Cycle 1
Health 2024-11-26 · Fire 2024-11-26
0 health deficiencies
No concentrated health issue counts in this cycle.
1 fire-safety deficiencies
Top issue: Services (1 deficiency)
Lancaster, PA
Trillium Place
5-star overall rating with 5-star inspections with 1 fire-safety deficiencies in the latest cycle
1520 Harrisburg Pike, Lancaster, PA
(717) 393-1301
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
160
Certified beds
Average residents
127
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1983-04-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
No
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.72
Registered nurse staffing · state 0.78 · national 0.68
LPN hours / resident day
1.41
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
3.18
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
5.31
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
4.96
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.45
Weekend registered nurse coverage · state 0.55 · national 0.47
Physical therapist
0.04
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.82
CMS adjusted RN staffing hours
Adjusted total hours
5.98
CMS adjusted total nurse staffing hours
Case-mix index
1.21
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
134
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
82.43
Composite VBP score used to determine payment impact.
Payment multiplier
1.0263
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
7.66
Baseline 17.58% · Performance 17.88% · Measure score 7.66 · Achievement 7.66 · Improvement 0
Healthcare-associated infections
8.03
Baseline 5.77% · Performance 5.44% · Measure score 8.03 · Achievement 8.03 · Improvement 3.79
Total nurse turnover
8.82
Baseline 40.28% · Performance 27.64% · Measure score 8.82 · Achievement 8.82 · Improvement 7.69
Adjusted total nurse staffing
8.47
Baseline 4.86 hours · Performance 5.49 hours · Measure score 8.47 · Achievement 8.47 · Improvement 6.30
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.48% |
10.72%
1.2 pts better
|
No Different than the National Rate · Eligible stays 152 · Observed rate 6.58% · Lower 95% interval 6.95% |
| Discharge to community | 56.82% |
50.57%
6.2 pts better
|
No Different than the National Rate · Eligible stays 133 · Observed rate 51.88% · Lower 95% interval 49.04% |
| Medicare spending per beneficiary | 0.71 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 93.02% |
95.27%
2.2 pts worse
|
Numerator 80 · Denominator 86 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 86 |
| Discharge self-care score | 42.31% |
53.69%
11.4 pts worse
|
Numerator 33 · Denominator 78 |
| Discharge mobility score | 28.21% |
50.94%
22.7 pts worse
|
Numerator 22 · Denominator 78 |
| Pressure ulcers or injuries, new or worsened | 4.65% |
2.29%
2.4 pts worse
|
Numerator 4 · Denominator 86 · Adjusted rate 5.59% |
| Healthcare-associated infections requiring hospitalization | 5.44% |
7.12%
1.7 pts better
|
No Different than the National Rate · Eligible stays 91 · Observed rate 1.1% · Lower 95% interval 3.24% |
| Staff COVID-19 vaccination coverage | 8.15% |
8.2%
About the same
|
Numerator 34 · Denominator 417 |
| Staff flu vaccination coverage | 96.9% |
42%
54.9 pts better
|
Numerator 687 · Denominator 709 |
| Discharge function score | 44.87% |
56.45%
11.6 pts worse
|
Numerator 35 · Denominator 78 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 46 · Denominator 46 |
| Resident COVID-19 vaccinations up to date | 30.95% |
25.2%
5.8 pts better
|
Numerator 13 · Denominator 42 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.6 |
1.7
1.1 pts better
|
1.9
1.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.6 · Observed 0.5 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.3 |
1.2
0.9 pts better
|
1.8
1.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.3 · Observed 0.3 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.8% |
86.9%
12.9 pts better
|
93.4%
6.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 99.2% · Q3 100.0% · Q4 100.0% · 4Q avg 99.8% |
| 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 | 4.4% |
3.2%
1.2 pts worse
|
3.3%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 4.0% · Q3 4.7% · Q4 5.0% · 4Q avg 4.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.8% |
6.5%
4.7 pts better
|
11.4%
9.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 2.6% · Q3 0.9% · Q4 1.8% · 4Q avg 1.8% |
| Percentage of long-stay residents who lose too much weight | 3.6% |
6.5%
2.9 pts better
|
5.4%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.3% · Q3 7.9% · Q4 3.1% · 4Q avg 3.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 20.9% |
19.9%
1 pts worse
|
19.6%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.4% · Q2 19.1% · Q3 20.6% · Q4 22.4% · 4Q avg 20.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 14.5% |
18.7%
4.2 pts better
|
16.7%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.4% · Q2 15.9% · Q3 12.2% · Q4 12.4% · 4Q avg 14.5% · 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 | 28.2% |
19.6%
8.6 pts worse
|
16.3%
11.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 42.1% · Q2 28.1% · Q3 25.3% · Q4 19.5% · 4Q avg 28.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 29.6% |
18.3%
11.3 pts worse
|
14.9%
14.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 42.9% · Q2 30.7% · Q3 19.6% · Q4 26.1% · 4Q avg 29.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.4% |
0.9%
0.5 pts better
|
1.0%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.8% · Q2 0.0% · Q3 0.0% · Q4 0.7% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.4% |
1.7%
0.3 pts better
|
1.7%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.8% · Q2 0.0% · Q3 2.4% · Q4 2.5% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 32.9% |
26.4%
6.5 pts worse
|
19.8%
13.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 41.9% · Q2 31.5% · Q3 25.4% · Q4 32.9% · 4Q avg 32.9% |
| Percentage of long-stay residents with pressure ulcers | 5.3% |
5.3%
About the same
|
5.1%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.4% · Q2 5.6% · Q3 4.7% · Q4 6.4% · 4Q avg 5.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 95.8% |
68.9%
26.9 pts better
|
81.7%
14.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 97.9% · Q2 94.1% · Q3 97.3% · Q4 93.8% · 4Q avg 95.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 6.0% |
9.8%
3.8 pts better
|
12.0%
6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 6.0% · Observed 5.8% · Expected 10.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.1% |
1.5%
0.4 pts better
|
1.6%
0.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 0.0% · Q3 2.4% · Q4 0.0% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 81.2% |
68.7%
12.5 pts better
|
79.7%
1.5 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 81.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 19.4% |
23.1%
3.7 pts better
|
23.9%
4.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 19.4% · Observed 17.4% · Expected 21.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-11-30 · Fire 2023-11-30
0 health deficiencies
No concentrated health issue counts in this cycle.
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2023-01-09 · Fire 2023-01-09
0 health deficiencies
No concentrated health issue counts in this cycle.
4 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-11-26
K531 · Services Deficiencies
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2024-12-10
E · Potential for more than minimal harm
2023-11-30
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2023-12-01
E · Potential for more than minimal harm
2023-11-30
K541 · Services Deficiencies
Fire Safety
Install properly constructed and protected linen or trash chutes.
Corrected 2023-12-01
E · Potential for more than minimal harm
2023-11-30
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-12-01
E · Potential for more than minimal harm
2023-01-09
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2023-02-10
E · Potential for more than minimal harm
2023-01-09
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 2023-02-10
E · Potential for more than minimal harm
2023-01-09
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-02-10
E · Potential for more than minimal harm
2023-01-09
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-02-10
Inspection history
Recent health citations
Penalties and ownership
What sits behind the stars
Ownership
Tandem Living
5% Or Greater Direct Ownership Interest · Organization
Bashore-Steury, Joshua
Operational/Managerial Control · Individual
Bomberger, Robert
Corporate Director · Individual
Bonanno, Adam
Corporate Director · Individual
Cassidy, Kari
Operational/Managerial Control · Individual
Dahl, Alison
Corporate Director · Individual
Eslinger, Jennifer
Operational/Managerial Control · Individual
Frey, Kimberly
Operational/Managerial Control · Individual
Fulmer, Gregory
Operational/Managerial Control · Individual
Fulton Bank, N.a.
5% Or Greater Security Interest · Organization
Gerhart, Elizabeth
Corporate Director · Individual
Goveia, Elyse
Operational/Managerial Control · Individual
Herr, James
Operational/Managerial Control · Individual
Manufacturers & Traders Trust Company
5% Or Greater Security Interest · Organization
Manufacturers & Traders Trust Company
5% Or Greater Mortgage Interest · Organization
Martin, James
Corporate Officer · Individual
Mortensen, Daniel
Operational/Managerial Control · Individual
Mwaura, John
Corporate Director · Individual
Myer, Sheldon
Corporate Officer · Individual
Parson, William
Corporate Director · Individual
Parson, William
Corporate Officer · Individual
Phy, Tiffany
Operational/Managerial Control · Individual
Reid, Robert
Corporate Director · Individual
Rohrer, Jennifer
Operational/Managerial Control · Individual
Ruth, Kendall
Corporate Director · Individual
Sauder, John
Operational/Managerial Control · Individual
Sauder, John
Corporate Director · Individual
Sauder, John
Corporate Officer · Individual
Sensenig, Jonathan
Corporate Director · Individual
Sullivan, Sharon
Operational/Managerial Control · Individual
Talbott, Thomas
Corporate Director · Individual
Talbott, Thomas
Corporate Officer · Individual
Tandem Living
Operational/Managerial Control · Organization
Ward, Rosalyn
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Homestead Village, Inc
Lancaster, PA
5-star overall rating with 4-star inspections with 2 recent health deficiencies
#2
Abbeyville Skilled Nursing And Rehabilitation Cent
Lancaster, PA
2-star overall rating with 2-star inspections with 11 recent health deficiencies
#3
Hamilton Arms Center
Lancaster, PA
3-star overall rating with 3-star inspections with $9,009 in total fines with 6 recent health deficiencies
Jump out