Inspection Reports for Brethren Village – Terrace Crossing
3001 LITITZ PIKE,, LANCASTER, PA, 17543
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
5.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
13% worse than Pennsylvania average
Pennsylvania average: 4.7 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
59% occupied
Based on a November 2024 inspection.
Census over time
Inspection Report
Follow-Up
Census: 58
Capacity: 98
Deficiencies: 3
Date: Nov 14, 2024
Visit Reason
The inspection was conducted as a full, unannounced renewal inspection with an incident review component.
Findings
The facility was found to have fully implemented the submitted plan of correction. Deficiencies included failure to report an incident within 24 hours, incomplete annual medical evaluations, and keeping discontinued medications in the medication cart.
Deficiencies (3)
Failure to report an incident to the Department within 24 hours as required.
Resident's most recent medical evaluation did not include health status or cognitive functioning.
Discontinued medication was still present in the home's medication cart.
Report Facts
License Capacity: 98
Residents Served: 58
Secured Dementia Care Unit Capacity: 26
Secured Dementia Care Unit Residents Served: 22
Resident Diagnosed with Mental Illness: 4
Resident Have Mobility Need: 22
Residents Age 60 or Older: 58
Total Daily Staff: 80
Waking Staff: 60
Inspection Report
Follow-Up
Census: 62
Capacity: 98
Deficiencies: 2
Date: Jan 4, 2024
Visit Reason
The inspection was a partial, unannounced follow-up visit conducted on 01/04/2024 and 01/05/2024 to verify the implementation of a previously submitted plan of correction related to an incident.
Findings
The submitted plan of correction was determined to be fully implemented, with continued compliance required. Two deficiencies were noted: failure to immediately report suspected resident abuse to the Pennsylvania Department of Aging and local police, and failure of a staff person to complete required training on emergency medical plan and reporting of incidents.
Deficiencies (2)
Failure to immediately report suspected resident abuse to the Pennsylvania Department of Aging and local police.
Staff person did not complete training in the home's emergency medical plan or reporting of reportable incidents and conditions.
Report Facts
License Capacity: 98
Residents Served: 62
Secured Dementia Care Unit Capacity: 25
Secured Dementia Care Unit Residents Served: 24
Residents Receiving Supplemental Security Income: 90
Residents Age 60 or Older: 62
Residents Diagnosed with Mental Illness: 1
Residents with Mobility Need: 28
Total Daily Staff: 90
Waking Staff: 68
Inspection Report
Renewal
Census: 62
Capacity: 98
Deficiencies: 10
Date: Sep 13, 2023
Visit Reason
The inspection was conducted as a renewal visit to review compliance with licensing requirements at Brethren Village - Terrace Crossing.
Findings
The inspection identified multiple deficiencies related to resident personal equipment, poisonous material storage, bathroom ventilation, medication storage and labeling, and resident records confidentiality. Plans of correction were accepted and implemented with ongoing monitoring and education.
Deficiencies (10)
Enabler bars in rooms 214 and 202 were not secured to the bed, posing an entrapment risk.
Poisonous materials were stored next to food items in the 4th floor pantry.
An unattended, unlocked housekeeping cart containing poisonous materials was observed in the Secure Dementia Care Unit hallway.
The exhaust fan in room 214's bathroom was inoperable and the bathroom lacked an operable window.
Unlocked pill box containing 14 pills was found unattended in Resident 1's bedroom.
Unlocked medications including ointments and drops were found unattended in Resident 2's bedroom.
Expired medications without current orders were found in Resident 2's room.
Pharmacy label on Resident 2's Humalog pen lacked date opened and staff initials.
OTC medications belonging to Resident 2 were not labeled with the resident's name.
PCA day shift checklist containing resident names and care needs was left unlocked and unattended on an open laptop in a common area.
Report Facts
License Capacity: 98
Residents Served: 62
Secured Dementia Care Unit Capacity: 25
Secured Dementia Care Unit Residents Served: 22
Current Hospice Residents: 1
Number of Pills: 14
Inspection Report
Renewal
Census: 60
Capacity: 98
Deficiencies: 6
Date: Jul 12, 2022
Visit Reason
The inspection was conducted as a renewal inspection of the facility's license to ensure compliance with regulatory requirements.
Findings
The inspection identified deficiencies related to medication management, including discontinued medications still present, improper labeling of insulin pens, lack of medications in stock, and missed medication administrations. The facility submitted a plan of correction which was fully implemented and accepted.
Deficiencies (6)
Resident 2 was prescribed a medication that was discontinued on 7/8/22; however, it was still in the medication cart on 7/13/22.
Resident 2’s insulin aspart 100 Unit/ML pen, labeled 'discard 14 days after first use,' was not dated upon opening.
On 07/13/2022, Resident 1 had prescriptions on the medication administration record for 2 pro re nata medications; neither medication was in stock or on hand in the home.
Resident 2's glucometer reading for 7/13/22 at 7:00 AM was inaccurate but documented as accurate on the MAR.
Resident 2 was prescribed medication to apply to infected areas three times a day, but it was not administered on 7/8/22.
Resident 2 was prescribed to take 1 tablet by mouth daily, but it was not administered on 7/6/22.
Report Facts
License Capacity: 98
Residents Served: 60
Secured Dementia Care Unit Capacity: 25
Secured Dementia Care Unit Residents Served: 23
Total Daily Staff: 85
Waking Staff: 64
Notice
Capacity: 98
Deficiencies: 0
Date: Sep 7, 2021
Visit Reason
The document serves as a renewal notification and license issuance for Brethren Village - Terrace Crossing Personal Care Home, confirming receipt of the renewal application and advising 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 confirming the facility's authorized capacity and service type.
Report Facts
Maximum capacity: 98
Secure Dementia Care Unit capacity: 26
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary | Signed the renewal notification letter |
Inspection Report
Routine
Deficiencies: 0
Date: Jul 29, 2021
Visit Reason
The inspection was conducted as a licensing inspection by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing.
Findings
No regulatory citations were identified as a result of this inspection.
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