Inspection Reports for
Brethren Village – Village Manor
3001 LITITZ PIKE,, LITITZ, PA, 17543
Back to Facility Profile16 Reports
Inspection Report — Mar 24, 2026
Renewal
Date: Mar 24, 2026
Visit Reason
The inspection was a renewal visit conducted to review compliance with licensing requirements and verify the submitted plan of correction.
Findings
The facility had multiple deficiencies including medication errors, confidentiality breaches, privacy violations, incomplete staff orientation and training, inadequate dining room seating, outdated emergency procedures, obstructed egress, lack of fire safety documentation, unsecured medications, and failure to follow prescriber's orders. Plans of correction were accepted or directed with completion dates mostly by May 2026.
Citations (14)
2600.16c The home failed to report a medication error involving Resident #1 who was administered 1 tablet of Mucinex ER 600 mg instead of the prescribed 2 tablets.
2600.17 Resident records confidentiality was breached when empty medication pillow packets containing private health information were left unlocked and accessible on the medication cart.
2600.42s Privacy was violated by hallway cameras facing directly into resident rooms #130 and #235.
2600.65a Staff Member A did not receive orientation on fire safety and emergency preparedness topics on their first day of work.
2600.65b Staff Member A did not complete required training on resident rights, emergency medical plan, abuse reporting, and incident reporting within 40 scheduled working hours.
2600.65f Several staff members did not receive required annual training on medication self-administration, resident needs, and safe management techniques during the 2025 training year.
2600.104a The dining room seating capacity of 26 was insufficient for 61 residents, requiring multiple seatings for meals.
2600.107d The home's written emergency procedures had not been reviewed, updated, or submitted to the local emergency management agency since 9/16/24.
2600.121a Residents left wheelchairs in hallways blocking egress to the main entrance during lunch.
2600.124 The home lacked documentation of written notification to the local fire department regarding the home's address, bedroom locations, and evacuation assistance needs.
2600.132b The last fire safety inspection and drill by a fire safety expert were conducted on 10/16/25 and 9/25/24 respectively, not annually.
2600.183b Prescription and OTC medications were found unlocked and unattended in resident bathrooms without proper physician assessment or orders.
2600.186a Several prescription medications for Residents #3, #7, and #9 were not prescribed by an authorized prescriber.
2600.187d The home failed to follow prescriber's orders for multiple residents, including incorrect dosages and medication administration errors.
Report Facts
Residents Served: 61
Staff Count: 62
Waking Staff: 47
Additional Seating Added: 10
Additional Tables Added: 2
Medication Observations Required: 4
Inspection Report — Sep 4, 2024
Renewal
Date: 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.
Citations (5)
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
Residents Served: 74
Total Daily Staff: 78
Waking Staff: 59
Inspection Report — Sep 6, 2023
Date: 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
Residents Age 60 or Older: 76
Diagnosed with Mental Illness: 2
Have Mobility Need: 6
Have Physical Disability: 1
Inspection Report — Jun 22, 2022
Renewal
Date: 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.
Citations (8)
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
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 — Feb 1, 2021
Date: 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
Inspection Report — Nov 13, 2019
Renewal
Date: Nov 13, 2019
Visit Reason
The inspection was conducted as a full, unannounced renewal and complaint review of Brethren Village - Village Manor on November 13 and 14, 2019.
Findings
The submitted plan of correction was accepted and fully implemented. The report includes a violation related to fire drill record timing documentation and corrective actions to ensure accurate timing in future drills.
Citations (1)
2600.132c - The fire drill records documented evacuation times rounded to the nearest whole minute rather than actual times in minutes and seconds.
Report Facts
Residents Served: 78
Current Hospice Residents: 2
Staff Total Daily: 82
Waking Staff: 62
Notice — Oct 17, 2019
Date: Oct 17, 2019
Visit Reason
This document serves as a renewal notification for the Personal Care Home license of Brethren Village - Village Manor, confirming receipt of the renewal application and informing about the requirement for an annual onsite inspection within the next twelve months.
Findings
No inspection findings are reported in this document. It is an administrative notice regarding license renewal and future inspection requirements.
Report Facts
Inspection Report — Jan 8, 2019
Renewal
Date: Jan 8, 2019
Visit Reason
The inspection was a renewal inspection conducted by the Department’s Bureau of Human Services Licensing on January 8 and 9, 2019 for Brethren Village - Village Manor.
Findings
A violation was found related to an unannounced fire drill not being conducted during November 2018. A plan of correction was submitted to address the deficiency with training and scheduling of fire drills.
Citations (1)
Regulation 55 Pa.Code §2600.132(a) requires an unannounced fire drill at least once a month. A fire drill was not conducted during November 2018.
Report Facts
Number of Residents Served: 74
Number of Residents who are 60 Years of Age or Older: 74
Number of Residents who Have Mental Illness: 1
Number of Current Hospice Residents: 0
Number of Hospice Residents in past year: 4
Inspection Report — Oct 17, 2018
Renewal
Date: Oct 17, 2018
Visit Reason
This document is a renewal license issued in response to the facility's renewal application to operate a Personal Care Home. The Department will conduct an onsite inspection within the next twelve months as part of the annual inspection requirement.
Findings
No inspection findings are reported in this document. It serves as a license renewal certificate and notification of upcoming inspection requirements.
Report Facts
Inspection Report — Feb 23, 2018
Complaint Investigation
Date: Feb 23, 2018
Visit Reason
The inspection was conducted as a complaint investigation triggered by an incident at the facility.
Complaint Details
The inspection was triggered by an incident involving Resident #1 who had a fall on 02/03/2018 resulting in several injuries. The complaint investigation found the facility failed to reassess and update the resident's care plan accordingly.
Findings
Two violations related to resident assessments and support plan updates following a resident fall were found. The facility had not completed required reassessments or updated the resident's support plan to reflect new care needs.
Citations (2)
Regulation 55 Pa.Code §2600.225(c) - The most recent assessment for Resident #1 did not document the resident as a fall risk after an incident resulting in injuries. A reassessment was not completed to evaluate the increased fall risk.
Regulation 55 Pa.Code §2600.227(d) - The resident support plan developed on 01/07/2018 was not updated to include physical and occupational therapy services added after the resident's fall on 02/03/2018.
Report Facts
Number of Residents Served: 74
Number of Current Hospice Residents: 1
Number of Hospice Residents in past year: 2
Number of Residents who are 60 Years of Age or Older: 74
Number of Residents who Have Mental Illness: 1
Inspection Report — Jan 18, 2018
Renewal
Date: Jan 18, 2018
Visit Reason
The inspection was conducted as an annual licensing renewal inspection of the Brethren Village Village Manor facility on January 18 and 19, 2018.
Findings
Violations of 55 Pa.Code Chapter 2600 related to Personal Care Homes were found during the inspection. The report includes specific deficiencies regarding contract specifications, direct care staff training, and medication administration procedures.
Citations (3)
55 Pa.Code §2600.25(c)(4) - The contract for Resident #1 does not specify the party responsible for payment.
55 Pa.Code §2600.65(d) - Direct care staff person A did not complete the required direct care training course and competency test by the specified date.
55 Pa.Code §2600.185(a) - The home did not implement procedures for safe use of glucometers and documentation of blood sugar readings, with multiple residents having unrecorded blood sugar levels in the Medication Administration Record.
Report Facts
Number of Residents Served: 74
Number of Current Hospice Residents: 2
Number of Hospice Residents in past year: 3
Inspection Report — Oct 23, 2017
Renewal
Date: Oct 23, 2017
Visit Reason
The document is a renewal application and license issuance for Brethren Village - Village Manor Personal Care Home, confirming the renewal of the facility's license pursuant to Title 55, PA Code, Chapter 2600.
Findings
The Department has approved the renewal application and issued a regular license for the facility. The Department will conduct an onsite inspection within the next twelve months as required by regulation.
Inspection Report — Jan 26, 2017
Renewal
Date: Jan 26, 2017
Visit Reason
The inspection was conducted as part of the Department of Human Services' annual licensing inspections on January 26 and 27, 2017, for renewal of the facility license.
Findings
Multiple violations of 55 Pa.Code Chapter 2600 were identified, including privacy concerns related to video recording, incomplete staff training records, food storage temperature monitoring issues, inadequate medication storage and administration procedures, and missing documentation of medication administration signatures. Plans of correction were submitted and partially implemented as of the report date.
Citations (7)
55 Pa.Code §2600.42(a) - The home recorded common areas with video cameras for up to 30 days without informing residents or posting signage indicating recording.
55 Pa.Code §2600.650(i) - The home's direct care staff training records did not include fire safety training provided by a fire safety expert for ancillary staff.
55 Pa.Code §2600.103(f) - The freezer on the 2nd floor lounge did not contain a thermometer to monitor temperature.
55 Pa.Code §2600.185(a) - The home lacked adequate procedures for safe use of glucometers, including incorrect dates and times and multiple stored readings not matching resident records.
55 Pa.Code §2600.187(a) - A staff person who checked a resident's blood sugar was not listed on the master signature key.
55 Pa.Code §2600.187(b) and (a)(14) - Documentation was missing for a blood sugar check performed on 12-2-16 at 4pm.
55 Pa.Code §2600.187(d) - Several residents did not receive prescribed insulin or treatments including wound care and medications on specified dates.
Report Facts
Number of Residents Served: 78
Total Daily Staff: 78
Walking Staff: 57
Number of Current Hospice Residents: 0
Number of Hospice Residents in Past Year: 2
Residents Age 60 or Older: 76
Residents with Physical Disability: 2
Residents Receiving Supplemental Security Income: 1
Notice — Oct 19, 2016
Date: Oct 19, 2016
Visit Reason
This document serves as a renewal notification for the Personal Care Home license of Brethren Village - Village Manor and informs that an annual 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 renewal and outlines the requirement for a future annual inspection.
Report Facts
Notice — March 10, 2017
Date: March 10, 2017
Visit Reason
The document is a response to a request for a waiver of 55 Pa.Code § 2600.190(b) relating to medication administration training for staff in specified licensed personal care homes.
Findings
A waiver is granted under specified conditions including providing diabetes training education, skills demonstration, documentation retention, and completion of a graduate-level Diabetes Nursing Specialization program by December 31, 2018.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jacqueline L. Rowe | Director | Signed the waiver approval letter. |
Inspection Report — October 21, 2021
Renewal
Date: October 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
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary, Office of Long-term Living | Signed the renewal letter |
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