William Penn Nursing And Rehab
Lewistown, Mifflin County, Pennsylvania · CCN 395335 · For-profit (LLC) · part of Valley West Health (12 facilities, chain average 3.3 stars)
CMS rates William Penn Nursing And Rehab 4 of 5 overall as of August 2026. 121 certified beds, 117 residents a day on average. 26 citations on record from the current inspection cycles; no fines on record.
CMS’s ratings
The Five-Star Quality Rating System, as CMS publishes it. Where CMS gives no rating, the reason CMS gives is printed instead.
| Overall | ★★★★☆ 4 of 5 |
|---|---|
| Health inspections | ★★★☆☆ 3 of 5 |
| Staffing | ★★★☆☆ 3 of 5 |
| Quality measures | ★★★★★ 5 of 5 |
| Quality: long-stay / short-stay | 4 / 5 of 5 |
Staffing
| Total nurse staffing | 3.39259 hours per resident per day |
|---|---|
| Registered nurses | 0.53647 hours per resident per day |
| Weekend total | 3.12562 hours per resident per day |
| Nursing staff turnover | 35.6% (registered nurses 16.7%) |
| Administrators who left | 0 |
Citations from health inspections
Each is a finding by a state surveyor on the date shown, in CMS’s words. The severity is CMS’s scope-and-severity grid, spelled out: harm on the left, how widespread on the right.
| Survey | Finding | Severity | Status |
|---|---|---|---|
| 2026-04-17 | Ensure medication error rates are not 5 percent or greater. Pharmacy Service Deficiencies · tag F0759 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2026-06-03 |
| 2026-04-17 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · tag F0812 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2026-06-03 |
| 2026-04-17 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · tag F0880 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2026-06-03 |
| 2026-04-17 | Ensure each resident receives an accurate assessment. Resident Assessment and Care Planning Deficiencies · tag F0641 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2026-06-03 |
| 2026-04-17 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Resident Assessment and Care Planning Deficiencies · tag F0656 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2026-06-03 |
| 2026-04-17 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · tag F0684 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2026-06-03 |
| 2026-04-17 | Provide safe, appropriate dialysis care/services for a resident who requires such services. Quality of Life and Care Deficiencies · tag F0698 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2026-06-03 |
| 2026-04-17 | Develop and implement policies and procedures for flu and pneumonia vaccinations. Infection Control Deficiencies · tag F0883 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2026-06-03 |
| 2025-05-09 | Ensure each resident receives an accurate assessment. Resident Assessment and Care Planning Deficiencies · tag F0641 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2025-06-10 |
| 2025-05-09 | Provide or obtain dental services for each resident. Quality of Life and Care Deficiencies · tag F0791 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2025-06-10 |
| 2025-05-09 | Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. Infection Control Deficiencies · tag F0887 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2025-06-10 |
| 2025-05-09 | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Resident Rights Deficiencies · tag F0550 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-06-10 |
| 2025-05-09 complaint survey |
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Nursing and Physician Services Deficiencies · tag F0725 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-06-10 |
| 2025-05-09 complaint survey |
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Pharmacy Service Deficiencies · tag F0761 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-06-10 |
| 2025-05-09 | Post nurse staffing information every day. Nursing and Physician Services Deficiencies · tag F0732 |
C No actual harm, with potential for minimal harm; widespread | Deficient, Provider has date of correction 2025-06-10 |
| 2024-06-25 | Ensure each resident receives an accurate assessment. Resident Assessment and Care Planning Deficiencies · tag F0641 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-07-24 |
| 2024-06-25 | Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Resident Rights Deficiencies · tag F0584 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-07-24 |
| 2024-06-25 | Assess the resident when there is a significant change in condition Resident Assessment and Care Planning Deficiencies · tag F0637 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-07-24 |
| 2024-06-25 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Resident Assessment and Care Planning Deficiencies · tag F0656 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-07-24 |
| 2024-06-25 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · tag F0684 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-07-24 |
| 2024-06-25 | Assist a resident in gaining access to vision and hearing services. Quality of Life and Care Deficiencies · tag F0685 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-07-24 |
| 2024-06-25 | Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. Quality of Life and Care Deficiencies · tag F0688 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-07-24 |
| 2024-06-25 | Provide safe and appropriate respiratory care for a resident when needed. Quality of Life and Care Deficiencies · tag F0695 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-07-24 |
| 2024-06-25 | 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. Pharmacy Service Deficiencies · tag F0758 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-07-24 |
| 2024-06-25 | Ensure medication error rates are not 5 percent or greater. Pharmacy Service Deficiencies · tag F0759 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-07-24 |
| 2024-06-25 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · tag F0880 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-07-24 |
Fines and payment denials
No fines or payment denials on record since 2023.
Who owns and runs it
Every owner, officer and manager CMS lists, as filed. These are the names in CMS’s ownership record; anyone named in the ownership record can ask about it on the about page.
| Name | Role | Share | Since |
|---|---|---|---|
| Western Pa Opco Holdings I LLC Organization | 5% or greater direct ownership interest | — | 2024-10-29 |
| Beverly Enterprises - Pennsylvania, Inc. Organization | adp of the snf | — | 2024-12-20 |
| Beverly Enterprises LLC Organization | adp of the snf | — | 2024-12-20 |
| Beverly Health And Rehabilitiation Services, Inc. Organization | adp of the snf | — | 2024-12-20 |
| Drumm Intermediary Sub Co LLC Organization | adp of the snf | — | 2024-12-20 |
| Drumm Merger Co Organization | adp of the snf | — | 2024-12-20 |
| Drumm Merger Co Sub LLC Organization | adp of the snf | — | 2024-12-20 |
| Fillmore Strategic Investors LLC Organization | adp of the snf | — | 2024-12-20 |
| Geary Property Holdings LLC Organization | adp of the snf | — | 2024-12-20 |
| Gph Lewistown Lp Organization | adp of the snf | — | 2024-12-20 |
| Pearl Senior Care, LLC. Organization | adp of the snf | — | 2024-12-20 |
| Surety Compliance Organization | adp of the snf | — | 2024-10-29 |
| Valley West Health LLC Organization | adp of the snf | — | 2024-12-20 |
| Washington State Investment Board Organization | adp of the snf | — | 2024-12-20 |
| Western Pa Opco Holdings I LLC Organization | adp of the snf | — | 2024-12-19 |
| Valley West Health LLC Organization | operational/managerial control | — | 2024-11-15 |
| Andrews, Heather Individual | adp of the snf | — | 2024-10-29 |
| Finn, Nicholas Individual | adp of the snf | — | 2024-10-29 |
| Franco, Aharon Individual | adp of the snf | — | 2024-10-29 |
| Karity, Sarah Individual | adp of the snf | — | 2024-10-29 |
| Linam, Kim Individual | adp of the snf | — | 2024-10-29 |
| Miller, Jean Individual | adp of the snf | — | 2024-11-15 |
| Rami, Isaac Individual | adp of the snf | — | 2024-10-29 |
| Rasmussen-Jones, Holly Individual | adp of the snf | — | 2024-10-29 |
| Roscoe, Brandon Individual | adp of the snf | — | 2024-12-20 |
| Traxler, Tana Individual | adp of the snf | — | 2024-12-20 |
| Willow, Teresa Individual | adp of the snf | — | 2024-12-20 |
| Franco, Aharon Individual | operational/managerial control | — | 2024-10-29 |
| Rami, Isaac Individual | operational/managerial control | — | 2024-10-29 |
| Karity, Sarah Individual | trustee of the snf | — | 2024-10-29 |
What changed
Nothing has changed in this record since it was first loaded. The next CMS refresh is the next chance.
Tell me when this record changes
One email when the monthly CMS refresh brings a new citation, a fine or payment denial, a rating change, a flag, or a change of ownership for William Penn Nursing And Rehab.
Source: Centers for Medicare & Medicaid Services, Provider Data Catalog (public domain), files dated 2026-08-01. Ratings are CMS’s; citations are state surveyors’ findings; nothing here is estimated or a recommendation. Every nursing home in Mifflin County.