Cycle 1
Health 2025-07-09 · Fire 2025-07-09
0 health deficiencies
No concentrated health issue counts in this cycle.
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Lancaster, PA
Rehabilitation Center At Brethren Village LLC
5-star overall rating with 5-star inspections
3001 Lititz Pike, Lancaster, PA
(717) 569-2657
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
20
Certified beds
Average residents
13
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2016-05-10
CMS approved date
Coverage
Medicare
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
2.69
Registered nurse staffing · state 0.78 · national 0.68
LPN hours / resident day
1.12
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
3.67
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
7.49
All reported nurse hours · state 3.89 · national 3.89
Licensed hours
3.81
RN + LPN hours · state 1.69 · national 1.54
Weekend hours
7.10
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
2.28
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
2.54
CMS adjusted RN staffing hours
Adjusted total hours
7.08
CMS adjusted total nurse staffing hours
Case-mix index
1.45
Higher values indicate more complex resident acuity
RN turnover
22%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
25%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
762
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
64.14
Composite VBP score used to determine payment impact.
Payment multiplier
1.0187
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.41
Baseline 19.08% · Performance 20.32% · Measure score 2.41 · Achievement 2.41 · Improvement 0
Healthcare-associated infections
6.84
Baseline 5.51% · Performance 5.79% · Measure score 6.84 · Achievement 6.84 · Improvement 0
Total nurse turnover
10
Baseline 50.00% · Performance 15.00% · Measure score 10 · Achievement 10 · Improvement 9
Adjusted total nurse staffing
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.59% |
10.72%
1.1 pts better
|
No Different than the National Rate · Eligible stays 205 · Observed rate 6.83% · Lower 95% interval 7.08% |
| Discharge to community | 70.95% |
50.57%
20.4 pts better
|
Better than the National Rate · Eligible stays 201 · Observed rate 70.65% · Lower 95% interval 65.09% |
| Medicare spending per beneficiary | 0.64 |
1.02
0.4 pts better
|
|
| Drug regimen review with follow-up | 99.23% |
95.27%
4 pts better
|
Numerator 129 · Denominator 130 |
| Falls with major injury | 0.77% |
0.77%
About the same
|
Numerator 1 · Denominator 130 |
| Discharge self-care score | 56.25% |
53.69%
2.6 pts better
|
Numerator 63 · Denominator 112 |
| Discharge mobility score | 44.64% |
50.94%
6.3 pts worse
|
Numerator 50 · Denominator 112 |
| Pressure ulcers or injuries, new or worsened | 2.31% |
2.29%
About the same
|
Numerator 3 · Denominator 130 · Adjusted rate 3.81% |
| Healthcare-associated infections requiring hospitalization | 5.79% |
7.12%
1.3 pts better
|
No Different than the National Rate · Eligible stays 123 · Observed rate 2.44% · Lower 95% interval 3.66% |
| Staff COVID-19 vaccination coverage | 2% |
8.2%
6.2 pts worse
|
Numerator 5 · Denominator 250 |
| Staff flu vaccination coverage | 55.29% |
42%
13.3 pts better
|
Numerator 209 · Denominator 378 |
| Discharge function score | 70.54% |
56.45%
14.1 pts better
|
Numerator 79 · Denominator 112 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 37 · Denominator 37 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 88 · Denominator 88 |
| Resident COVID-19 vaccinations up to date | 16% |
25.2%
9.2 pts worse
|
Numerator 12 · Denominator 75 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 90.1% |
68.9%
21.2 pts better
|
81.7%
8.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 94.1% · Q2 89.2% · Q3 93.6% · Q4 82.7% · 4Q avg 90.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 16.7% |
9.8%
6.9 pts worse
|
12.0%
4.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 16.7% · Observed 14.9% · Expected 9.9% · 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 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 | 72.0% |
68.7%
3.3 pts better
|
79.7%
7.7 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 72.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 19.2% |
23.1%
3.9 pts better
|
23.9%
4.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 19.2% · Observed 15.7% · Expected 19.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-06-28 · Fire 2024-06-28
0 health deficiencies
No concentrated health issue counts in this cycle.
1 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Cycle 3
Health 2023-07-06 · Fire 2023-07-06
1 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
B · Minimal harm
2024-06-28
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-07-01
Inspection history
Recent health citations
D · Potential for more than minimal harm
2023-07-06
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 2023-08-03
Penalties and ownership
What sits behind the stars
Ownership
Brethren Village
5% Or Greater Direct Ownership Interest · Organization
Bellanca, Tina
Corporate Director · Individual
Boyd, Brian
Corporate Director · Individual
Brethren Village
Operational/Managerial Control · Organization
Covenant Alliance Rehab East LLC
Operational/Managerial Control · Organization
Dahl, Jeffrey
Corporate Director · Individual
Eshelman, Joanne
Corporate Director · Individual
Eshelman, Tyler
Corporate Director · Individual
Eshleman, Nancy
Operational/Managerial Control · Individual
Faus, Steven
Corporate Director · Individual
First National Bank Of Pennsylvania
5% Or Greater Mortgage Interest · Organization
Friends Services For The Aging
Operational/Managerial Control · Organization
Gibbel, John
Corporate Director · Individual
Horvath, Tara
Operational/Managerial Control · Individual
Martzall, Rodney
Operational/Managerial Control · Individual
Martzall, Rodney
Corporate Officer · Individual
Metzler, Connie
Corporate Director · Individual
Norris, Brad
Operational/Managerial Control · Individual
Quillin, Ashley
Operational/Managerial Control · Individual
Riegen, Kathryn
Corporate Director · Individual
Scheid, Christopher
Operational/Managerial Control · Individual
Snader, John
Operational/Managerial Control · Individual
Snader, John
Corporate Officer · Individual
Tennis, Brett
Corporate Director · Individual
Upmc
Operational/Managerial Control · Organization
Wenzel, Stephen
Corporate Director · Individual
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
Neffsville Nursing And Rehabilitation
Lancaster, PA
2-star overall rating with 2-star inspections with 11 recent health deficiencies with 8 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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