Average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Brethren Village during CMS and state inspections, most recent first.
A resident had a PRN order for Ativan 0.5 mg for anxiety/restlessness and received multiple doses over the course of a month. Review of the MAR and clinical record showed repeated administration of the PRN anti-anxiety medication without any documented attempts at non-pharmacological interventions beforehand. In an interview, the NHA and DON confirmed that such non-pharmacological measures were not attempted prior to giving the PRN Ativan.
A resident with a PRN order for Oxycodone 5 mg every 6 hours for severe pain was given the medication multiple times when pain levels were documented as zero. Facility policy defined the 0–10 pain scale and specified that severe pain corresponds to scores of 8–10, but review of the MAR showed Oxycodone was administered despite no reported pain. In an interview, the NHA and DON confirmed that the pain scale parameters in the physician’s PRN order were not followed.
A resident with hemiplegia, contractures, and a history of falls, who required a two-person assist for transfers, was transferred by a CNA alone using a bear hug technique. This improper transfer resulted in the resident sustaining a subcapital humeral fracture, as confirmed by x-ray. Facility investigation substantiated that the care plan was not followed, leading to actual harm.
A resident with a spinal cord injury and diabetes suffered harm due to neglect in wound care at a facility. The resident's pressure ulcer worsened after the facility failed to renew a treatment order and did not ensure the availability of necessary medication. This led to the wound becoming infected and requiring hospitalization for surgical intervention.
A resident with a history of pressure ulcers experienced wound deterioration and infection due to inconsistent treatment and lack of communication in an LTC facility. Despite being at risk, the resident's wound care was missed on several occasions, and a critical medication was delayed, leading to a Stage 4 ulcer and hospitalization for surgical intervention.
A resident's wound care was not administered as per physician's orders on multiple occasions, and the required medication was delayed. The LPN did not notify the physician or follow up on the medication, leading to a deviation from the prescribed treatment.
Failure to Attempt Non-Pharmacological Interventions Before PRN Anti-Anxiety Medication
Penalty
Summary
The facility failed to ensure that non-pharmacological interventions were attempted prior to administering a PRN anti-anxiety medication to a resident. Clinical record review showed that the resident had a physician’s order for Ativan 0.5 mg every four hours as needed for anxiety or restlessness and that the medication was administered multiple times throughout January 2026, including on January 1, 2, 3, 5, 6, 8, 9, 10, 11, 21, 22, 26, and 27. Review of the resident’s clinical record did not show any documentation that non-pharmacological interventions were attempted before giving the PRN Ativan on these dates. In an interview on January 30, 2026, at 10:50 a.m., the Nursing Home Administrator and Director of Nursing confirmed that no non-pharmacological interventions were attempted prior to the administration of the PRN Ativan, corroborating the lack of evidence in the clinical record.
Failure to Follow PRN Pain Medication Orders Based on Pain Scale
Penalty
Summary
The facility failed to follow a physician’s order for as-needed (PRN) pain medication for one resident when nursing staff administered Oxycodone 5 mg for pain levels documented as zero. Facility policy titled “Pain Observation/Evaluation,” revised January 2026, defined the 0–10 pain scale and specified that mild pain corresponds to 0–3, moderate to 4–7, and severe to 8–10. The resident had a physician’s order for Oxycodone 5 mg to be given every 6 hours as needed for severe pain. Review of the January Medication Administration Record showed that the resident received Oxycodone 5 mg every 6 hours as needed on multiple dates despite pain levels recorded as zero at the time of administration. In an interview, the Nursing Home Administrator and DON confirmed that the pain scale specified in the physician’s PRN pain medication order was not followed according to the order.
Failure to Follow Care Plan During Transfer Results in Resident Fracture
Penalty
Summary
A deficiency occurred when a resident with a history of hemiplegia, hemiparesis following a stroke, severe protein-calorie malnutrition, a history of falls, and contractures was not provided care according to their individualized care plan. The care plan and Kardex specified that the resident required an extensive two-person assist for transfers due to limited physical mobility and right-sided weakness. Despite these documented requirements, a certified nurse aide (CNA) transferred the resident alone using a bear hug technique, rather than with the assistance of a second staff member as required. As a result of this improper transfer, the resident reported hearing a pop in the right shoulder and experienced pain and tenderness. An immediate x-ray confirmed a subcapital humeral fracture. Facility investigation, including staff and resident interviews, substantiated that the CNA did not follow the care plan, leading to actual harm to the resident. The facility confirmed that the transfer was not performed according to the resident's care plan, resulting in the injury.
Neglect in Wound Care Leads to Resident Harm
Penalty
Summary
Brethren Village was found to be non-compliant with the requirement to ensure residents are free from neglect, as evidenced by the inadequate wound care provided to a resident with a thoracic spinal cord injury and diabetes. The resident was admitted with an improving Stage 3 pressure ulcer on the coccyx, which required specific wound treatment. However, the facility failed to consistently apply the prescribed treatment, leading to the deterioration of the wound. The facility's records showed that the wound treatment order expired and was not renewed, resulting in missed treatments on several days. Additionally, when a new treatment was ordered, the necessary medication was not available due to a computer entry error, and the staff did not follow up with the pharmacy or notify the physician about the unavailability of the medication. This lack of action led to the wound becoming unstageable, with increased slough and infection, as confirmed by a wound culture. The resident's condition worsened, requiring hospitalization for surgical debridement and intravenous antibiotics. The facility's failure to provide consistent and correct wound care resulted in actual harm to the resident, including unnecessary pain and hospitalization. The deficiency was substantiated by the facility's own investigation, which confirmed neglect by a staff member.
Plan Of Correction
Preparation and submission of the plan of correction is required by state and federal law. This plan of correction does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding. Santyl was received January 27th and treatment applied appropriately on that date forward. Education and corrective action provided to team member involved January 27, 2025. Team member terminated 2/6/2025. Team member who did not transcribe medication properly educated and corrective action January 31, 2025. Audits was done on past month of treatments to identify any trends and patterns. Completed February 6, 2025. Licensed staff educated on notification of physician's residents and resident representative if treatment is not available. Completed by February 8, 2025. Order set for wounds added to EMR, education provided to licensed team members on use of order set and documentation. Completed by February 8, 2025. Audits on wound order set began February 13, 2025 x 4 weeks. Wound Policy and procedure was reviewed, updated and wound team educated. Completed by January 30, 2025.
Inadequate Wound Care Leads to Resident Hospitalization
Penalty
Summary
The facility failed to provide consistent and appropriate treatment for an unstageable pressure ulcer for Resident CL1, resulting in wound deterioration, infection, and hospitalization. Resident CL1 was admitted with an improving Stage 3 pressure ulcer and was identified as 'At Risk' for developing pressure ulcers. The care plan included interventions such as turning and positioning, adequate nutrition, and wound treatment as ordered. However, there were missed wound care treatments on specific dates, and the attending physician was not notified of these omissions. The wound deteriorated, becoming unstageable with increased slough and drainage, and a new treatment was recommended. Despite a physician's order for Santyl, the medication was not delivered promptly, and alternative treatments were used without notifying the physician or supervisor. This lack of communication and follow-up led to further deterioration of the wound, which developed tunneling and purulent discharge, indicating infection. A wound culture confirmed the presence of multiple organisms, and the resident was placed on antibiotics and scheduled for a wound clinic consult. The wound was assessed as a Stage 4 pressure ulcer with necrotic tissue and exposed bone, requiring operative debridement and IV antibiotics. The resident was subsequently hospitalized for surgical intervention, highlighting the facility's failure to ensure consistent and appropriate wound care, resulting in actual harm to the resident.
Plan Of Correction
Preparation and submission of the plan of correction is required by state and federal law. This plan of correction does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding. Santyl was received January 27th and treatment applied appropriately on that date forward. Education and corrective action provided to team member involved January 27, 2025. Team member terminated 2/6/2025. Team member who did not transcribe medication properly educated and corrective action January 31, 2025. Audits was done on past month of treatments to identify any trends and patterns. Completed February 6, 2025. Licensed staff educated on notification of physician's residents and resident representative if treatment is not available. Completed by February 8, 2025. Order set for wounds added to EMR, education provided to licensed team members on use of order set and documentation. Completed by February 8, 2025. Audits on wound order set began February 13, 2025 x 4 weeks. All findings to be reported to Quality Assurance Committee. Wound Policy and procedure was reviewed, updated and wound team educated. Completed by January 30, 2025. Education and corrective action provided to Wound Care Certified nurse. (Wound team leader). Wound Care nurse terminated February 5, 2025.
Failure to Follow Wound Care Orders
Penalty
Summary
The facility failed to ensure that staff met professional standards for a licensed nurse in following a physician's wound care order for a resident identified as CL1. The resident had an unstageable coccyx wound that required specific treatment as per a physician's order, which included cleansing with normal saline, applying Medihoney and Calcium Alginate, and covering with a dressing daily. However, the clinical records revealed that the wound was not treated on three specific days, and there was no documentation that the physician was notified of the missed treatments. Additionally, a new wound care order was issued, but the required Santyl medication was not delivered to the facility until four days later. During this period, the wound was treated with an alternative method not in accordance with the physician's order. The nurse responsible did not follow up with the pharmacy, inform the supervisor, or notify the physician about the unavailability of the medication and the deviation from the prescribed treatment. This failure to adhere to professional standards and facility policies was confirmed through staff interviews and a review of relevant records.
Plan Of Correction
Preparation and submission of the plan of correction is required by state and federal law. This plan of correction does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding. Santyl was received January 27th and treatment applied appropriately on that date forward. Education and corrective action provided to team member involved January 27, 2025. Team member terminated 2/6/2025. Audits was done on past month of treatments to identify any trends and patterns. Completed February 6, 2025. Licensed staff educated on notification of physician's residents and resident representative if treatment is not available. Completed by February 8, 2025. Order set for wounds added to EMR, education provided to licensed team members on use of order set and documentation. Completed by February 8, 2025. Audits on wound order set began February 13, 2025 x 4 weeks.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Lancaster
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Rehabilitation Center At Brethren Village Llc | 0 mi | ★★★★★ | 0 | 0 |
| Neffsville Nursing And Rehabilitation | 0.1 mi | ★★★★★ | 5 | 1 |
| Landis Homes | 2 mi | ★★★★★ | 1 | 0 |
| Calvary Fellowship Homes Inc | 3.1 mi | — | 0 | 0 |
| Luther Acres Manor | 3.2 mi | ★★★★★ | 2 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.