5/5
CMS (the Centers for Medicare & Medicaid Services) is the federal agency that rates nursing home quality. Its Overall Rating runs from 1 to 5 stars, combining health inspections, staffing, and quality measures, with inspections weighted most heavily.
5/5
CMS (the Centers for Medicare & Medicaid Services) is the federal agency that rates nursing home quality. Its Overall Rating runs from 1 to 5 stars, combining health inspections, staffing, and quality measures, with inspections weighted most heavily.
Part of the broader Willow Valley Communities retirement system, The Glen at Willow Valley is a 76-bed nonprofit community managed by operator Margaret Donegan. The facility coordinates skilled nursing, memory support, short-term rehab, and respite care. The building operates on a private-pay dominant model with zero Medicaid integration; new admissions split into 72% private-pay and 28% Medicare clients, yielding a long-term average length of stay of 410 days. The community runs a 78% occupancy rate and recorded a highly stable financial year, posting a 2023 net income of $5.7 million backed by a $101.1 million overall revenue base.
Public health tracking records reveal an exceptional regulatory and staffing profile, highlighted by an inspection history that tracks 83% below the Pennsylvania deficiency average. The home’s latest unannounced evaluation in September 2024 resulted in zero deficiencies, while its lifetime citation-per-inspection rate stands at zero critical violations, alongside zero recorded consumer complaints or federal fines.
Daily nursing attention is deep, averaging 5 hours and 38 minutes per resident to rank 20th statewide. This internal staff base includes an expansive therapy framework and 165 direct care nurse aides, keeping outside agency contractor usage at a low 0.2%. Clinical quality summaries show strong numbers across almost all sectors, including a 0.1% resident depression rate and excellent vaccination updates, though the tracking files note that serious injuries from long-stay falls run 78% higher than the state baseline.
Prospective residents seeking permanent memory support or advanced nursing care can review these official tracking reports to evaluate the operator’s clinical baseline. Since the state archives confirm near-perfect inspection scores, top-tier daily care hours, and outstanding behavioral health metrics alongside comprehensive campus amenities like art studios and fitness areas, the documentation shows a highly organized, premium environment.
The Overall CMS Rating combines results from health inspections, staffing levels and quality measures. Health inspections carry the most weight. Staffing and quality scores can increase or decrease the final rating based on performance compared to state and national standards.
Based on the results of the facility's three most recent standard inspections and any complaint investigations. CMS reviews the number, scope, and severity of deficiencies, with more recent findings weighted more heavily.
Measures average nursing staff hours per resident per day, including Registered Nurses (RNs) and total nursing staff. Ratings are adjusted based on the level of care residents require and are compared to state and national benchmarks.
Based on clinical and physical health indicators reported to CMS, such as hospital readmissions, falls, pressure ulcers, and improvements in mobility. These measures reflect how well residents' health needs are being managed.
Daily nursing hours per resident by staff type, reported to CMS. Higher is generally better — compare this facility to state and national averages to see where staffing stands.
This home is ranked 21st out of 207 homes in Pennsylvania for nurse hours. Total adjusted nursing hours per resident per day, combining RN, LPN, and aide time. CMS adjusts this for case-mix so facilities can be fairly compared.
| Staff type | Hours / Day / Resident | vs state avg |
|---|---|---|
|
Registered Nurse (RN)
RNs hold the highest nursing license and can assess residents, interpret test results, and direct care plans. More RN hours per day often signals stronger clinical oversight and faster response to health changes.
| 42m per day | ▼ 10% State avg: 47m per day · National avg: 41m per day |
|
LPN / LVN
Licensed Practical Nurses (LPNs) or Licensed Vocational Nurses (LVNs) deliver routine hands-on care — medication administration, wound dressing, and monitoring vital signs. They work under RN supervision and make up a large share of daily bedside care.
| 1h 7m per day | ▲ 23% State avg: 54m per day · National avg: 52m per day |
|
Nurse Aide
Certified Nurse Aides (CNAs) provide the most direct day-to-day assistance: bathing, dressing, feeding, and mobility. Nurse aide hours are typically the largest staffing category and directly affect residents' quality of life.
| 2h 49m per day | ▲ 28% State avg: 2h 12m per day · National avg: 2h 20m per day |
|
Weekend Total Nursing
Combined nursing hours (RN + LPN + Nurse Aide) per resident per day on weekends. Staffing often drops on weekends — this figure reveals whether the facility maintains adequate coverage outside of weekday hours.
| 4h 17m per day | ▲ 21% State avg: 3h 32m per day · National avg: 3h 27m per day |
|
Physical Therapist
Hours per resident per day provided by licensed Physical Therapists (PTs) or PT Assistants. PT services help residents recover mobility after injury or illness and are especially important for post-acute (short-stay) rehabilitation.
| 3m per day | ▼ 42% State avg: 6m per day · National avg: 4m per day |
|
Weekend RN
Registered nurse hours specifically on weekends. Facilities sometimes reduce RN presence on Saturdays and Sundays — a low weekend RN figure compared to weekday hours can indicate reduced clinical oversight when most administrative staff are absent.
| 27m per day | ▼ 16% State avg: 33m per day · National avg: 29m per day |
Average number of days residents stay at this facility, based on CMS cost report data. Shorter stays often reflect post-acute or rehab care; longer stays reflect long-term care.
Similar to the Pennsylvania average: 78.7%The Glen at Willow Valley is legally operated by Willow Valley Communities.
In Pennsylvania, the Department of Human Services (for assisted living facilities) and the Department of Health (for nursing homes) conduct unannounced inspections to verify adherence to state regulations.
A composite 0–100 score combining this facility's inspections, citations, complaints, and enforcement actions relative to the Pennsylvania state average. The score below shows how many points this facility sits above or below the typical Pennsylvania assisted living residence score (the benchmark); higher is better.This is a proprietary Assisted Living Magazine score.
17 points above the Pennsylvania average for assisted living residences (83/100)
Rank #1 / 460 in Pennsylvania Inspection Score — State benchmarked This home is ranked 1st out of 460 homes in Pennsylvania for Inspection Score. Shows this facility's inspection score compared to the Pennsylvania average among 460 comparable communities in the ranking pool. Rankings are based only on facilities in Pennsylvania that report data for that category. Facilities without available data are excluded from the ranking. This is a proprietary Assisted Living Magazine score. Inspection score: 100 out of 100. Letter grade A+. 17 points above the Pennsylvania average for assisted living residences (83/100)
A higher number of waivers may indicate the facility relies on staff who don't fully meet standard credential requirements. A lower number may suggest the facility meets staffing qualification standards without exemptions.
This scorecard compares key inspection, citation, and complaint metrics at this facility against the Pennsylvania state average. Metrics rated ≥15% worse than average are highlighted in red; those ≥15% better are highlighted in green.
Citations
| This Facility | PA Average | vs. PA Avg |
|---|---|---|---|
|
Total citations
Formal regulatory issues recorded by inspectors across all inspection types.
| 3 | 63 | This facility has 95% fewer total citations than a typical Pennsylvania assisted living residence (3 vs. PA avg 63).↓ 95% better Rank #22 / 478 Total citations — State benchmarked This home is ranked 22nd out of 478 homes in Pennsylvania for Total citations. Shows this facility's total citations compared to the Pennsylvania average among 478 comparable communities in the ranking pool. Rankings are based only on facilities in Pennsylvania that report data for that category. Facilities without available data are excluded from the ranking. |
|
Citations per year
Average citations per year since 2021.
| 0.6 | 12.6 | This facility has 95% fewer citations per year than a typical Pennsylvania assisted living residence (0.6 vs. PA avg 12.6).↓ 95% better |
|
Citations per inspection
Average citations per inspection.
| 0.8 | 5.7 | This facility has 86% fewer citations per inspection than a typical Pennsylvania assisted living residence (0.8 vs. PA avg 5.7).↓ 86% better Rank #23 / 478 Citations per inspection — State benchmarked This home is ranked 23rd out of 478 homes in Pennsylvania for Citations per inspection. Shows this facility's citations per inspection compared to the Pennsylvania average among 478 comparable communities in the ranking pool. Rankings are based only on facilities in Pennsylvania that report data for that category. Facilities without available data are excluded from the ranking. |
Inspections
| This Facility | PA Average | vs. PA Avg |
|---|---|---|---|
|
Total inspections
Combined count of all routine and focused inspections. Excludes complaint investigations.
| 4 | 11 | This facility has had 64% fewer total inspections than the Pennsylvania average (4 vs. PA avg 11). More inspections can mean more regulatory scrutiny rather than worse care.↓ 64% fewer |
|
Inspections with citations
Inspections that resulted in at least one regulatory citation.
| 1 | 8 | This facility has 88% fewer inspections with citations than a typical Pennsylvania assisted living residence (1 vs. PA avg 8).↓ 88% better |
|
Inspection citation rate
Percentage of inspections that resulted in at least one citation.
| 25% | 73% | This facility has 48 percentage points lower inspection citation rate than a typical Pennsylvania assisted living residence (25% vs. PA avg 73%).↓ 48% better Rank #23 / 478 Inspection citation rate — State benchmarked This home is ranked 23rd out of 478 homes in Pennsylvania for % of inspections with citations. Shows this facility's % of inspections with citations compared to the Pennsylvania average among 478 comparable communities in the ranking pool. Rankings are based only on facilities in Pennsylvania that report data for that category. Facilities without available data are excluded from the ranking. |
Complaints & Investigations
| This Facility | PA Average | vs. PA Avg |
|---|---|---|---|
|
Total complaints
Formal expressions of concern made by residents, families, or staff.
| 0 | 4 | This facility has 100% fewer total complaints than a typical Pennsylvania assisted living residence (0 vs. PA avg 4).↓ 100% better Rank #1 / 478 Total complaints — State benchmarked This home is ranked 1st out of 478 homes in Pennsylvania for Complaint inspections. Shows this facility's complaint inspections compared to the Pennsylvania average among 478 comparable communities in the ranking pool. Rankings are based only on facilities in Pennsylvania that report data for that category. Facilities without available data are excluded from the ranking. |
|
Complaints per year
Average complaints per year since 2021.
| 0 | 0.8 | This facility has 100% fewer complaints per year than a typical Pennsylvania assisted living residence (0 vs. PA avg 0.8).↓ 100% better |
An editor-reviewed summary of the themes and findings across this facility's recent inspection reports.
Pennsylvania average 6.7
Last Health inspection on Nov 2023
Pennsylvania average 31.3
Pennsylvania average 4.4
Health citations are formal notices following inspections when they fail to comply with safety and care standards.
All 2 citations resulted from standard inspections.
100% better than Pennsylvania averagePennsylvania average: 0.3
67% worse than Pennsylvania averagePennsylvania average: 0.6
Corrected
Corrected
Reporting period: October 1 – December 31, 2025 (Q4 2025). Source: CMS Payroll-Based Journal report.
18% fewer staff per resident than Pennsylvania average
0% compared with Pennsylvania average
This data comes from the CMS Payroll-Based Journal report covering October 1 – December 31, 2025.
Manages medical care and health needs.
All 37 RN Staff are full-time employees. No contractors work on this role.
37
Average shift length. Calculated as total hours divided by days worked and average staff per day.
7.9 hoursAssists with medical care and medications.
All 63 LPN Staff are full-time employees. No contractors work on this role.
63
Average shift length. Calculated as total hours divided by days worked and average staff per day.
7.9 hoursHelps with daily care and mobility.
All 165 CNA Staff are full-time employees. No contractors work on this role.
165
Average shift length. Calculated as total hours divided by days worked and average staff per day.
7.6 hours
This data comes from the CMS Payroll-Based Journal report covering October 1 – December 31, 2025.
Total hours from contractors
177 contractor hours this quarter
This data comes from the CMS Payroll-Based Journal report covering October 1 – December 31, 2025.
| Certified Nursing Assistant | 165 | 0 | 165 | 57,243 | 92 | 100% | 7.6 |
| Licensed Practical Nurse | 63 | 0 | 63 | 22,996 | 92 | 100% | 7.9 |
| Registered Nurse | 37 | 0 | 37 | 9,478 | 92 | 100% | 7.9 |
| Other Dietary Services Staff | 15 | 0 | 15 | 4,753 | 92 | 100% | 7.8 |
| Clinical Nurse Specialist | 14 | 0 | 14 | 4,454 | 70 | 76% | 8 |
| Dental Services Staff | 4 | 0 | 4 | 1,741 | 65 | 71% | 8.3 |
| Physical Therapy Assistant | 11 | 0 | 11 | 1,536 | 73 | 79% | 5 |
| Respiratory Therapy Technician | 15 | 0 | 15 | 1,198 | 75 | 82% | 4.9 |
| Speech Language Pathologist | 4 | 0 | 4 | 1,043 | 68 | 74% | 6.7 |
| Qualified Social Worker | 6 | 0 | 6 | 997 | 69 | 75% | 5.5 |
| Nurse Aide in Training | 14 | 0 | 14 | 975 | 55 | 60% | 7.5 |
| Therapeutic Recreation Specialist | 4 | 0 | 4 | 862 | 66 | 72% | 6 |
| Physical Therapy Aide | 4 | 0 | 4 | 521 | 54 | 59% | 6.4 |
| Administrator | 1 | 0 | 1 | 456 | 57 | 62% | 8 |
| Nurse Practitioner | 1 | 0 | 1 | 448 | 56 | 61% | 8 |
| Occupational Therapy Aide | 1 | 0 | 1 | 440 | 59 | 64% | 7.5 |
| Occupational Therapy Assistant | 0 | 1 | 1 | 149 | 50 | 54% | 3 |
| Medical Director | 0 | 1 | 1 | 28 | 12 | 13% | 2.3 |
Federal penalties imposed by CMS for regulatory violations, including civil money penalties (fines) and denials of payment for new Medicare/Medicaid admissions.
Source: CMS Penalties Database
No penalties in the past 3 years
No civil money penalties or payment denials were reported in the last 3 years.
These measures show how residents usually do over time at this home, based on health outcomes and preventive care.
A composite score based on pressure ulcers, falls with injury, weight loss, walking ability decline, and activities of daily living decline.
8.5
22% better than Pennsylvania averagePennsylvania average: 11.0
A composite score based on activities of daily living decline, walking ability decline, and incontinence.
17.8
20% better than Pennsylvania averagePennsylvania average: 22.2
Percent of long-stay residents whose need for help with daily activities has increased
18.6%
In line with Pennsylvania averagePennsylvania average: 19.0%
Percent of long-stay residents whose ability to move independently worsened
11.1%
47% better than Pennsylvania averagePennsylvania average: 21.1%
Percent of low risk long-stay residents who lose control of their bowels or bladder
23.6%
12% better than Pennsylvania averagePennsylvania average: 26.7%
Percent of long-stay residents experiencing one or more falls with major injury
5.7%
78% worse than Pennsylvania averagePennsylvania average: 3.2%
Percent of long-stay high risk residents with pressure ulcers
3.3%
40% better than Pennsylvania averagePennsylvania average: 5.5%
Percent of long-stay residents with a urinary tract infection
0.8%
52% better than Pennsylvania averagePennsylvania average: 1.8%
Percent of long-stay residents who lose too much weight
3.9%
41% better than Pennsylvania averagePennsylvania average: 6.6%
Percent of long-stay residents who have depressive symptoms
0.1%
98% better than Pennsylvania averagePennsylvania average: 5.5%
Percent of long-stay residents who received an antipsychotic medication
12.3%
28% better than Pennsylvania averagePennsylvania average: 17.1%
Percent of long-stay residents assessed and appropriately given the pneumococcal vaccine
98.7%
14% better than Pennsylvania averagePennsylvania average: 86.9%
Percent of long-stay residents assessed and appropriately given the seasonal influenza vaccine
98.3%
5% better than Pennsylvania averagePennsylvania average: 93.5%
Percent of short-stay residents assessed and appropriately given the pneumococcal vaccine
92.6%
35% better than Pennsylvania averagePennsylvania average: 68.8%
Percent of short-stay residents who newly received an antipsychotic medication
0.5%
65% better than Pennsylvania averagePennsylvania average: 1.5%
Percent of short-stay residents assessed and appropriately given the seasonal influenza vaccine
83.9%
22% better than Pennsylvania averagePennsylvania average: 68.7%
Quality measures are calculated from Minimum Data Set (MDS) assessments. For most measures, lower percentages indicate better care quality.
28% of new residents, usually for short-term rehab.
72% of new residents, often for short stays.
Source: CMS Long-Term Care Facility Characteristics (Data as of Jan 2026)
Total residents
241Residents meet regularly to discuss policies, care quality, and activities
Family members meet regularly to discuss policies, care quality, and activities
State-approved Nurse Aide Training and Competency Evaluation Program on-site
Part of a Continuing Care Retirement Community offering multiple care levels
Organized group of family members that meets regularly to discuss facility policies, resident care, and activities.
Organized group of residents that meets regularly to discuss facility policies, quality of life, and activities.
Data sourced from CMS Long-Term Care Facility Characteristics quarterly report. Payer mix reflects the current resident census by primary payment source.
Historical financial and operational data for The Glen at Willow Valley from 2011–2023, based on CMS SNF Cost Reports.
Key figures below are for fiscal year ending in 12/2023.
Based on CMS SNF Cost Report for fiscal year ending in 12/2023.
Net patient revenue — what the home actually collects for resident care, after contractual allowances, bad debt and discounts are subtracted from its gross charges (CMS cost report, Worksheet G-3). It covers resident care only; money the home earns from other sources is shown separately as "Other income."
Net patient income: net patient revenue minus the home's total operating expenses. A positive figure means it earns more from resident care than it spends to deliver it; a negative figure means the opposite. It excludes non-operating "other income."
Net patient revenue — what the home actually collects for resident care, after contractual allowances, bad debt and discounts are subtracted from its gross charges (CMS cost report, Worksheet G-3). It covers resident care only; money the home earns from other sources is shown separately as "Other income."
Net patient income: net patient revenue minus the home's total operating expenses. A positive figure means it earns more from resident care than it spends to deliver it; a negative figure means the opposite. It excludes non-operating "other income."
Money the home earns outside of resident care — such as investments, grants, rentals and other non-operating sources (CMS cost report, Worksheet G-3). It is tracked separately from net patient revenue: it is not part of that figure, and it is not included in net patient income.
Staff salaries plus wage-related costs — benefits such as payroll taxes, health insurance and retirement — from the home's own accounting records (CMS cost report, Worksheet A). Contract or agency labor is counted separately, under other operating costs.
Rank #1 / 209Payroll — State benchmarkedThis home is ranked 1st out of 209 homes in Pennsylvania for Payroll. Shows total annual staff payroll benchmarked to the Pennsylvania average. Higher payroll investment relative to peers often signals better staffing and less reliance on cheaper contract labor.Rankings are based only on facilities in Pennsylvania that report data for that category. Facilities without available data are excluded from the ranking.Click the rank badge to see the full State ranking.Click here to see the full State ranking.
Payroll as a share of revenue: staff salaries and wage-related benefits divided by net patient revenue. A higher figure means more of each revenue dollar goes to staff pay.
Rank #190 / 209Payroll % — State benchmarkedThis home is ranked 190th out of 209 homes in Pennsylvania for Payroll %. Shows payroll as a percentage of revenue versus the Pennsylvania average. Well-run Pennsylvania facilities typically land around 53–62% — the top third Statewide. Below 25% may signal understaffing or heavy agency use — read with Staffing ratings.Rankings are based only on facilities in Pennsylvania that report data for that category. Facilities without available data are excluded from the ranking.Click the rank badge to see the full State ranking.Click here to see the full State ranking.
Everything it costs to run the home apart from payroll — food, utilities, supplies, maintenance, contract labor and administration. Calculated as total operating expense minus payroll (staff salaries and wage-related benefits).
The home's total operating expense for the year — all the costs of running it, salaries included (CMS cost report, Worksheet G-3).
Pets Allowed
Residents typically stay for brief periods, with frequent admissions and discharges throughout the year.
Most new residents arrive under private pay (72% of admissions), and a typical private pay stay runs around 1 years.
Coverage residents most often arrive under.
Coverage residents most often leave under.
4.4 miles from city center
Estimated distance in miles from Lancaster's city center to The Glen at Willow Valley's address, calculated via Google Maps.
Add your location
The Glen at Willow Valley is located in SQUARE LANCASTER, Pennsylvania.
Here are the financial assistance programs available to residents in Pennsylvania.
The Glen at Willow Valley is legally operated by Willow Valley Communities.
The Glen at Willow Valley has a walk score of 6. Car-dependent. Most errands require a car, with limited nearby walkable options.
According to PA state health department records, The Glen at Willow Valley's license number is 321910.
According to PA state health department records, The Glen at Willow Valley's license expires on February 19, 2027.
The Glen at Willow Valley's occupancy is 78%.
Yes, The Glen at Willow Valley allows residents to bring their pets.
The Glen at Willow Valley is registered as a non-profit in PA.
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