Deficiency Index

Lakeside at Willow Valley

Willow Street, Pennsylvania · CCN 395771

10 surveys since 2011. The first finding at harm level was recorded in 2015.

Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.

Citations on record
24
Surveys
10
Harm or worse
1
Immediate jeopardy
0
The record, 2011–2024
’11’15’20’24
No harm recordedHarm or worseNot surveyed
Harm or worse1

Findings where a surveyor recorded actual harm to a resident.

Beyond CMS’s monthly file9/10

Older surveys no longer in CMS’s monthly file or on Care Compare. They are shown here.

The facility

Certified beds
80
Ownership
Non profit - Corporation
Chain
Independent
County
Lancaster
Medicare-certified since
1989

CMS ratings

Overall
5
Health inspection
5
Staffing
5
Quality measures
5

CMS’s own Five-Star ratings.

Compared with similar facilities

Not shown for this facility: too few citations in window (n=2, floor 20).

Last survey on record

Dec 4, 2024

705 days ago.

Counts surveys with at least one finding. A clean survey leaves no record here, so the real gap may be shorter.

Staffing

MeasureThis facilityPeer median
Nurse hours per resident day4.874.44
Registered-nurse hours per resident day1.42—
Annual nurse turnover36.5%37.5%

As reported by the facility to CMS, beside the peer-group median.

Enforcement

No fines, payment denials or special-focus designation on the current CMS record.

Severity of recent findings

Citations by CMS scope and severity. Rows are harm level, columns are how widespread the finding was.
SeverityIsolatedPatternWidespread
Immediate jeopardyJ—K—L—
Actual harmG—H—I—
No harm, potential for more than minimalD—E1100.0%F—
No harm, potential for minimalA—B—C—
CMS’s current file: 1 of the 24 citations on record.

In the surveyor’s words

From the most serious findings on record at Lakeside at Willow Valley, in the surveyor’s own words.

  • No harm, potential for more than minimal, patternF812Dec 4, 2024

    Based on review of facility policy, review of facility documentation, observations, and interview with staff, it was determined that the facility failed to store food and maintain appropriate sanitation in accordance with professional standards for food service safety. Findings included: Review of facility policy, Food Storage, reviewed January 2024, indicated that all food items should be labeled, dated, and rotated to insure FIFO (first in, first out) method of storing and use and to prevent outdated food from being used. Review of facility policy, Sanitation Process, revealed that sanitizer must be mixed at the proper concentration and checked at regular intervals with a test kit and logged on sanitizer log. […]

  • No harm, potential for more than minimal, patternF880Mar 1, 2022

    Based upon observation it was determined that the facility failed to screen visitors for COVID 19 [CONDITION(S)] symptoms prior to entering the facility for 4 out of 4 days of the survey. Findings include: Observation on February 24, 2022 at 9:00 a.m., February 25, 2022 at 11:00 a.m., February 28, 2022 at 8:30 a.m. and March 1, 2022 at 9:00 a.m. revealed that surveyors entered the facility without prior screening for the COVID 19 virus symptoms. Observation at the reception desk revealed that a sign-in form was provided to visitors. The sign-in form indicated that visitors were to either be screened at the entrance or confirm that the visitor had no signs/symptoms of COVID-19. Interview with the Nursing Home Administrator on February 28, 2022 at 11:00 a.m. […]

Read 20 findings in full →The most serious and the most recent: 20 of 24 on record.

Every survey on record

FindingsAt actual harm or above

  • Dec 4, 2024Standard1 finding
  • Mar 1, 2022Standard1 finding
  • Mar 30, 2018Standard5 findings
  • May 17, 2016Standard and complaint3 findings
  • Nov 2, 2015Complaint1 finding · 1 harm
  • Mar 23, 2015Standard3 findings
  • Apr 7, 2014Standard1 finding
  • Feb 22, 2013—2 findings
Show the 2 earlier surveys
  • Mar 20, 2012—3 findings
  • Feb 7, 2011—4 findings

Surveys that found no deficiencies are not in CMS’s files and do not appear here.

Comparable facilities

The nearest facilities to this one in the same peer group, by weighted findings.

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