Inspection Reports for
Cross Keys Village – the Brethren Home Community
2990 CARLISLE PIKE,, NEW OXFORD, PA, 17350
Back to Facility Profile20 Reports
Notice — Aug 20, 2026
Date: Aug 20, 2026
Visit Reason
The document serves as a response to a request for a waiver of Pennsylvania Code § 2600.190(b) to allow unlicensed direct care staff to administer subcutaneous injections of GLP-1 agonist medications.
Findings
The waiver is granted with conditions including required training, annual education, monitoring processes, written policies, and availability of licensed clinical contact for medication administration.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Theresa Hartman | Bureau Director, Human Services Licensing | Signed the waiver approval letter. |
Inspection Report — Jun 23, 2026
Renewal
Date: Jun 23, 2026
Visit Reason
The inspection was conducted as a renewal and incident review to verify compliance and the implementation of a submitted plan of correction.
Findings
The facility was found to have multiple deficiencies related to resident privacy, evacuation times, medication administration errors, refusal of medication documentation, following prescriber's orders, and legibility of record entries. Immediate corrective actions were taken and plans of correction were accepted with ongoing monitoring and education planned.
Citations (6)
42s Privacy: A staff member took and posted a picture of a resident without permission, violating resident privacy rights. The staff member was terminated and corrective education and audits were planned.
132d Evacuation: The fire drill evacuation time exceeded the maximum safe time of 15 minutes, taking 19 minutes and 50 seconds. Additional drills and education were implemented to ensure compliance.
186b Medication Used by Resident: Resident #7 was administered medications prescribed for Resident #8, constituting a medication error. Immediate assessment and education were provided.
187c Refusal of Medication: Resident #2 refused medication for three consecutive days, but the prescribing physician was not notified as required. Notification and education were completed.
187d Follow Prescriber's Orders: Multiple medication administration errors occurred, including incorrect dosages and missed medications. All errors were assessed, reported, and staff were reeducated.
251b Record Entries Legible: Correction fluid was used on a resident's medical evaluation record, violating documentation standards. Education and audits were planned to prevent recurrence.
Report Facts
Residents Served: 92
Staff Count: 92
Waking Staff: 69
Evacuation Time: 19.83
Inspection Report — Oct 22, 2024
Renewal
Date: Oct 22, 2024
Visit Reason
The inspection was conducted as a renewal visit to review compliance with licensing requirements at the facility.
Findings
The inspection identified multiple deficiencies including unlocked confidential resident records, unsecured poisonous materials accessible to residents, uncovered trash receptacles, outdated emergency management procedures, discontinued medications present in the medication cart, inaccurate medication administration records, and failure to follow prescriber's orders. Plans of correction were accepted and implemented by December 17, 2024.
Citations (7)
Laptop on medication cart was unlocked and unattended with resident medication information accessible.
Various poisonous materials were unlocked, unattended, and accessible to residents unable to safely use or avoid them.
Full, uncovered, unattended trash can was found on the 2nd floor.
Emergency preparedness plan was not reviewed and revised annually as required.
Discontinued medication was found in the medication cart.
Blood glucose readings documented on the medication administration record did not match glucometer readings.
Medications were administered despite prescriber orders to hold based on systolic blood pressure or heart rate readings.
Report Facts
Residents Served: 91
Staffing: 91
Waking Staff: 68
Inspection Report — Aug 23, 2023
Renewal
Date: Aug 23, 2023
Visit Reason
The inspection was conducted as a renewal review of the facility's compliance with licensing requirements on 08/23/2023 and 08/24/2023.
Findings
The submitted plan of correction was fully implemented and compliance was maintained. Two deficiencies were noted: delays in issuing resident refund checks within the required 30-day period, and exceeding the maximum safe evacuation time during fire drills.
Citations (2)
Resident refund checks were not issued within the required 30-day period following discharge.
The home exceeded the maximum safe evacuation time of 15 minutes during fire drills conducted on 3/10/23 and 9/19/22.
Report Facts
Residents Served: 90
Refund Delay Days: 30
Evacuation Time Limit: 15
Evacuation Time: 16.17
Evacuation Time: 27.9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Billing and Reimbursement | Notified accounting team of deficient refund practice and responsible for auditing refunds | |
| Billing Specialist | Responsible for processing Resident Census History Report and refunds | |
| Administrator | Reviewed regulations, implemented fire drill record use, educated staff and residents on fire drill procedures | |
| Resident Services Manager | Educated on fire drill regulations by Administrator | |
| PC Admissions Counselor | Educated on Fire Drill Acknowledgement form and responsible for completing it with new admissions |
Inspection Report — Jun 29, 2022
Renewal
Date: Jun 29, 2022
Visit Reason
The inspection was an unannounced full renewal inspection conducted on 06/29/2022 and 06/30/2022 to review compliance with licensing regulations.
Findings
Two deficiencies were identified: unsecured poisonous materials accessible to residents, and an outdated fire drill conducted by a fire safety expert. Plans of correction were accepted and implemented with scheduled audits and fire drills.
Citations (2)
Unsecured poisonous materials (4 one gallon bottles of laundry detergent) were found accessible to residents in the 2900 hall laundry area, violating safety requirements.
The last fire drill observed by a fire safety expert was conducted on 10/15/2019, failing to meet the annual requirement.
Report Facts
Residents Served: 87
Current Hospice Residents: 5
Total Daily Staff: 92
Waking Staff: 69
Notice — Sep 7, 2021
Date: Sep 7, 2021
Visit Reason
The document serves as a renewal notification and license issuance for the Personal Care Home facility, Cross Keys Village - The Brethren Home Community, and advises that an onsite inspection will be conducted within the next twelve months as required by regulation.
Findings
No inspection findings are reported in this document; it confirms the issuance of a regular license following the renewal application and outlines the requirement for a future annual inspection.
Report Facts
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary | Signed the renewal notification letter |
Notice — Sep 28, 2020
Date: Sep 28, 2020
Visit Reason
The document serves as a license renewal approval and notification that an annual inspection will be conducted within the next twelve months as required by regulation.
Findings
No inspection findings are reported in this document. It confirms receipt of the renewal application and issuance of a regular license.
Report Facts
Inspection Report — Jan 29, 2020
Complaint Investigation
Date: Jan 29, 2020
Visit Reason
The inspection was conducted as a complaint investigation related to an incident involving Resident 1's aggressive behavior and supervision issues.
Complaint Details
The complaint investigation was substantiated based on findings that Resident 1 was involved in seven incidents of aggressive behavior between 1/24/2020 and 1/28/2020 and the facility did not provide adequate supervision to prevent these incidents.
Findings
The facility failed to provide sufficient supervision to Resident 1, who exhibited aggressive behavior toward other residents in multiple incidents between 1/24/2020 and 1/28/2020. The home did not adequately intervene to prevent ongoing incidents.
Citations (1)
Resident 1's assessment and support plan state that direct care staff must intervene and provide 1:1 supervision until agitation diminishes. The home failed to provide sufficient supervision to Resident 1 to prevent ongoing aggressive incidents with other residents.
Report Facts
Residents Served: 90
Incidents of aggressive behavior: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Justin M. Lee | Legal Entity Representative | Signed the Plan of Correction |
Inspection Report — Sep 3, 2019
Annual Inspection
Date: Sep 3, 2019
Visit Reason
The Department’s Bureau of Human Services Licensing conducted an annual inspection of the facility on September 3 and 4, 2019 to assess compliance with 55 Pa.Code Ch. 2600 relating to Personal Care Homes.
Findings
Violations of 55 Pa.Code Ch. 2600 were found during the inspection and are detailed in the enclosed violation report. The facility must correct all citations by the specified dates and maintain continued compliance.
Report Facts
Residents Served: 90
Residents Served in Secured Dementia Care Unit: 14
Current Hospice Residents: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Justin M. Lee | PLHA | Signed Plan of Correction documents |
| Hope O'Pake | Department Representative on-site during inspection | |
| Laura Heemer | Department Representative on-site during inspection |
Notice — Jul 30, 2019
Date: Jul 30, 2019
Visit Reason
The document serves as a renewal notification and license issuance for Cross Keys Village - The Brethren Home Community to operate a Personal Care Home. It informs the facility of the requirement for an annual onsite inspection within the next twelve months.
Findings
No inspection findings are reported in this document. It is a license renewal notice and certificate of compliance.
Report Facts
Inspection Report — Sep 18, 2018
Renewal
Date: Sep 18, 2018
Visit Reason
The inspection was a renewal licensing inspection conducted on September 18 and 19, 2018, to assess compliance with 55 Pa.Code Chapter 2600 relating to Personal Care Homes.
Findings
Multiple violations were found related to resident privacy, staff training, fire safety, physical environment security, evacuation drills, and pre-admission screening for the secured dementia care unit. Plans of correction were submitted with varying implementation statuses.
Citations (7)
55 Pa.Code §2600.42(s) - Numerous cameras recorded video footage including resident bedrooms without proper privacy safeguards. The footage was retained for two weeks.
55 Pa.Code §2600.65(f) - Annual training for direct care staff in 2017 did not include required topics such as medication self-administration and care for residents with mental illness.
55 Pa.Code §2600.65(g) - No fire safety training was provided to staff by a fire safety expert during 2017.
55 Pa.Code §2600.105(g)(1) - Accumulation of pink lint was found in the lint trap of a laundry dryer not in use on the 3rd floor.
55 Pa.Code §2600.121(a) - The secured dementia care unit door required staff assistance with swipe cards for entry and exit; no visitor swipe cards were available.
55 Pa.Code §2600.132(d) - Evacuation drills in 2017 exceeded the maximum safe evacuation time of 13 minutes, with times up to 26 minutes and 41 seconds.
55 Pa.Code §2600.231(c) - Resident 1's preadmission screening form for the secured dementia care unit was not completed in collaboration with a physician or geriatric assessment team.
Report Facts
Number of Residents Served: 87
Number of Deficiencies: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Eurith Long-Emerson | PCHA | Administrator named in multiple findings and plan of correction signatures. |
| Michael Showers | Department representative conducting the inspection. | |
| Jason McCloskey | Department representative conducting the inspection. |
Inspection Report — Nov 3, 2017
Original Licensing
Date: Nov 3, 2017
Visit Reason
The inspection was a licensing inspection conducted by the Department of Human Services on November 3, 2017, triggered by an incident.
Findings
Multiple violations of 55 Pa.Code Chapter 2600 were found related to medication errors, improper medication storage, failure to document medication administration, and failure to follow prescriber directions. Plans of correction were submitted with target dates mostly set for December 2017.
Citations (4)
Regulation 2600.16(c): The home failed to report a medication error incident to the Department within 24 hours as required. The incident occurred on 10/26/2017 and was reported on 11/2/2017.
Regulation 2600.183(d): A discontinued artificial tears medication prescribed for Resident 1 was found in the medication cart on 10/26/2017.
Regulation 2600.187(b)(13) and (a)(14): Staff failed to document administration of prescribed Ciprodex ear drops for Resident 3 on 10/27 and 10/28/2017 in the Electronic Medication Administration Record.
Regulation 2600.187(d): Resident 2 was administered a discontinued artificial tears medication instead of the prescribed Olopatadine on 10/26/2017.
Report Facts
Number of Residents Served: 84
Number of Current Hospice Residents: 5
Number of Hospice Residents in past year: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Pam Hensal | Administrator | Named as Administrator and Legal Entity Representative signing plans of correction. |
Inspection Report — Sep 26, 2017
Renewal
Date: Sep 26, 2017
Visit Reason
The inspection was conducted as a renewal licensing inspection of the Adult Residential Licensing for Cross Keys Village The Brethren Home Community on September 26 and 27, 2017.
Findings
Multiple violations of 55 Pa.Code Chapter 2600 related to personal care homes were found, including failure to notify the local fire department of emergency evacuation details, incomplete fire drill records, improper medication storage, documentation errors in glucometer readings, and incomplete support plans for residents.
Citations (5)
55 Pa.Code 2600.124 - The facility did not have documentation that the local fire department was notified in writing of the address of the home, location of bedrooms, and assistance needed to evacuate in an emergency.
55 Pa.Code 2600.132(c) - The written fire drill record for the drill held on 11/26/15 did not include evacuation time, number of residents evacuated, or number of staff participating.
55 Pa.Code 2600.181(d) - Resident #1 stored medications on top of the dresser instead of locked in a safe and secure location to protect against contamination, spillage, and theft.
55 Pa.Code 2600.185(a) - Documentation errors were found comparing glucometer readings to Medication Administration Records for Residents #2 and #3, including multiple 'No Entry' records.
55 Pa.Code 2600.227(a) - The support plan for Resident #2 was developed after admission and did not document admission dates properly on the Department's support plan form.
Report Facts
Number of Residents Served: 89
Number of Residents Served in Secured Dementia Care Unit: 15
Number of Hospice Residents in past year: 3
Number of Residents who are 60 Years of Age or Older: 89
Number of Residents who Have Mental Illness: 4
Number of Residents who Have an Intellectual Disability: 1
Number of Residents who Have a Mobility Need: 30
Number of Residents who Have a Physical Disability: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Pamela Hensal | Administrator | Named as facility administrator and legal entity representative signing plans of correction |
| Israel Springs | Department representative on-site during inspection | |
| Kellie Cargile | Department representative on-site during inspection |
Inspection Report — Jul 31, 2017
Renewal
Date: Jul 31, 2017
Visit Reason
The document is a renewal application and license issuance for Cross Keys Village - The Brethren Home Community Personal Care Home. The Department of Human Services will conduct an onsite inspection within the next twelve months as required by regulation.
Findings
No inspection findings are reported in this document. It confirms the renewal application has been received and a regular license is being issued.
Report Facts
Inspection Report — May 22, 2017
Complaint Investigation
Date: May 22, 2017
Visit Reason
The inspection was conducted as a complaint investigation related to violations of 55 Pa.Code Chapter 2600 for Personal Care Homes at Cross Keys Village - The Brethren Home Community.
Complaint Details
The inspection was complaint-driven. The complaint alleged neglect of Resident #1, which was substantiated by findings of inadequate supervision, assessment, and support planning leading to falls and injury.
Findings
The facility was found to have violations related to neglect of a resident resulting in serious injury, failure to complete reassessments after significant changes in resident condition, and failure to update the resident support plan to include therapies. The facility submitted plans of correction addressing these issues.
Citations (5)
55 Pa.Code §2600.42(b): The facility neglected Resident #1 by failing to adequately supervise and assess the resident's increased risk of falls and pain, resulting in serious injury and hospitalization.
55 Pa.Code §2600.225(c): The facility failed to complete a reassessment of Resident #1 after significant changes in the resident's ability following multiple falls.
55 Pa.Code §2600.227(d): The facility failed to update Resident #1's support plan to include occupational and physical therapies received to address increased fall risk and mobility issues.
55 Pa.Code §2600.231(c): The facility did not complete a preadmission screening form within 72 hours prior to admission of Resident #1 to the Secured Dementia Care Unit (SDCU).
55 Pa.Code §2600.234(a): The facility did not develop, implement, and document a support plan within 72 hours of Resident #1's admission to the SDCU.
Report Facts
Number of Residents Served: 90
Number of Resident Falls: 7
Number of Residents Age 60 or Older: 90
Number of Residents with Mental Illness: 6
Number of Residents with Mobility Need: 21
Number of Residents Served in Secured Dementia Care Unit: 16
Number of Current Hospice Residents: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Pamela Hensal | Administrator | Named as facility administrator and legal entity representative signing plans of correction |
| Brett Swanger | Human Services Licensing Supervisor | Signed the initial licensing inspection letter |
| Israel Springs | Department representative on-site during inspection | |
| Michael Palermo | Department representative on-site during inspection |
Inspection Report — Oct 18, 2016
Annual Inspection
Date: Oct 18, 2016
Visit Reason
The inspection was conducted as part of the Department of Human Services' annual licensing inspections on October 18, 19, and November 8, 2016, including a renewal and incident investigation.
Findings
The inspection found multiple violations of 55 Pa.Code Chapter 2600 related to personal care homes, including failure to report suspected abuse, incomplete investigations, improper storage of poisonous materials, prohibited portable space heaters, incomplete pre-admission screening forms, and missing directions for electronic locking devices. Plans of correction were submitted and partially or fully implemented for all violations.
Citations (7)
2600.15(a) - The home failed to immediately report suspected abuse of Resident #3 as required by the Older Adults Protective Services Act.
2600.16(b) - The home did not complete a thorough investigation into alleged verbal and physical abuse of Resident #3 and failed to interview key staff and residents.
2600.82(c) - Poisonous materials including bleach and detergent were found unlocked and accessible to residents, posing a safety risk.
2600.127(a) - Portable space heaters were prohibited but three heat producing fireplaces remained hardwired and permanently installed.
2600.132(e) - A sleeping hours fire drill was not conducted within six months as required; the previous drill was on 2/17/2016.
2600.224(a) - Pre-admission screening forms for Residents 1 and 2 were on a format different from the Department's approved form.
2600.233(c) - Directions for operation of electronic card locking devices were not posted at the door labeled number 2965 in the secure dementia care unit.
Report Facts
Number of Residents Served: 80
Number of Residents in Secured Dementia Unit: 10
Number of Current Hospice Residents: 1
Number of Hospice Residents in Past Year: 2
Total Daily Staff: 91
Waking Staff: 68
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Eurith Long-Emerson | PCHA | Named as Administrator and signer of violation reports and plans of correction |
| Michael Showers | Department representative conducting inspections | |
| Cybil Bomberger | Department representative conducting inspections |
Notice — Jul 27, 2016
Date: Jul 27, 2016
Visit Reason
This document serves as a renewal notification for the Personal Care Home license of Cross Keys Village - The Brethren Home Community. It informs the facility of the Department's requirement to conduct an annual onsite inspection within the next twelve months.
Findings
No inspection findings are reported in this document. It is a license renewal letter confirming issuance of a regular license based on the renewal application.
Report Facts
Notice — May 5, 2016
Date: May 5, 2016
Visit Reason
The document is a response to a request for a waiver of Pennsylvania Code qualifications for direct care staff persons at The Brethren Home Community.
Findings
The Department of Human Services granted the waiver after determining that the homeschool program meets high school diploma educational requirements.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tara Pride | Director of Regulatory Implementation | Signed the waiver approval letter. |
Notice — Apr 22, 2016
Date: Apr 22, 2016
Visit Reason
The document is a response to a waiver request for qualifications of direct care staff persons under 55 Pa.Code § 2600.54(a) for a personal care home.
Findings
The waiver request was returned for additional information to ensure qualified staff provide services according to licensing regulations. The letter requests supporting documentation confirming homeschooling program completion and high school requirements.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tara Pride | Director of Regulatory Implementation | Signed the letter regarding waiver request |
Inspection Report — July 27, 2018
Renewal
Date: July 27, 2018
Visit Reason
The document is a renewal application and license issuance for Cross Keys Village - The Brethren Home Community to operate a Personal Care Home. It notifies the facility of the requirement for an annual onsite inspection within the next twelve months.
Findings
No inspection findings are reported in this document. It is a license renewal notice with no deficiencies or compliance issues mentioned.
Report Facts
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