Skip to main content

Public Record

Ephrata Manor

Nursing HomeEphrata, PACMS 395857
20 citations on record

From CMS

Facility profile

CMS overall rating
4 / 5

*CMS Five-Star

Certified beds
120

*CMS

Avg. residents per day
107.5

*CMS

Inspection record

On record from CMS

Citations on record
20

*CMS

Inspections on file
7

*CMS

Last inspection
2026-02-02

*CMS

Citations

20 citations on record

Each deficiency cited on a CMS health inspection of this facility, sourced from the federal record. Open a report for the raw CMS Scope and Severity grade on each finding.

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

  • 0745Generalpotential for harm

    Provide medically-related social services to help each resident achieve the highest possible quality of life.

  • 0325Generalpotential for harm

    Have properly installed hallway dispensers for alcohol-based hand rub.

  • 0351Generalpotential for harm

    Install an approved automatic sprinkler system.

  • 0363Generalpotential for harm

    Install corridor and hallway doors that block smoke.

  • 0758Generalpotential for harm

    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.

  • 0686Seriousactual harm

    Provide appropriate pressure ulcer care and prevent new ulcers from developing.

  • 0730Generalpotential for harm

    Observe each nurse aide's job performance and give regular training.

  • 0758Generalpotential for harm

    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.

  • 0947Generalpotential for harm

    Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.

  • 0321Generalpotential for harm

    Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

  • 0353Generalno actual harm

    Inspect, test, and maintain automatic sprinkler systems.

  • 0355Generalno actual harm

    Properly select, install, inspect, or maintain portable fire extinguishes.

  • 0580Generalpotential for harm

    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

  • 0638Generalpotential for harm

    Assure that each resident’s assessment is updated at least once every 3 months.

  • 0656Generalpotential for harm

    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

  • 0756Generalpotential for harm

    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

  • 0161Generalpotential for harm

    Use approved construction type or materials.

  • 0511Generalpotential for harm

    Have properly installed electrical wiring and gas equipment.

  • 0920Generalpotential for harm

    Ensure proper usage of power strips and extension cords.

  • 0758Generalpotential for harm

    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.

Inspection history

Every health inspection on record

Each CMS health inspection of this facility, and the deficiencies the surveyors cited. Where the verbatim Form 2567 statement of deficiencies is on file, it links to the full report.

  • Inspection1 deficiency

    F 0745 Provide medically-related social services to help each resident achieve the highest possible quality of life. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records, hospital…

    Read full statement of deficiencies
  • Inspection4 deficiencies
    View inspection report
  • Inspection4 deficiencies
    View inspection report
  • Inspection10 deficiencies
    View inspection report
  • Inspection10 deficiencies

    F 0580 Level of Harm - Minimal harm or potential for actual harm Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Based upon clinical record review and interview it was determined the facility failed to…

    Read full statement of deficiencies
  • Inspection5 deficiencies

    F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Based upon clinical record…

    Read full statement of deficiencies
  • Inspection5 deficiencies
    View inspection report

FAQ

Questions and answers

What is Ephrata Manor?
Ephrata Manor is a Medicare- and Medicaid-certified nursing home in Ephrata, PA, tracked by the Centers for Medicare & Medicaid Services (CMS). Its CMS Certification Number (CCN) is 395857.
What is the CMS rating for Ephrata Manor?
Ephrata Manor has a CMS overall rating of 4 out of 5 stars. CMS rates nursing homes on health inspections, staffing, and quality measures.
How many beds does Ephrata Manor have?
Ephrata Manor is certified for 120 beds. It serves an average of 107.5 residents per day.
How many citations does Ephrata Manor have?
Ephrata Manor has 20 citations on record from CMS health inspections, each tied to a federal deficiency tag.
When was Ephrata Manor last inspected?
Ephrata Manor was last inspected on February 2, 2026. CMS surveys nursing homes about once a year and after complaints.
What can I do if I have concerns about care at this facility?
Start by raising the concern with the facility administrator or director of nursing. Every state also runs a free long-term care ombudsman program that advocates for residents and families; the federal Eldercare Locator at eldercare.acl.gov can connect you with yours. Complaints about quality of care can also be filed with your state survey agency.

*Sourced from the Centers for Medicare & Medicaid Services (CMS). See the official record on CMS Care Compare. If you believe any information is inaccurate, report it here.

/nursing-home/395857-ephrata-manor