Inspection Reports for Brethren Village – Village Manor
3001 LITITZ PIKE,, PA, 17543
Back to Facility ProfileDeficiencies per Year
8
6
4
2
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Renewal
Census: 74
Capacity: 114
Deficiencies: 5
Sep 4, 2024
Visit Reason
The inspection was conducted as a renewal and incident review of the Brethren Village - Village Manor facility on 09/04/2024 and 09/05/2024.
Findings
The submitted plan of correction was determined to be fully implemented. Several deficiencies were identified including incomplete criminal background checks, unsecured mobility devices, discontinued medications present in medication carts, medication administration errors, and unsecured resident medical information on a laptop. Corrective actions and ongoing monitoring plans were accepted and implemented.
Deficiencies (5)
| Description |
|---|
| A complete criminal background check was not completed for a staff member until after hire. |
| Mobility devices for residents were not securely fastened to the bed. |
| Discontinued medication was found in the home's medication cart. |
| Resident medications were administered incorrectly, including medication given in the wrong eye or wrong dosage. |
| Resident medical information was unlocked, unattended, and accessible on a laptop located on the medication cart. |
Report Facts
License Capacity: 114
Residents Served: 74
Total Daily Staff: 78
Waking Staff: 59
Inspection Report
Census: 76
Capacity: 114
Deficiencies: 0
Sep 6, 2023
Visit Reason
The inspection was conducted as a partial, unannounced visit due to an incident.
Findings
No regulatory citations or deficiencies were identified during the inspection.
Report Facts
Total Daily Staff: 82
Waking Staff: 62
Residents Served: 76
License Capacity: 114
Residents Age 60 or Older: 76
Diagnosed with Mental Illness: 2
Have Mobility Need: 6
Have Physical Disability: 1
Inspection Report
Renewal
Census: 72
Capacity: 114
Deficiencies: 8
Jun 22, 2022
Visit Reason
The inspection was conducted as a renewal inspection of the facility license.
Findings
The inspection identified multiple deficiencies including issues with resident refunds, resident personal equipment safety hazards, obstructed egress routes, medication administration errors, improper medication storage, incomplete medication records, and delayed resident assessments. Plans of correction were accepted and implemented for all deficiencies.
Deficiencies (8)
| Description |
|---|
| Resident refund was not issued within the required 30 days after discharge. |
| Enabler bars on residents' beds had openings exceeding FDA guidelines and were not covered, posing potential hazards. |
| Exits and egress routes were obstructed by chairs, barricades, caution tape, and stop signs. |
| Medication pass observed where medication was left with resident and staff left the room before medication was taken. |
| Blister packs of medications were taped and repackaged improperly, risking medication loss. |
| Glucometer readings were incorrectly documented and later edited without impact on insulin administration. |
| Medication administration records did not consistently document insulin doses given on sliding scale. |
| Resident's additional assessment was not completed within required timeframe due to hospitalization and rehab stay. |
Report Facts
License Capacity: 114
Residents Served: 72
Total Daily Staff: 75
Waking Staff: 56
Current Hospice Residents: 1
Residents with Mobility Need: 3
Residents with Physical Disability: 1
Residents Diagnosed with Mental Illness: 1
Notice
Capacity: 114
Deficiencies: 0
Feb 1, 2021
Visit Reason
The document serves as a renewal notification and issuance of a regular license for Brethren Village – Village Manor Personal Care Home, confirming compliance and informing about the upcoming annual inspection within the next twelve months.
Findings
The Department has approved the renewal application and issued a regular license. The facility is reminded that an onsite inspection will be conducted within the next twelve months to ensure compliance with applicable regulations.
Report Facts
Total licensed capacity: 114
Inspection Report
Renewal
Capacity: 114
Deficiencies: 0
Oct 21, 2021
Visit Reason
The document is a renewal application and license issuance for Brethren Village - Village Manor, a Personal Care Home, confirming the facility's authorization to operate and indicating that an annual inspection will be conducted within the next twelve months.
Findings
The Department has issued a regular license in response to the renewal application and advises that an onsite inspection will be conducted within the next twelve months to ensure compliance with applicable regulations.
Report Facts
Maximum capacity: 114
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary, Office of Long-term Living | Signed the renewal letter |
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