Your report for Brethren Village
Overall Score
CMS Five-Star Quality Rating- Much below average
- Below average
- Average
- Above average
- Much above average
Where it ranks
- PennsylvaniaAbove only 42% of peers653 rated homes · average 3.0★
- Lancaster CountyAbove only 30% of peers31 rated homes · average 3.7★
- United StatesAbove only 41% of peers14,574 rated homes · average 3.0★
How the rating is built
- Health inspectionsStarting point2★−0.8 vs PA avg
- StaffingCan add or remove a star5★+1.7 vs PA avg
- Quality measuresCan add or remove a star4★+0.5 vs PA avg
CMS starts from the health inspection stars, then adds or subtracts a star for staffing and for quality measures. Stars are assigned relative to other facilities in the same state.
- Abuse citation flagCMS shows an abuse icon: inspectors cited the facility for abuse that led to harm within the past year, or for abuse that could have led to harm in each of the last two years.
Ratings & measures
Tap a row to see what it meansHealth inspection ratingCMS stars from the last three on-site inspection cycles2★Above only 20% of peersPA avg2.8★U.S. avg2.8★
Stars assigned from the last three standard surveys and every complaint investigation in that window, weighted toward the most recent and the most serious findings. CMS assigns these stars relative to other facilities in the same state.
It carries the most weight in the overall rating and is the only domain based on what trained inspectors saw on site rather than what the facility reported.
Staffing ratingCMS stars from payroll-reported hours and turnover5★Above 81% of peersPA avg3.3★U.S. avg2.9★
Nurse and aide hours per resident day from payroll records CMS collects every quarter, adjusted for how much care residents need, plus staff turnover and weekend coverage.
More hours and lower turnover are the strongest predictors of fewer falls, pressure sores, and avoidable hospital stays.
Quality measures ratingCMS stars from clinical outcomes and resident assessments4★Above only 46% of peersPA avg3.5★U.S. avg3.6★
Clinical outcomes from resident assessments and Medicare claims: falls with injury, pressure ulcers, hospitalizations, antipsychotic use, and more, for both short-stay and long-stay residents.
It shows whether care is working, but part of it comes from the facility’s own assessments, so read it alongside the inspection results.
Total nurse hoursPer resident per day, all nursing staff4.87hrsTop 10%PA avg3.89Benchmark4.10
All licensed nurse and aide hours worked, divided by the number of residents, on an average day. Reported from payroll, not self-reported.
Federal research links 4.1 hours a day to fewer avoidable harms. Below about 3 hours, residents wait longer for help with basics like toileting and repositioning.
RN hoursPer resident per day, registered nurses only0.67hrsAbove 50% of peersPA avg0.78Benchmark0.75
Registered nurse hours only. RNs assess residents, manage medications, and catch changes in condition; LPNs and aides deliver most hands-on care.
RN coverage is the staffing measure most tied to fewer hospital transfers and infections, and it is where thinly staffed facilities cut first.
Nursing staff turnoverShare of nursing staff who left within a year · lower is better28%Top 10%PA avg47%RN turnover39%
The share of nursing staff who left within the past year, from the same payroll data.
High turnover means residents are cared for by people who do not know them, and it is one of the strongest predictors of inspection problems.
Fines in the last three yearsCivil money penalties imposed by CMS · lower is better$8,190Above only 40% of peersPA avg$28,640Fines · denials1 · 0
Civil money penalties CMS imposed after serious or uncorrected deficiencies, and denials of Medicare payment for new admissions.
Penalties follow the worst inspection findings. A recent fine is the clearest sign that inspectors found real harm.
Inspection history
Last three inspection cyclesCitations by monthApr 2023 – Aug 2025
- No actual harm (D–F)
- Actual harm (G–I)
- Immediate jeopardy (J–L)
- $Fine or payment denial
Showing
Click a month or a year to filter the findings below. Arrow keys move between months; Esc clears.
Aug 26, 2025Cycle 1worst G · actual harm
- F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Freedom from Abuse, Neglect, and ExploitationG · isolatedCorrected Oct 15, 2025
Feb 6, 2025Cycle 1worst G · actual harm
- F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Freedom from Abuse, Neglect, and ExploitationG · isolatedCorrected Mar 13, 2025
- F658Ensure services provided by the nursing facility meet professional standards of quality.Resident Assessment and Care PlanningD · isolatedCorrected Mar 13, 2025
- F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Quality of Life and CareG · isolatedCorrected Mar 13, 2025
Apr 6, 2023Cycle 3worst G · actual harm$8,190
- F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Freedom from Abuse, Neglect, and ExploitationG · isolatedCorrected May 20, 2023
- F758Implement 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.Pharmacy ServiceD · isolatedCorrected May 20, 2023
- Provide appropriate treatment and care according to orders, residentâs preferences and goals.Quality of Life and CareD · isolatedCorrected May 20, 2023
Staffing
From quarterly payroll reportsHours per resident per day
- All nursing staffRNs, LPNs and aides combined4.87hrs
- Registered nursesRN hours only0.67hrs
- Licensed practical nursesLPN hours1.10hrs
- Nurse aidesCNA hours3.09hrs
- Weekend nursingAll staff on Saturdays and Sundays4.45hrs
- Pennsylvania average
- Research benchmark (4.10 total, 0.75 RN)
Turnover & capacity
- Nursing staff turnoverShare who left within a year · lower is better28%Top 10%PA avg 47%
- RN turnoverRegistered nurses only39%Not ranked by CMS
- Administrators who leftIn the past year1Leadership changed
- Occupancy120 certified beds · ~116 residents a day97%Top 3%PA avg 82%
Fines & penalties
Roughly the past three yearsEnforcement summary
- $8,190In fines
- 1Fine
- 0Payment denials
- $28,640PA avg in fines
Actions on record
- Apr 6, 2023Civil money penalty$8,190
Ownership
As filed with CMSStructure
- Ownership type
- Non profit - Corporation
- Chain
- Independent
- Certification
- Medicare and Medicaid
- Location type
- Urban
- Ownership change
- None in the last 12 months
People and entities on file
- Brethren Village
- Covenant Alliance Rehab East LLC
- Friends Services for the Aging
- Upmc
- Nancy Eshleman
- Tara Horvath
- Rodney Martzall
- Brad Norris
- +3 more
- Tina Bellanca
- Brian Boyd
- Jeffrey Dahl
- Joanne Eshelman
- Tyler Eshelman
- Steven Faus
- John Gibbel
- Connie Metzler
- +3 more
- Rodney Martzall
- John Snader
- First National Bank of Pennsylvania
Person Organization
Sources & notes
Public data, updated quarterlyData sources
- CMS Care Compare · Provider InformationStar ratings, staffing hours, turnover, penalties and flags · processed February 2026.
- CMS Health CitationsEvery deficiency from the last three inspection cycles, with scope, severity and inspection cycle.
- CMS Penalties and Ownership filesCivil money penalties, payment denials, and the owners and managers on file.
Notes
- CMS Certification Number 395328 · 3001 LITITZ PIKE, LANCASTER, PA, 17606.
- Percentiles compare this facility with every rated nursing home in Pennsylvania and Lancaster County. Turnover and fines are inverted so a high percentile is always good.
- This is an informational summary of public data, not medical, legal, or placement advice. Facilities cannot pay to change it; a facility that believes a record is wrong can dispute it with CMS.









