01 / INSPECTION LEDGER
Survey cycles in this release
| Cycle | Health date | Health deficiencies | Fire date | Fire deficiencies |
|---|---|---|---|---|
| Cycle 1 | 2024-09-20 | 2 | 2024-09-20 | 3 |
| Cycle 2 | 2023-11-03 | 7 | 2023-11-03 | 3 |
| Cycle 3 | 2022-12-16 | 2 | 2022-12-16 | 3 |
CMS CCN 3958572026-08-01 PROCESSING DATE
NURSING HOME PUBLIC RECORD
Ephrata Manor
99 Bethany Road · Ephrata, PA 17522 · Lancaster County
Certified beds120CMS provider file
Recent citation rows20current CMS citation release
Penalty rows1current CMS penalties file
Read this record carefully.
The citation files cover the three most recent standard inspections plus qualifying complaint and infection-control inspections in the prior three years. A correction date is a CMS field; this site does not independently verify conditions. Absence from a file is not proof that no issue exists.
02 / CITATION DETAIL
20 rows in the current release
1 rows carry G–L scope/severity codes; 0 carry J–L. 1 tag codes appear on more than one survey date. These counts describe citation rows, not residents or incidents.
2026-02-02 · HEALTHF0745Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Correction field: Deficient, Provider has date of correction · 2026-03-03 · complaint2024-09-20 · HEALTHF0758Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2024-10-182024-09-20 · FIREK0325Severity D · isolated; potential for more than minimal harm
Smoke Deficiencies
Have properly installed hallway dispensers for alcohol-based hand rub.
Correction field: Deficient, Provider has date of correction · 2024-10-152024-09-20 · FIREK0351Severity D · isolated; potential for more than minimal harm
Smoke Deficiencies
Install an approved automatic sprinkler system.
Correction field: Deficient, Provider has date of correction · 2024-10-152024-09-20 · FIREK0363Severity D · isolated; potential for more than minimal harm
Smoke Deficiencies
Install corridor and hallway doors that block smoke.
Correction field: Deficient, Provider has date of correction · 2024-10-152023-11-03 · HEALTHF0580Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Correction field: Deficient, Provider has date of correction · 2023-11-302023-11-03 · HEALTHF0638Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Assure that each resident’s assessment is updated at least once every 3 months.
Correction field: Deficient, Provider has date of correction · 2023-11-302023-11-03 · HEALTHF0656Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Correction field: Deficient, Provider has date of correction · 2023-11-302023-11-03 · HEALTHF0686Severity G · isolated actual harm
Quality of Life and Care Deficiencies
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Correction field: Deficient, Provider has date of correction · 2023-11-302023-11-03 · HEALTHF0730Severity D · isolated; potential for more than minimal harm
Nursing and Physician Services Deficiencies
Observe each nurse aide's job performance and give regular training.
Correction field: Deficient, Provider has date of correction · 2023-11-302023-11-03 · HEALTHF0758Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2023-11-302023-11-03 · HEALTHF0947Severity D · isolated; potential for more than minimal harm
Nursing and Physician Services Deficiencies
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Correction field: Deficient, Provider has date of correction · 2023-11-302023-11-03 · FIREK0321Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Correction field: Deficient, Provider has date of correction · 2023-11-032023-11-03 · FIREK0353Severity C · widespread; potential for minimal harm
Smoke Deficiencies
Inspect, test, and maintain automatic sprinkler systems.
Correction field: Deficient, Provider has date of correction · 2023-11-032023-11-03 · FIREK0355Severity C · widespread; potential for minimal harm
Smoke Deficiencies
Properly select, install, inspect, or maintain portable fire extinguishes.
Correction field: Deficient, Provider has date of correction · 2023-11-032022-12-16 · HEALTHF0756Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Correction field: Deficient, Provider has date of correction · 2023-01-302022-12-16 · HEALTHF0758Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2023-01-302022-12-16 · FIREK0161Severity D · isolated; potential for more than minimal harm
Construction Deficiencies
Use approved construction type or materials.
Correction field: Deficient, Provider has date of correction · 2023-01-312022-12-16 · FIREK0511Severity D · isolated; potential for more than minimal harm
Services Deficiencies
Have properly installed electrical wiring and gas equipment.
Correction field: Deficient, Provider has date of correction · 2023-01-312022-12-16 · FIREK0920Severity D · isolated; potential for more than minimal harm
Gas, Vacuum, and Electrical Systems Deficiencies
Ensure proper usage of power strips and extension cords.
Correction field: Deficient, Provider has date of correction · 2023-01-3103 / ENFORCEMENT FILE
Penalties reported by CMS
Fine amounts and payment-denial days are shown exactly as aggregated from the current penalties file. They do not imply an unpaid balance.
| Date | Type | Fine amount | Payment-denial days |
|---|---|---|---|
| 2023-11-03 | Fine | $13,845 | 0 |
04 / OWNERSHIP DISCLOSURES
Who appears in the CMS file
- UNITED CHURCH OF CHRIST HOMESOrganization · 5% OR GREATER DIRECT OWNERSHIP INTEREST100% · since 01/01/1981
- BLOSE, LEROYIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 04/26/2018
- BOONE, REBECCAIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 04/23/2020
- DEANER, KAYIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 04/27/2023
- DOMINGOS, TITAIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 07/25/2024
- FIELDS, TONYIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 04/27/2023
- HEIN, DWIGHTIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 04/28/2025
- KERN, CRAIGIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 04/25/2025
- LYONS, JAMESIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 04/25/2024
- PAUL, EMERSONIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 04/28/2022
- PRINZ, DONNAIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 04/27/2023
- RANKIN, CHRISTOPHERIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 04/27/2023
- RIEKER, JOHNIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 04/26/2018
- RUSSELL, GALENIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 04/22/2021
- WOMACK, KENNETHIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 04/28/2022
- EYSTER, SHARONIndividual · CORPORATE OFFICERNOT APPLICABLE · since 10/31/2022
- FIELDS, MEREDITHIndividual · CORPORATE OFFICERNOT APPLICABLE · since 02/10/2025
- GOURLEY, RONALDIndividual · CORPORATE OFFICERNOT APPLICABLE · since 12/13/2024
Names and roles are self-reported CMS disclosure fields. Exact-name pages do not prove that similarly named people or organizations are the same entity.
05 / CMS STAFFING FIELDS
Reported hours and turnover
Staffing fields are provider-reported and case-mix context matters. CMS applies footnotes and exclusions not reproduced as a new score here.
Total nurse hours4.22per resident day
RN hours0.79per resident day
Weekend nurse hours3.86per resident day
Staff turnover43.5%CMS reported field
06 / LOCAL RECORDS
Open the Ephrata ledger →