Provider Name: BRETHREN VILLAGE
Address: 3001 LITITZ PIKE, LANCASTER, PA 17606
Phone: (717) 569-2657
County: Lancaster (440)
Ownership Type: Non profit - Corporation
Certified Beds: 120
Average Residents Per Day: 110. ()
Provider Type: Medicare and Medicaid, Resides in Hospital: No
Legal Business Name: BRETHREN VILLAGE
First Approved Date: May 5, 1975
Affiliated Entity: ()
Retirement Community: Y, Special Focus Status:
Ownership Change in Last 12 Months: N
Resident Family Council: Both
Sprinkler System Status: Yes
Overall Rating: 3 ()
Health Inspection Rating: 2 ()
QM Rating: 5 ()
Long Stay QM Rating: 5 ()
Short Stay QM Rating: 5 ()
Staffing Rating: 4 ()
Staffing Report Note:
PT Staffing Note:
Nurse Aide Staff Hours Per Day, per resident: 2.71806, LPN Staff Hours Per Day: 1.2171, RN Staff Hours Per Day: 0.5413, Licensed Staff Hours Per Day: 1.7585
Total Nurse Staff Hours Per Day, per resident: 4.47657
Weekend Nurse Staff Hours: 4.16935, Weekend RN Staff Hours: 0.3013
PT Staff Hours Per Day, per resident: 0.0148
Nurse Staff Turnover: 44.7, Nurse Turnover Note:
RN Turnover: 62.5, RN Turnover Note:
Admin Left Number: 0, Admin Turnover Note:
Case Mix Nurse Aide Hours Per Day, per resident: 2.2965, Case Mix LPN Hours Per Day: 0.6944, Case Mix RN Hours Per Day: 0.3155
Adjusted Nurse Aide Hours Per Day, per resident: 2.41119, Adjusted LPN Hours Per Day: 1.2934, Adjusted RN Hours Per Day: 0.6465
Total Adjusted Nurse Hours Per Day, per resident: 4.26743
Adjusted Weekend Nurse Hours Per Day, per resident: 3.97456
Health Survey Dates and Scores: Cycle 1: 2023-04-06 (Score: 28), Cycle 2: 2022-04-07 (Score: 8), Cycle 3: 2021-03-25 (Score: 133)
Total Weighted Health Score: 38.833
Reported Incidents: 2, Substantiated Complaints: 0
Infection Control Citations:
Fines and Penalties: Number of Fines: 2, Total Fines in Dollars: 8845.01, Payment Denials Number: 0, Total Penalties Number: 2
Location and GPS: 3001 LITITZ PIKE,LANCASTER,PA,17606 (40.1064, -76.305)
Process Date: 2024-03-01
Each record details specific health deficiencies found during inspections, categorized by type, severity, and whether they were corrected. Below are the severity levels and their implications:
Type: Health, Deficiency: Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Severity: G - Level 3: Actual harm that is not immediate jeopardy. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-05-20
Type: Health, Deficiency: Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-05-20
Type: Health, Deficiency: Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-05-20
Type: Health, Deficiency: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-08-17
Type: Health, Deficiency: Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-05-15
Type: Health, Deficiency: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Severity: K - Level 4: Immediate jeopardy to resident health or safety. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-05-11
Type: Health, Deficiency: Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-05-11
Each record details specific fire safety deficiencies found during inspections, categorized by type, severity, and whether they were corrected. Below are the severity levels and their implications:
Type: Fire Safety, Tag: 0541, Version: New
Description: Install properly constructed and protected linen or trash chutes.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-05-12
Type: Fire Safety, Tag: 0923, Version: New
Description: Have proper medical gas storage and administration areas.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-06-01