CROSS KEYS VILLAGE-BRETHREN HOME COMMUNITY, THE

Nursing Home Inspector

BOX 128, 2990 CARLISLE PK
NEW OXFORD, PA 17350
Adams County
Phone: 717-624-2161
Provider Number: 395108
Last Inspection: 09/21/2017

About the Nursing Home

Number of Beds: 270
Number of Residents: 208
Beds Available: 62
Percent Occupancy: 77%
Insurance Accepted: Medicare & Medicaid
Types of Councils: Resident
Ownership: Non profit - Church related
Within Hospital?: NO

About State Inspection Deficiencies

Nursing Homes that are Medicare and/or Medicaid certified are licensed by the state and are required to comply with rigid standards enforced by regular facility inspections and extensive evaluations.

The state inspection deficiencies provided here are accounts reported by state inspectors of every discrepancy found where the home failed to meet the minimum standards set forth by state and federal regulations. If a home does not show any deficiencies, it has met the minimum standards required.

Please note: Findings in these inspections do not present a complete picture of the quality of care provided. Information in this database should be interpreted carefully and used in conjunction with other sources, as well as a visit to the nursing home.


Deficiency Ratings

Our nursing home inspector tool compares the severity of deficiences rather than the number of deficiences. We calculate the severity of each deficiency using the formula:

Severity Rating = Scope + Level of Harm.

Deficiency Rating= Sum of ALL Severity Ratings

Severity Scope Level of Harm
2 1-Isolated 1-Potential for minimal harm
3 2-Pattern 1-Potential for minimal harm
3 1-Isolated 2-Minimal harm or potential for actual harm
4 3-Widespread 1-Potential for minimal harm
4 2-Pattern 2-Minimal harm or potential for actual harm
4 1-Isolated 3-Actual harm
5 3-Widespread 2-Minimal harm or potential for actual harm
5 2-Pattern 3-Actual harm
5 1-Isolated 4-Immediate jeopardy to resident health or safety
6 3-Widespread 3-Actual harm
6 2-Pattern 4-Immediate jeopardy to resident health or safety
7 3-Widespread 4-Immediate jeopardy to resident health or safety

Deficiency Ratings
By Region

Lower Numbers Are Better

 

62

Facility
41

County
23

PA
20

USA

Deficiency Ratings
By Year

Lower Numbers Are Better

 

62

2017
28

2016
23

2015

Medicare Ratings

Overall Rating: Overall Rating
Health Rating: Health Rating
Staff Rating: Staff Rating
Quality Rating: Quality Rating

 

Details by Inspection Date

9/21/2017 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. Pattern : Minimal 4 11/13/2017
 
Failed To: 1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. Isolated : Minimal 3 11/13/2017
 
Failed To: Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. Isolated : Minimal 3 11/13/2017
 
Failed To: Conduct initial and periodic assessments of each resident's functional capacity. Isolated : Minimal 3 11/13/2017
 
Failed To: Ensure each resident receives an accurate assessment by a qualified health professional. Isolated : Minimal 3 11/13/2017
 
Failed To: Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Pattern : Minimal 4 11/13/2017
 
Failed To: Allow residents the right to participate in the planning or revision of care and treatment. Isolated : Minimal 3 11/13/2017
 
Failed To: Ensure services provided by the nursing facility meet professional standards of quality. Isolated : Minimal 3 11/13/2017
 
Failed To: Provide necessary care and services to maintain or improve the highest well being of each resident . Pattern : Minimal 4 11/13/2017
 
Failed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Pattern : Minimal 4 11/13/2017
 
Failed To: Ensure residents maintain acceptable nutritional status. Isolated : Minimal 3 11/13/2017
 
Failed To: Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature. Pattern : Minimal 4 11/13/2017
 
Failed To: Make sure that paid feeding assistants 1) completed training; 2) work under the supervision of a RN or LPN; and 3) feed only residents who have no complicated feeding problems. Isolated : Minimal 3 11/13/2017
 
Failed To: Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse. Pattern : Minimal 4 11/13/2017
 
Failed To: Have a program that investigates, controls and keeps infection from spreading. Isolated : Minimal 3 11/13/2017
 
Failed To: Put firmly secured handrails on each side of hallways. Isolated : Minimal 3 11/13/2017
 
Failed To: Give or get quality laboratory services/tests in a timely manner to meet the needs of residents. Isolated : Minimal 3 11/13/2017
 
Failed To: Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action. Widespread : Minimal 5 11/13/2017
 

8/12/2016 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Keep residents' personal and medical records private and confidential. Isolated : Minimal 3 10/1/2016
 
Failed To: Allow residents to self-administer drugs if determined safe. Isolated : Minimal 3 10/1/2016
 
Failed To: Ensure each resident receives an accurate assessment by a qualified health professional. Isolated : Minimal 3 10/1/2016
 
Failed To: Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Isolated : Minimal 3 10/1/2016
 
Failed To: Provide care by qualified persons according to each resident's written plan of care. Isolated : Minimal 3 10/1/2016
 
Failed To: Properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses. Isolated : Minimal 3 10/1/2016
 
Failed To: Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse. Isolated : Minimal 3 10/1/2016
 
Failed To: Employ staff that are licensed, certified, or registered in accordance with state laws. Isolated : Minimal 3 10/1/2016
 
Failed To: Keep accurate, complete and organized clinical records on each resident that meet professional standards. Pattern : Minimal 4 10/1/2016
 

9/24/2015 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Protect each resident from mistreatment, neglect and misappropriation of personal property. Isolated : Actual 4 11/18/2015
 
Failed To: Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. Isolated : Minimal 3 11/18/2015
 
Failed To: Ensure each resident receives an accurate assessment by a qualified health professional. Isolated : Minimal 3 11/18/2015
 
Failed To: Provide necessary care and services to maintain or improve the highest well being of each resident . Pattern : Minimal 4 11/18/2015
 
Failed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Isolated : Actual 4 11/18/2015
 
Failed To: Have enough backup water supply for essential areas of the nursing home. Widespread : Minimal 5 11/18/2015
 

Complaint Investigation Deficiencies

These deficiencies resulted from complaints investigated by the state inspectors and substantiated.

5/10/2017 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Keep accurate, complete and organized clinical records on each resident that meet professional standards. Isolated : Minimal 3 6/9/2017
 

5/16/2016 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: 1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. Isolated : Minimal 3 6/6/2016
 

3/30/2016 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. Isolated : Minimal 3 5/4/2016
 

3/23/2016 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Protect each resident from mistreatment, neglect and misappropriation of personal property. Isolated : Minimal 3 5/4/2016
 
Failed To: Keep accurate, complete and organized clinical records on each resident that meet professional standards. Isolated : Minimal 3 5/4/2016
 

3/16/2016 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Ensure services provided by the nursing facility meet professional standards of quality. Isolated : Minimal 3 5/4/2016
 
Failed To: Provide necessary care and services to maintain or improve the highest well being of each resident . Isolated : Minimal 3 5/4/2016
 
Failed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Isolated : Minimal 3 5/4/2016
 

About The Staff

(Higher Numbers Are Better)

Staffing Hours Per Day Per Resident... This Facility County Avg PA State Avg
Number of Residents 208 123.80 110.03
Registered Nurses 0.72 0.57 0.94
Licensed Practical / Vocational Nurses 1.29 0.98 0.85
Certified Nursing Assistants 3.09 2.25 2.26
Total Staff Hours 5.09 3.81 4.05

 


About the Residents

(Lower Numbers Are Better)

Percent of Residents... This Facility% County Avg% PA State Avg%
of high risk long-stay residents with pressure ulcers 4 2 5
of long-stay residents assessed and appropriately given the pneumococcal vaccine 100 98 94
of long-stay residents assessed and appropriately given the seasonal influenza vaccine 100 98 95
of long-stay residents experiencing one or more falls with major injury 3 4 3
of long-stay residents who have depressive symptoms 0 1 2
of long-stay residents who lose too much weight 10 6 7
of long-stay residents who received an antianxiety or hypnotic medication 17 24 22
of long-stay residents who received an antipsychotic medication 15 18 15
of long-stay residents who self-report moderate to severe pain 5 7 6
of long-stay residents who were physically restrained 0 0 0
of long-stay residents whose ability to move independently worsened 22 16 20
of long-stay residents whose need for help with daily activities has increased 13 15 15
of long-stay residents with a catheter inserted and left in their bladder 1 1 1
of long-stay residents with a urinary tract infection 3 2 3
of low risk long-stay residents who lose control of their bowels or bladder 62 58 56
of short-stay residents assessed and appropriately given the pneumococcal vaccine 97 90 83
of short-stay residents who had an outpatient emergency department visit 9 9 10
of short-stay residents who made improvements in function 72 67 64
of short-stay residents who newly received an antipsychotic medication 1 1 1
of short-stay residents who self-report moderate to severe pain 18 17 15
of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine 96 91 82
of short-stay residents who were rehospitalized after a nursing home admission 18 17 20
of short-stay residents who were successfully discharged to the community 56 53 52
of short-stay residents with pressure ulcers that are new or worsened 1 0 0