Cycle 1
Health 2024-09-05 · Fire 2024-09-05
2 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Manheim, PA
Mt Hope Nazarene Retirement Community
5-star overall rating with 4-star inspections with 2 recent health deficiencies
3026 Mount Hope Home Road, Manheim, PA
(717) 665-6365
Overall
5 / 5
CMS overall stars
Health inspections
4 / 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
50
Certified beds
Average residents
49
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2008-07-01
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
0.66
Registered nurse staffing · state 0.78 · national 0.68
LPN hours / resident day
1.05
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
2.15
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.86
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
3.66
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
0.02
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.74
CMS adjusted RN staffing hours
Adjusted total hours
4.35
CMS adjusted total nurse staffing hours
Case-mix index
1.21
Higher values indicate more complex resident acuity
RN turnover
30%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
34%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
5,191
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
37.07
Composite VBP score used to determine payment impact.
Payment multiplier
0.9904
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
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
1.77
Performance 56.45% · Measure score 1.77 · Achievement 1.77 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
5.65
Baseline 4.72 hours · Performance 4.68 hours · Measure score 5.65 · Achievement 5.65 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays 5 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 3 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | Not Available |
1.02
|
Too few residents or stays to report publicly. |
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 3 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 4 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 6.56% |
8.2%
1.6 pts worse
|
Numerator 4 · Denominator 61 |
| Staff flu vaccination coverage | 75.34% |
42%
33.3 pts better
|
Numerator 55 · Denominator 73 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 95.9% |
86.9%
9 pts better
|
93.4%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 95.8% · Q2 91.5% · Q3 100.0% · Q4 95.9% · 4Q avg 95.9% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.0% |
93.5%
4.5 pts better
|
95.5%
2.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.1% |
3.2%
0.1 pts better
|
3.3%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 4.3% · Q3 2.0% · Q4 2.0% · 4Q avg 3.1% · 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 | 1.6% |
6.5%
4.9 pts better
|
5.4%
3.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 6.5% · Q4 0.0% · 4Q avg 1.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 20.2% |
19.9%
0.3 pts worse
|
19.6%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.7% · Q2 19.6% · Q3 18.8% · Q4 20.8% · 4Q avg 20.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 11.6% |
18.7%
7.1 pts better
|
16.7%
5.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.0% · Q2 12.5% · Q3 14.3% · Q4 9.5% · 4Q avg 11.6% · 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 | 10.4% |
19.6%
9.2 pts better
|
16.3%
5.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.6% · Q2 12.9% · Q3 8.6% · Q4 13.2% · 4Q avg 10.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 14.2% |
18.3%
4.1 pts better
|
14.9%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.4% · Q2 11.1% · Q3 10.6% · Q4 23.4% · 4Q avg 14.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.5% |
0.9%
0.4 pts better
|
1.0%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.0% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.6% |
1.7%
0.9 pts worse
|
1.7%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 2.2% · Q3 0.0% · Q4 4.1% · 4Q avg 2.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 22.8% |
26.4%
3.6 pts better
|
19.8%
3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.7% · Q2 23.4% · Q3 17.9% · Q4 23.2% · 4Q avg 22.8% |
| Percentage of long-stay residents with pressure ulcers | 1.3% |
5.3%
4 pts better
|
5.1%
3.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 0.0% · Q3 2.8% · Q4 0.0% · 4Q avg 1.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-11-02 · Fire 2023-11-02
2 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2022-11-16 · Fire 2022-11-16
10 health deficiencies
Top issue: Resident Rights (4 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Inspection history
Recent health citations
E · Potential for more than minimal harm
2024-09-05
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-10-04
D · Potential for more than minimal harm
2024-09-05
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2024-10-04
D · Potential for more than minimal harm
2023-11-02
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-12-05
D · Potential for more than minimal harm
2023-11-02
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-12-05
E · Potential for more than minimal harm
2022-11-16
F575 · Resident Rights Deficiencies
Health
Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency.
Corrected 2022-12-20
E · Potential for more than minimal harm
2022-11-16
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2022-12-30
E · Potential for more than minimal harm
2022-11-16
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2022-12-20
E · Potential for more than minimal harm
2022-11-16
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2022-12-15
E · Potential for more than minimal harm
2022-11-16
F700 · Quality of Life and Care Deficiencies
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2022-12-30
E · Potential for more than minimal harm
2022-11-16
F909 · Environmental Deficiencies
Health
Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
Corrected 2022-12-22
D · Potential for more than minimal harm
2022-11-16
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2022-12-20
D · Potential for more than minimal harm
2022-11-16
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-01-05
D · Potential for more than minimal harm
2022-11-16
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-01-14
D · Potential for more than minimal harm
2022-11-16
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2022-12-24
Penalties and ownership
What sits behind the stars
Ownership
Ephrata Church Of The Nazarene
5% Or Greater Direct Ownership Interest · Organization
Cafrelli, Steven
Corporate Officer · Individual
Ephrata Church Of The Nazarene
5% Or Greater Security Interest · Organization
Ephrata Church Of The Nazarene
5% Or Greater Mortgage Interest · Organization
Fillmore, Debbie
Corporate Director · Individual
Fillmore, Debbie
Corporate Officer · Individual
Hambrick, Rocklin
Corporate Officer · Individual
Lovell, Susie
Corporate Director · Individual
Lovell, Susie
Corporate Officer · Individual
Lucas, Joanna
Corporate Director · Individual
Lucas, Joanna
Corporate Officer · Individual
Martin, Leon
Corporate Director · Individual
Maxim, Marina
Operational/Managerial Control · Individual
Maxim, Marina
Corporate Director · Individual
Peck, Michael
Operational/Managerial Control · Individual
Peck, Michael
Corporate Director · Individual
Snyder, Charlyn
Corporate Director · Individual
Snyder, Charlyn
Corporate Officer · Individual
Snyder, Kevin
Corporate Director · Individual
Stehr, Joanne
Corporate Director · Individual
Sterner, Jeff
Corporate Director · Individual
Sterner, Jeff
Corporate Officer · Individual
Tornabe, Michele
Operational/Managerial Control · Individual
Tornabe, Michele
Corporate Director · Individual
Wickenheiser, Thomas
Operational/Managerial Control · Individual
Wickenheiser, Thomas
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Pleasant View Communities
Manheim, PA
5-star overall rating with 4-star inspections with 1 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
Cornwall Manor
Cornwall, PA
5-star overall rating with 5-star inspections with 1 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Elizabethtown Nursing And Rehabilitation
Elizabethtown, PA
1-star overall rating with 1-star inspections with $88,614 in total fines with 11 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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