Cycle 1
Health 2024-11-15 · Fire 2024-11-15
11 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Lancaster, PA
Neffsville Nursing And Rehabilitation
2-star overall rating with 2-star inspections with 11 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
2829 Lititz Pike, Lancaster, PA
(717) 569-3211
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
240
Certified beds
Average residents
188
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1976-10-01
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
0.57
Registered nurse staffing · state 0.78 · national 0.68
LPN hours / resident day
0.69
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
1.99
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.25
All reported nurse hours · state 3.89 · national 3.89
Licensed hours
1.25
RN + LPN hours · state 1.69 · national 1.54
Weekend hours
3.02
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.50
Weekend registered nurse coverage · state 0.55 · national 0.47
Physical therapist
0.03
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.66
CMS adjusted RN staffing hours
Adjusted total hours
3.79
CMS adjusted total nurse staffing hours
Case-mix index
1.17
Higher values indicate more complex resident acuity
RN turnover
30%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
43%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,969
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
41.92
Composite VBP score used to determine payment impact.
Payment multiplier
0.9948
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
7.53
Performance 17.94% · Measure score 7.53 · Achievement 7.53 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
2.09
Performance 7.21% · Measure score 2.09 · Achievement 2.09 · This facility did not have sufficient data to calculate a baseline period measure result.
Total nurse turnover
4.67
Performance 44.59% · Measure score 4.67 · Achievement 4.67 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
2.48
Baseline 2.78 hours · Performance 3.67 hours · Measure score 2.48 · Achievement 2.09 · Improvement 2.48
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.98% |
10.72%
0.3 pts worse
|
No Different than the National Rate · Eligible stays 97 · Observed rate 13.4% · Lower 95% interval 7.73% |
| Discharge to community | 47.31% |
50.57%
3.3 pts worse
|
No Different than the National Rate · Eligible stays 83 · Observed rate 39.76% · Lower 95% interval 39.62% |
| Medicare spending per beneficiary | 0.79 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 91.67% |
95.27%
3.6 pts worse
|
Numerator 55 · Denominator 60 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 60 |
| Discharge self-care score | 45.65% |
53.69%
8 pts worse
|
Numerator 21 · Denominator 46 |
| Discharge mobility score | 43.48% |
50.94%
7.5 pts worse
|
Numerator 20 · Denominator 46 |
| Pressure ulcers or injuries, new or worsened | 6.67% |
2.29%
4.4 pts worse
|
Numerator 4 · Denominator 60 · Adjusted rate 5.62% |
| Healthcare-associated infections requiring hospitalization | 7.21% |
7.12%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 58 · Observed rate 8.62% · Lower 95% interval 4.27% |
| Staff COVID-19 vaccination coverage | 1.67% |
8.2%
6.5 pts worse
|
Numerator 2 · Denominator 120 |
| Staff flu vaccination coverage | 65.93% |
42%
23.9 pts better
|
Numerator 89 · Denominator 135 |
| Discharge function score | 52.17% |
56.45%
4.3 pts worse
|
Numerator 24 · Denominator 46 |
| Transfer of health information to provider | 92% |
95.95%
4 pts worse
|
Numerator 23 · Denominator 25 |
| 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 | 24.14% |
25.2%
1.1 pts worse
|
Numerator 7 · Denominator 29 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 91.8% |
86.9%
4.9 pts better
|
93.4%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 91.0% · Q2 96.6% · Q3 89.2% · Q4 90.2% · 4Q avg 91.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 96.3% |
93.5%
2.8 pts better
|
95.5%
0.8 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 96.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.0% |
3.2%
1.2 pts better
|
3.3%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 2.3% · Q3 1.7% · Q4 1.8% · 4Q avg 2.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 6.8% |
6.5%
0.3 pts worse
|
11.4%
4.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.0% · Q2 3.6% · Q3 7.6% · Q4 6.9% · 4Q avg 6.8% |
| Percentage of long-stay residents who lose too much weight | 4.2% |
6.5%
2.3 pts better
|
5.4%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 4.8% · Q3 5.2% · Q4 2.1% · 4Q avg 4.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 23.8% |
19.9%
3.9 pts worse
|
19.6%
4.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.5% · Q2 22.4% · Q3 20.0% · Q4 27.3% · 4Q avg 23.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 28.5% |
18.7%
9.8 pts worse
|
16.7%
11.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.6% · Q2 30.0% · Q3 28.9% · Q4 27.5% · 4Q avg 28.5% · 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 | 26.4% |
19.6%
6.8 pts worse
|
16.3%
10.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.1% · Q2 21.9% · Q3 24.3% · Q4 30.7% · 4Q avg 26.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 27.5% |
18.3%
9.2 pts worse
|
14.9%
12.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.8% · Q2 25.0% · Q3 22.5% · Q4 35.3% · 4Q avg 27.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 3.7% |
0.9%
2.8 pts worse
|
1.0%
2.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.1% · Q2 3.3% · Q3 4.4% · Q4 2.7% · 4Q avg 3.7% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 4.1% |
1.7%
2.4 pts worse
|
1.7%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 2.9% · Q3 5.7% · Q4 4.3% · 4Q avg 4.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 31.5% |
26.4%
5.1 pts worse
|
19.8%
11.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 32.0% · Q2 32.5% · Q3 29.7% · Q4 31.8% · 4Q avg 31.5% |
| Percentage of long-stay residents with pressure ulcers | 5.9% |
5.3%
0.6 pts worse
|
5.1%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 7.0% · Q3 7.2% · Q4 5.1% · 4Q avg 5.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 70.2% |
68.9%
1.3 pts better
|
81.7%
11.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 71.8% · Q2 69.4% · Q3 71.1% · Q4 68.3% · 4Q avg 70.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 18.5% |
9.8%
8.7 pts worse
|
12.0%
6.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 18.5% · Observed 18.4% · Expected 11.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 3.2% |
1.5%
1.7 pts worse
|
1.6%
1.6 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 5.1% · Q2 2.5% · Q3 3.0% · Q4 1.7% · 4Q avg 3.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 70.3% |
68.7%
1.6 pts better
|
79.7%
9.4 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 70.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.8% |
23.1%
1.7 pts worse
|
23.9%
0.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.8% · Observed 26.3% · Expected 25.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-12-21 · Fire 2023-12-21
11 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2023-03-03 · Fire 2023-03-03
9 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
5 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-11-15
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-02-14
F · Potential for more than minimal harm
2024-11-15
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2025-01-03
E · Potential for more than minimal harm
2024-11-15
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 2025-02-14
E · Potential for more than minimal harm
2024-11-15
K912 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2025-01-03
C · Minimal harm
2024-11-15
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2025-01-03
C · Minimal harm
2024-11-15
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-01-03
C · Minimal harm
2024-11-15
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-01-03
C · Minimal harm
2024-11-15
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2025-01-03
E · Potential for more than minimal harm
2023-12-21
K929 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure precautions for handling oxygen cylinders and equipment are correctly followed.
Corrected 2024-01-03
D · Potential for more than minimal harm
2023-12-21
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-01-03
D · Potential for more than minimal harm
2023-12-21
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-01-03
D · Potential for more than minimal harm
2023-12-21
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-01-03
C · Minimal harm
2023-12-21
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-01-03
F · Potential for more than minimal harm
2023-03-03
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-04-18
F · Potential for more than minimal harm
2023-03-03
K932 · Smoke Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2023-04-18
E · Potential for more than minimal harm
2023-03-03
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2023-04-18
D · Potential for more than minimal harm
2023-03-03
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 2023-04-18
C · Minimal harm
2023-03-03
K100 · Construction Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2023-04-18
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-12-03
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2025-12-04
G · Actual harm
2025-09-10
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-10-07
D · Potential for more than minimal harm
2025-09-10
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-10-07
F · Potential for more than minimal harm
2025-03-25
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 2025-04-25
D · Potential for more than minimal harm
2025-01-02
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-01-23
F · Potential for more than minimal harm
2024-11-15
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-01-04
E · Potential for more than minimal harm
2024-11-15
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-01-04
E · Potential for more than minimal harm
2024-11-15
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 2025-01-04
D · Potential for more than minimal harm
2024-11-15
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-01-04
D · Potential for more than minimal harm
2024-11-15
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2025-01-04
D · Potential for more than minimal harm
2024-11-15
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 2025-01-04
D · Potential for more than minimal harm
2024-11-15
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-01-04
E · Potential for more than minimal harm
2023-12-21
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2024-02-01
E · Potential for more than minimal harm
2023-12-21
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-02-01
E · Potential for more than minimal harm
2023-12-21
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-02-01
D · Potential for more than minimal harm
2023-12-21
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-02-01
D · Potential for more than minimal harm
2023-12-21
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-02-01
D · Potential for more than minimal harm
2023-12-21
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 2024-02-01
D · Potential for more than minimal harm
2023-12-21
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2024-02-01
D · Potential for more than minimal harm
2023-12-21
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 2024-02-01
D · Potential for more than minimal harm
2023-12-21
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2024-02-01
D · Potential for more than minimal harm
2023-12-21
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-02-01
B · Minimal harm
2023-12-21
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-02-01
F · Potential for more than minimal harm
2023-03-03
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 2023-04-18
E · Potential for more than minimal harm
2023-03-03
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2023-04-18
D · Potential for more than minimal harm
2023-03-03
F553 · Resident Rights Deficiencies
Health
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Corrected 2023-04-18
D · Potential for more than minimal harm
2023-03-03
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 2023-04-18
D · Potential for more than minimal harm
2023-03-03
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-04-18
D · Potential for more than minimal harm
2023-03-03
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-04-18
D · Potential for more than minimal harm
2023-03-03
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-04-18
D · Potential for more than minimal harm
2023-03-03
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-04-18
Penalties and ownership
What sits behind the stars
Ownership
Spacebar Opco LLC
5% Or Greater Direct Ownership Interest · Organization
Ai Elements LLC
5% Or Greater Indirect Ownership Interest · Organization
Strawberry Hill Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Tilde Propco Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Clinical Consulting Services LLC
Operational/Managerial Control · Organization
Fisher Yohn, Carla
Operational/Managerial Control · Individual
Peck, Michael
Operational/Managerial Control · Individual
Priority Care Group LLC
Operational/Managerial Control · Organization
Summation Financial Services LLC
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
#1
Brethren Village
Lancaster, PA
3-star overall rating with 2-star inspections with abuse icon flag with $8,190 in total fines with 1 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
Rehabilitation Center At Brethren Village LLC
Lancaster, PA
5-star overall rating with 5-star inspections
#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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