
Lititz, PA
5-star overall rating with 4-star inspections with 1 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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