GLEN AT WILLOW VALLEY

675 WILLOW VALLEY SQUARE, LANCASTER, PA 17602 (717) 464-6161
Non profit - Corporation 262 Beds Independent Data: November 2025
Trust Grade
88/100
#44 of 653 in PA
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Last Inspection: November 2023

Within standard 12-15 month inspection cycle. Federal law requires annual inspections.

Overview

Glen at Willow Valley in Lancaster, Pennsylvania, has a Trust Grade of B+, indicating it is above average and recommended for families seeking care. It ranks #44 out of 653 facilities in the state and #4 out of 31 in Lancaster County, placing it in the top half for both metrics. The facility's performance has been stable, with only one issue reported in both 2021 and 2023, reflecting consistency in care quality. Staffing is a strong point, rated 5 out of 5 stars with a turnover rate of 26%, significantly lower than the Pennsylvania average, which suggests a stable and experienced team. However, there have been some concerns; a serious incident involved a resident falling and sustaining an injury due to inadequate supervision, and another instance involved a medication error where a resident received a duplicate dose of prescribed medications. Overall, while the facility demonstrates strong staffing and performance, families should be aware of the incidents that highlight areas for improvement.

Trust Score
B+
88/100
In Pennsylvania
#44/653
Top 6%
Safety Record
Moderate
Needs review
Inspections
Holding Steady
1 → 1 violations
Staff Stability
✓ Good
26% annual turnover. Excellent stability, 22 points below Pennsylvania's 48% average. Staff who stay learn residents' needs.
Penalties
✓ Good
No fines on record. Clean compliance history, better than most Pennsylvania facilities.
Skilled Nurses
✓ Good
Each resident gets 48 minutes of Registered Nurse (RN) attention daily — more than average for Pennsylvania. RNs are trained to catch health problems early.
Violations
✓ Good
Only 2 deficiencies on record. Cleaner than most facilities. Minor issues only.
★★★★★
5.0
Overall Rating
★★★★★
5.0
Staff Levels
★★★★★
5.0
Care Quality
★★★★★
5.0
Inspection Score
↔
Stable
2021: 1 issues
2023: 1 issues

The Good

  • 5-Star Staffing Rating · Excellent nurse staffing levels
  • 5-Star Quality Measures · Strong clinical quality outcomes
  • Low Staff Turnover (26%) · Staff stability means consistent care
  • Full Sprinkler Coverage · Fire safety systems throughout facility
  • No fines on record
  • Staff turnover is low (26%)

    22 points below Pennsylvania average of 48%

Facility shows strength in staffing levels, quality measures, staff retention, fire safety.

The Bad

No Significant Concerns Identified

This facility shows no red flags. Among Pennsylvania's 100 nursing homes, only 1% achieve this.

The Ugly 2 deficiencies on record

1 actual harm
Nov 2023 1 deficiency
CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Quality of Care (Tag F0684)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview it was determined the facility failed to obtain or follow physician orders f...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview it was determined the facility failed to obtain or follow physician orders for four of 40 residents reviewed. (Residents 19, 72, 134, and Resident 156) Findings include: Review of Resident 19's physician orders revealed an order dated May 8, 2023 for Tramadol Tablet (narcotic pain reliever) 50 milligrams (mg) give half a tablet by mouth two times a day for pain. Further review of Resident 19's physician orders revealed an order dated June 14, 2023 for Lorazepam (antianxiety medication) 0.5 mg tablet give one tablet by mouth two times a day for anxiety. Review of Resident 19's progress notes revealed a nurse's note dated October 21, 2023, which stated: Noted during am count of narcotics the resident received duplicate dose of [Lorazepam] 0.5mg and Tramadol 25mg between the hours of [6:00 p.m. - 8:00 p.m.] Review of Resident 19's Controlled Drug Receipts revealed Licensed Nurse Employee E3 signed out the resident's Tramadol and Lorazepam on October 20, 2023, at 6:00 p.m. Review of Resident 19's October Medication Administration Record (MAR) revealed Licensed Nurse Employee E3 did not sign the medications out as being administered on the MAR. Further review of Resident 19's Controlled Drug Receipts and October MAR revealed the next shift nurse saw that the medications were not administered per the MAR, and therefore the resident was given additional doses of the medications. Interview with the Nursing Home Administrator on November 17, 2023, at 11:25 a.m. confirmed the above findings. Review of Resident 72's physician orders revealed an order dated September 23, 2023 for Dulcolax Tablet (stool softener) Delayed Release 5 mg Give 2 tablet by mouth every 24 hours as needed for Constipation. Bowel protocol - give on day 3 as needed. Further review of Resident 72's physician orders revealed an order dated September 23, 2023 for Dulcolax Suppository 10 mg Insert 1 suppository rectally every 24 hours as needed for constipation. Bowel protocol -give on day 4 as needed. Review of Resident 72's bowel movement records revealed the resident had no bowel movement from October 20 2023 on evening shift until October 26, 2023 on day shift. A total of 6 days. Review of Resident 72's Medication Administration Record revealed Resident 72 was administered the Dulcolax tablets after 5 days of no bowel movement on November 25, 2023 at 7:46 p.m. and was documented as ineffective. Further review of the Medication Administration Record for October 2023 revealed Resident 72 was not offered the suppository. Further review of Resident 72's bowel movement record revealed the resident had no bowel movement from November 9, 2023 on day shift until November 15, 2023 on day shift, a total of 6 days. Review of Resident 72's Medication Administration Record revealed Resident 72 administered the Dulcolax tablets after 5 days with no bowel movement on November 14, 2023 at 10:01 a.m. and was documented as effective however there was no bowel movement documented on the bowel movement record on November 14, 2023. Further review of the Medication Administration record for November 2023 revealed Resident 72 was not offered the suppository. The facility failed to follow physician orders for bowel protocol by not administered bowel medication after 3 or 4 days of no bowel movement as ordered. Review of Resident 134's diagnosis list includes End Stage Renal Disease (ESRD- kidneys no longer function well enough to meet a body's needs), and Hypotension (Low blood pressure, which can cause fainting or dizziness because the brain doesn't receive enough blood). Review of Resident 134's clinical record revealed resident receives Hemodialysis (procedure where a machine and a special filter are used to clean your blood) two times a week, every Monday and Friday. Review of Resident 134's Physician's Order Sheet (POS) dated October 18, 2023, revealed an order for a daily weight before breakfast, to call the physician for a weight gain of two pounds in one day and three pounds in three days. Review of Resident 134's October 2023, Medication Administration Record (MAR) revealed no documented evidence that the resident's daily weight was taken on the following dates: October 19, 20, 21, 23, 26, 29, and 30, 2023. Review of Resident 134's November 2023, MAR revealed no documented evidence that the resident's daily weight was taken on the following dates: November 2, 5, 6, 7, and November 14, 2023. Review of Resident 134's weight and vitals record revealed a weight of 131.2 pounds on October 24, 2023, and 134.7 pounds on October 27, 2023, a 3.5-pound weight gain in three days. In addition, a weight of 133 pounds was identified on November 10, 2023, and 135.7 pounds was identified on November 11, 2023, a 2.7 weight gain in a day. Review of Resident 134's clinical record failed to reveal the physician was notified of Resident 134's identified weight gains. Interview with the Director of Nursing on November 17, 2023, at 11:00 a.m., confirmed that the physician's order regarding daily weights was not followed. Review of Resident 134's POS/progress notes dated November 8, 2023, revealed Acute visit to review BP (blood pressure), Amlodipine (a medication to treat increased blood pressure) 2.5 mg PO (by mouth) daily discontinued in hospital mid-October due to concern for low BP with fall (? Decreased fluid volume due to dialysis). The physician ordered to start Amlodipine 2.5 mg by mouth on non-dialysis days daily hold SBP (Systolic Blood Pressure) < 130 mm hg. Review of the November 2023, MAR revealed Resident 134 was administered with Amlodipine 2.5mg without checking blood pressure on the following dates: November 9, 11, 12, 14, 15, and 16, 2023. Interview with the Director of Nursing was conducted on November 17, 2023, at 11:00 a.m. The DON reported that the physician's order is faxed to the pharmacy and transcribed into the EMR (Electronic Medical Record), the nurse on duty verifies/checks the order. The DON reported that the agency nurse did not ensure that the blood pressure parameter order was transcribed into the resident's EMR and therefore Amlodipine medication was administered without first checking the resident's blood pressure thus determining if the medication needed to be held. The DON confirmed that the facility did not follow the physician's order regarding blood pressure parameters. Review of Resident 156's progress notes revealed a nursing entry dated October 8, 2023 stating Assessed resident's surgical wound and found 4cm (centimeters) X 1.5cm yellowish/macerated (the process of skin softening and breaking down as a result of prolonged exposure to foreign fluids) area at very bottom of incision site and low-grade temp of 99.9 spoke to on call PA-C (physician assistant) who advised to send resident to ER (emergency room) for prompt treatment. Further review of Resident 156's Progress notes revealed the resident returned to the facility on October 9, 2023. Review of resident readmission nursing assessment dated [DATE] at 4:40 p.m. revealed mid back surgical scar with scabs .area at distal (bottom) portion measures 3.0 x 1.0 with opening draining serosanguinous (mixture of blood and clear fluid) fluid in moderate amount on 2x2 dressing (2 inch by 2 inch square of sterile gauze). Area redressed to collect and further drainage for now. Review of resident 156's physician orders revealed an order dated October 10, 2023 for Use soap and water to clean back incision then pat dry and leave OTA (open to air). Further review of resident 156's physician orders revealed there was an order dated October 14, 2023 for Santyl ointment (removed damaged tissue from wounds) apply to lower back surgical wound topically every day shift. The facility failed to provide wound care to an open wound on a surgical site from when resident 156 was readmitted to the facility on [DATE] until October 14, 2023 when the order for Santyl was completed. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.5(f) Clinical records 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services
Dec 2021 1 deficiency 1 Harm
SERIOUS (G)

Actual Harm - a resident was hurt due to facility failures

Accident Prevention (Tag F0689)

A resident was harmed · This affected 1 resident

Based on clinical record review, review of facility documentation and interview, it was determined that the facility failed to provide supervision to prevent a second fall resulting in actual harm of ...

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Based on clinical record review, review of facility documentation and interview, it was determined that the facility failed to provide supervision to prevent a second fall resulting in actual harm of a identified probable nasal fracture to one of eight residents reviewed (Resident 53). This was identified as past non compliance effective September 30, 2021. Findings include: Review of facility policies and procedures failed to reveal a policy identifying when additonal supervision is warranted for outside appointments or activities. Review of Resident 53's diagnosis list revealed diagnoses including vascular dementia (irreversible, progressive degenerative disease of the brain resulting in loss of reality, contact and functioning ability). Review of Resident 53's Quarterly Minimum Data Set (MDS - periodic assessment of resident needs) dated September 13, 2021 revealed Resident 53's Brief Interview for Mental Status Score indicated severe cognitive impairment. Further review of Resident 53's Quarterly MDS revealed Resident 53 required the extensive assistance of one staff member to transfer in and out of a wheelchair. Review of Resident 53's current care plan revealed Resident 53 is at risk for falls related to a history of falls and to remind resident to request transfer assistance from staff. Review of Resident 53's Morse Fall Scale dated August 24, 2021 revealed a score of 80 indicating Resident 53 had a high probable risk for falls. Review of Resident 53's progress notes dated August 26, 2021 revealed aide alerted nurse resident had fallen. Resident was just given pain med at 1353 [1:53 p.m.] . Resident was sitting in assist dining room in w/c [wheelchair]. W/c was locked. Resident had gotten up with w/c locked and fallen near table. Resident incontinent of bladder. Resident with abrasion to L [left] side of face and lump noted to L forehead. Resident confused and impulsive. Further review of Resident 53's progress notes dated August 27, 2021 revealed went to assess resident and noted facial swelling around bilateral orbits [around eyes] with ecchymosis [bruising]. Neuro checks have been stable with VS [vital signs]. [physician] notified of my concerns for possible orbital [bones around eyes] fractures. Order received to send resident out for CT scan of head and face w/o [without] contrast. All required information faxed to CT scan office. LMSA [area emergency transportation company] notified and time will be 04:30 [4:30 p.m.] Daughter called and message left. Resident is stable at present. No c/o [complaints of] pain. Further review of Resident 53's progress notes dated August 27, 2021 revealed it was reported that on 8/27/21 at 1907 pm [7:07 p.m.] the evening supervisor received a call from [hospital] ER [emergency room] [nurse] saying that the resident had fallen at the [hospital] outpatient pavilion after a CT scan and was transferred to the ER for an evaluation. Further review of Resident 53's progress notes dated August 28, 2021 revealed received in report at change of shift that resident was in [hospital] and would most likely be returning. At 23:30 [11:30 p.m.] on 8/27/21 spoke with [nurse at hospital]. She reported that the resident would be returning. The nurse reported that the resident had gone for a CT scan of her head and it indicated a left frontal and orbital fracture, along with a left hematoma. Prior to returning, the resident had a fall and she was brought back to [hospital] to have another CT scan done. The 2nd CT scan indicated a possible nasal fracture. This was in addition to the first CT scan. The resident arrived at 12:30 a.m. on 8/28/21. Her VSS [vital signs stable], she had no c/o pain/discomfort. Her b/l [bilateral - both sides] eyes are both bruised with the left eye closed over. She is resting comfortably at this time. Review of Employee E4's witness statement dated August 31, 2021 revealed that Employee E4 received a telephone call from Licensed RN Employee E3 and Licensed RN Employee E5 requesting information on scheduling a CT scan. Employee E4 supplied the requested information and offered to arrange transportation for Resident 53. Employee E4 subsequently arranged for transportation for Resident 53 to the hospital for the CT Scan. Interview with Employee E4 on December 2, 2021 at 9:50 a.m. revealed that Employee E4 set up transportation for Resident 53. The interview further revealed that Employee E4 did not obtain a staff person to accompany resident 53 to the hospital for the CT Scan. The interview further revealed that Employee E4 would normally ask the clinical manager if the resident needs assistance at the appointment, however Employee E4 was unfamiliar with Resident 53 because Resident 53 was not a resident on the unit where Employee E4 worked. Employee E4 was assisting Licensed Employee E5, clinical manager on Resident 53's nursing unit. Employee E4 also stated that employee was not informed that Resident 53 would need a staff person to accompany the resident to the appointment. Review of Licensed Employee E3's witness statement dated August 31, 2021 revealed that Licensed Employee E3 received a phone call from Licensed Employee E5 requesting assistance to schedule a CT Scan for Resident 53. Licensed Employee E3 called Employee E4 for assistance. Interview with Licensed RN Employee E3 on December 2, 2021 at 10:02 a.m. revealed Licensed RN Employee E3 received a telephone call from Licensed Employee E5 requesting assistance with scheduling a CT Scan. Licensed Employee E3 contacted Employee E4 to assist Licensed Employee E5. Licensed Employee E3 did not obtain a staff person to accompany Resident 53 to the hospital for the CT Scan. The interview further revealed that assigning staff persons to accompany residents to appointments is a clinical judgment by the clinical managers to determine if the resident requires someone to accompany them. Review of Licensed Employee E5's witness statement dated August 31, 2021 revealed Licensed Employee E5 asked Licensed Employee E3 how to make arrangements for a CT scan for Resident 53. Licensed Employee E3 and Licensed Employee E5 were unsure how to set up transportation and called Employee E4 for assistance. Licensed Employee E5 prepared Resident 53 for transport and obtained the appropriate paperwork. Licensed Employee E5 spoke with the transportation driver regarding Resident 53's recent fall and the transportation driver would be taking resident directly into the CT scan department. Licensed Employee E5's witness statement revealed I thought he was going to stay with her since it was such a short procedure. Licensed Employee E5 no longer works at the facility, therefore an interview of Licensed Employee E5 was not able to be obtained. Review of Resident 53's CT scan of facial bones results dated August 27, 2021 at 5:08 p.m. revealed Left orbital floor fracture without entrapment. The nasal bone is intact. Review of Resident 53's CT scan of facial bones result dated August 27, 2021 at 9:01 p.m. revealed Again noted is a mildly depressed orbital floor fracture. There are probable nasal fractures. The above information was conveyed to the Nursing Home Administrator and Director of Nursing on December 2, 2021 at approximately 11:00 a.m. The facility failed to provide supervision for a resident with history of falls, severe cognitive impairment, high probable fall risk, extensive staff assistance, and recent fall; during an outside diagnostic appointment, resulting in Resident 53 falling from the wheelchair and requiring a second CT Scan with a result of probable nasal fractures resulting in actual harm to Resident 53. Pa. Code 210.18(b)(1) Management
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated K - Pattern L - Widespread
Actual Harm
G - Isolated H - Pattern I - Widespread
Potential for Harm
D - Isolated E - Pattern F - Widespread
No Harm (Minor)
A - Isolated B - Pattern C - Widespread

Questions to Ask on Your Visit

  • "Can I speak with families of current residents?"
  • "What's your RN coverage like on weekends and overnight?"

Our Honest Assessment

Strengths
  • • Grade B+ (88/100). Above average facility, better than most options in Pennsylvania.
  • • No fines on record. Clean compliance history, better than most Pennsylvania facilities.
  • • 26% annual turnover. Excellent stability, 22 points below Pennsylvania's 48% average. Staff who stay learn residents' needs.
Concerns
  • • 2 deficiencies on record, including 1 serious (caused harm) violation. Ask about corrective actions taken.
Bottom line: Generally positive indicators. Standard due diligence and a personal visit recommended.

About This Facility

What is Glen At Willow Valley's CMS Rating?

CMS assigns GLEN AT WILLOW VALLEY an overall rating of 5 out of 5 stars, which is considered much above average nationally. Within Pennsylvania, this rating places the facility higher than 99% of the state's 100 nursing homes. This rating reflects solid performance across the metrics CMS uses to evaluate nursing home quality.

How is Glen At Willow Valley Staffed?

CMS rates GLEN AT WILLOW VALLEY's staffing level at 5 out of 5 stars, which is much above average compared to other nursing homes. Staff turnover is 26%, compared to the Pennsylvania average of 46%. This relatively stable workforce can support continuity of care.

What Have Inspectors Found at Glen At Willow Valley?

State health inspectors documented 2 deficiencies at GLEN AT WILLOW VALLEY during 2021 to 2023. These included: 1 that caused actual resident harm and 1 with potential for harm. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.

Who Owns and Operates Glen At Willow Valley?

GLEN AT WILLOW VALLEY is owned by a non-profit organization. Non-profit facilities reinvest revenue into operations rather than distributing to shareholders. The facility operates independently rather than as part of a larger chain. With 262 certified beds and approximately 227 residents (about 87% occupancy), it is a large facility located in LANCASTER, Pennsylvania.

How Does Glen At Willow Valley Compare to Other Pennsylvania Nursing Homes?

Compared to the 100 nursing homes in Pennsylvania, GLEN AT WILLOW VALLEY's overall rating (5 stars) is above the state average of 3.0, staff turnover (26%) is significantly lower than the state average of 46%, and health inspection rating (5 stars) is much above the national benchmark.

What Should Families Ask When Visiting Glen At Willow Valley?

Based on this facility's data, families visiting should ask: "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?"

Is Glen At Willow Valley Safe?

Based on CMS inspection data, GLEN AT WILLOW VALLEY has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 5-star overall rating and ranks #1 of 100 nursing homes in Pennsylvania. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.

Do Nurses at Glen At Willow Valley Stick Around?

Staff at GLEN AT WILLOW VALLEY tend to stick around. With a turnover rate of 26%, the facility is 20 percentage points below the Pennsylvania average of 46%. Low turnover is a positive sign. It means caregivers have time to learn each resident's needs, medications, and personal preferences. Consistent staff also notice subtle changes in a resident's condition more quickly. Registered Nurse turnover is also low at 17%, meaning experienced RNs are available to handle complex medical needs.

Was Glen At Willow Valley Ever Fined?

GLEN AT WILLOW VALLEY has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.

Is Glen At Willow Valley on Any Federal Watch List?

GLEN AT WILLOW VALLEY is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.

GLEN AT WILLOW VALLEY

675 WILLOW VALLEY SQUARE, LANCASTER, PA 17602 | (717) 464-6161

B+
Trust Grade (88/100)
5.0
CMS Rating
2
Deficiencies

Strengths

  • 5-star staffing
  • 5-star quality
  • Low turnover (26%)

Concerns

  • Review findings

Ask about: Rn Coverage

nursinghomedata.org | Data: CMS November 2025