Inspection Reports for Cross Keys Village – the Brethren Home Community
2990 CARLISLE PIKE,, PA, 17350
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
2.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
40% better than Pennsylvania average
Pennsylvania average: 4.7 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
88% occupied
Based on a October 2024 inspection.
Census over time
Inspection Report
Renewal
Census: 91
Capacity: 104
Deficiencies: 7
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confidential resident records, unsecured poisonous materials accessible to residents, uncovered trash receptacles, outdated emergency management procedures, discontinued medications present in the medication cart, inaccurate medication administration records, and failure to follow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.
Deficiencies (7)
| Description |
|---|
| 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
License Capacity: 104
Residents Served: 91
Staffing: 91
Waking Staff: 68
Inspection Report
Renewal
Census: 90
Capacity: 104
Deficiencies: 2
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.
Deficiencies (2)
| Description |
|---|
| 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
License Capacity: 104
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
Renewal
Census: 87
Capacity: 104
Deficiencies: 2
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.
Deficiencies (2)
| Description |
|---|
| 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
License Capacity: 104
Residents Served: 87
Current Hospice Residents: 5
Total Daily Staff: 92
Waking Staff: 69
Notice
Capacity: 104
Deficiencies: 0
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
Maximum capacity: 104
Secure Dementia Care Unit capacity: 18
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary | Signed the renewal notification letter |
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