Cycle 1
Health 2025-02-07 · Fire 2025-02-07
0 health deficiencies
No concentrated health issue counts in this cycle.
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Kutztown, PA
Willow Brook Rehabilitation And Healthcare Center
5-star overall rating with 5-star inspections with 3 fire-safety deficiencies in the latest cycle
120 Trexler Avenue, Kutztown, PA
(610) 683-6220
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
140
Certified beds
Average residents
135
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Prestige Healthcare Administrative Services
Operator or chain grouping
Approved since
1984-11-07
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
15 facilities
Chain averages 3 overall / 3 health / 3 staffing / 4 quality stars
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
0.42
Registered nurse staffing · state 0.78 · national 0.68
LPN hours / resident day
0.91
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
2.09
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.42
All reported nurse hours · state 3.89 · national 3.89
Licensed hours
1.33
RN + LPN hours · state 1.69 · national 1.54
Weekend hours
3.27
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.28
Weekend registered nurse coverage · state 0.55 · national 0.47
Physical therapist
0.07
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.40
CMS adjusted RN staffing hours
Adjusted total hours
3.29
CMS adjusted total nurse staffing hours
Case-mix index
1.42
Higher values indicate more complex resident acuity
RN turnover
41%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
49%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,527
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
39.58
Composite VBP score used to determine payment impact.
Payment multiplier
0.9925
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.83
Baseline 16.53% · Performance 19.19% · Measure score 4.83 · Achievement 4.83 · Improvement 0
Healthcare-associated infections
4.98
Baseline 4.67% · Performance 6.35% · Measure score 4.98 · Achievement 4.98 · Improvement 0
Total nurse turnover
2.95
Baseline 30.44% · Performance 51.61% · Measure score 2.95 · Achievement 2.95 · Improvement 0
Adjusted total nurse staffing
3.07
Baseline 2.44 hours · Performance 3.63 hours · Measure score 3.07 · Achievement 1.95 · Improvement 3.07
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.47% |
10.72%
1.2 pts better
|
No Different than the National Rate · Eligible stays 194 · Observed rate 9.28% · Lower 95% interval 6.63% |
| Discharge to community | 42.65% |
50.57%
7.9 pts worse
|
No Different than the National Rate · Eligible stays 170 · Observed rate 31.76% · Lower 95% interval 34.91% |
| Medicare spending per beneficiary | 1.12 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 115 · Denominator 115 |
| Falls with major injury | 0.87% |
0.77%
0.1 pts worse
|
Numerator 1 · Denominator 115 |
| Discharge self-care score | 80.3% |
53.69%
26.6 pts better
|
Numerator 53 · Denominator 66 |
| Discharge mobility score | 72.73% |
50.94%
21.8 pts better
|
Numerator 48 · Denominator 66 |
| Pressure ulcers or injuries, new or worsened | 1.74% |
2.29%
0.6 pts better
|
Numerator 2 · Denominator 115 · Adjusted rate 1.05% |
| Healthcare-associated infections requiring hospitalization | 6.35% |
7.12%
0.8 pts better
|
No Different than the National Rate · Eligible stays 109 · Observed rate 5.5% · Lower 95% interval 3.83% |
| Staff COVID-19 vaccination coverage | 3% |
8.2%
5.2 pts worse
|
Numerator 3 · Denominator 100 |
| Staff flu vaccination coverage | 75.34% |
42%
33.3 pts better
|
Numerator 110 · Denominator 146 |
| Discharge function score | 86.36% |
56.45%
29.9 pts better
|
Numerator 57 · Denominator 66 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 31 · Denominator 31 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 39 · Denominator 39 |
| Resident COVID-19 vaccinations up to date | 35.71% |
25.2%
10.5 pts better
|
Numerator 25 · Denominator 70 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.7 |
1.7
About the same
|
1.9
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 1.8 · Expected 2.1 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.5 |
1.2
0.3 pts worse
|
1.8
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.5 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
86.9%
13.1 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
93.5%
6.5 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.5% |
3.2%
0.7 pts better
|
3.3%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 3.3% · Q3 2.6% · Q4 0.8% · 4Q avg 2.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 25.7% |
6.5%
19.2 pts worse
|
11.4%
14.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.4% · Q2 17.9% · Q3 25.5% · Q4 38.5% · 4Q avg 25.7% |
| Percentage of long-stay residents who lose too much weight | 5.1% |
6.5%
1.4 pts better
|
5.4%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.4% · Q2 4.7% · Q3 4.8% · Q4 3.6% · 4Q avg 5.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 19.0% |
19.9%
0.9 pts better
|
19.6%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.5% · Q2 18.1% · Q3 21.3% · Q4 19.1% · 4Q avg 19.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 27.0% |
18.7%
8.3 pts worse
|
16.7%
10.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.3% · Q2 25.8% · Q3 27.8% · Q4 26.0% · 4Q avg 27.0% · 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 | 3.9% |
19.6%
15.7 pts better
|
16.3%
12.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.5% · Q2 8.0% · Q3 0.0% · Q4 1.4% · 4Q avg 3.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 5.3% |
18.3%
13 pts better
|
14.9%
9.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.9% · Q2 9.6% · Q3 4.0% · Q4 1.9% · 4Q avg 5.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.9%
0.9 pts better
|
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% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
1.7%
1.7 pts better
|
1.7%
1.7 pts better
|
Long 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 long-stay residents with new or worsened bowel or bladder incontinence | 18.5% |
26.4%
7.9 pts better
|
19.8%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 22.1% · Q2 20.3% · Q3 17.4% · Q4 14.2% · 4Q avg 18.5% |
| Percentage of long-stay residents with pressure ulcers | 2.6% |
5.3%
2.7 pts better
|
5.1%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 4.2% · Q3 2.1% · Q4 0.6% · 4Q avg 2.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.7% |
68.9%
30.8 pts better
|
81.7%
18 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 99.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.6% |
9.8%
1.8 pts worse
|
12.0%
0.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.6% · Observed 12.2% · Expected 11.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.8% |
1.5%
1.3 pts worse
|
1.6%
1.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 5.4% · Q3 3.5% · Q4 0.0% · 4Q avg 2.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 93.8% |
68.7%
25.1 pts better
|
79.7%
14.1 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 93.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 20.7% |
23.1%
2.4 pts better
|
23.9%
3.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 20.7% · Observed 20.9% · Expected 24.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-03-15 · Fire 2024-03-15
2 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2023-03-16 · Fire 2023-03-16
3 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
11 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-02-07
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-04-08
E · Potential for more than minimal harm
2025-02-07
K100 · Construction Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2025-04-08
E · Potential for more than minimal harm
2025-02-07
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 2025-04-08
E · Potential for more than minimal harm
2024-03-15
K325 · Smoke Deficiencies
Fire Safety
Have properly installed hallway dispensers for alcohol-based hand rub.
Corrected 2024-04-16
E · Potential for more than minimal harm
2024-03-15
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-04-16
E · Potential for more than minimal harm
2024-03-15
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2024-04-16
E · Potential for more than minimal harm
2024-03-15
K541 · Services Deficiencies
Fire Safety
Install properly constructed and protected linen or trash chutes.
Corrected 2024-04-16
E · Potential for more than minimal harm
2024-03-15
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-04-16
F · Potential for more than minimal harm
2024-01-23
K343 · Smoke Deficiencies
Fire Safety
Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire.
Corrected 2024-02-29
E · Potential for more than minimal harm
2024-01-23
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2024-02-29
F · Potential for more than minimal harm
2023-03-16
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-05-11
E · Potential for more than minimal harm
2023-03-16
K133 · Construction Deficiencies
Fire Safety
Install a two-hour-resistant firewall separation.
Corrected 2023-05-11
E · Potential for more than minimal harm
2023-03-16
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2023-05-11
E · Potential for more than minimal harm
2023-03-16
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 2023-05-11
E · Potential for more than minimal harm
2023-03-16
K541 · Services Deficiencies
Fire Safety
Install properly constructed and protected linen or trash chutes.
Corrected 2023-05-11
C · Minimal harm
2023-03-16
K100 · Construction Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2023-05-11
C · Minimal harm
2023-03-16
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-05-11
C · Minimal harm
2023-03-16
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-05-11
C · Minimal harm
2023-03-16
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-05-11
Inspection history
Recent health citations
F · Potential for more than minimal harm
2024-03-15
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 2024-04-16
C · Minimal harm
2024-03-15
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2024-04-16
D · Potential for more than minimal harm
2023-03-16
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 2023-04-28
D · Potential for more than minimal harm
2023-03-16
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 2023-04-28
D · Potential for more than minimal harm
2023-03-16
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 2023-04-28
Penalties and ownership
What sits behind the stars
Ownership
Willow Brook Rehab LLC
5% Or Greater Direct Ownership Interest · Organization
Pa Noble Parentco LLC
5% Or Greater Indirect Ownership Interest · Organization
Star Pa I Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Clyde Ii LLC
5% Or Greater Indirect Ownership Interest · Organization
Roos-Meiser, Samantha
W-2 Managing Employee · Individual
Stern, Moshe
5% Or Greater Indirect Ownership Interest · Individual
Nearby options
Other facilities in reach
#1
Lutheran Home At Topton, The
Topton, PA
4-star overall rating with 4-star inspections with 3 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#2
Mosser Nursing Home
Trexlertown, PA
4-star overall rating with 4-star inspections with 4 recent health deficiencies
#3
Complete Care At Lehigh LLC
Macungie, PA
4-star overall rating with 4-star inspections with 5 recent health deficiencies
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