Deficiency Index

Rehabilitation Center at Brethren Village LLC

Lancaster, Pennsylvania · CCN 396140

4 surveys since 2018, and no finding has been recorded at harm level.

Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.

Citations on record
4
Surveys
4
Harm or worse
0
Immediate jeopardy
0
The record, 2018–2023
’18’20’23
No harm recordedHarm or worseNot surveyed
Harm or worseNone

No finding on record has been cited at harm level or above.

Beyond CMS’s monthly file3/4

Older surveys no longer in CMS’s monthly file or on Care Compare. They are shown here.

The facility

Certified beds
20
Ownership
Non profit - Corporation
Chain
Independent
County
Lancaster
Medicare-certified since
2016

CMS ratings

Overall
5
Health inspection
5
Staffing
5
Quality measures
3

CMS’s own Five-Star ratings.

Compared with similar facilities

Not shown for this facility: too few citations in window (n=2, floor 20).

Last survey on record

Jul 6, 2023

1,222 days ago.

Counts surveys with at least one finding. A clean survey leaves no record here, so the real gap may be shorter.

Staffing

MeasureThis facilityPeer median
Nurse hours per resident day8.524.80
Registered-nurse hours per resident day3.31—
Annual nurse turnover31.8%31.9%

As reported by the facility to CMS, beside the peer-group median.

Enforcement

No fines, payment denials or special-focus designation on the current CMS record.

Severity of recent findings

Citations by CMS scope and severity. Rows are harm level, columns are how widespread the finding was.
SeverityIsolatedPatternWidespread
Immediate jeopardyJ—K—L—
Actual harmG—H—I—
No harm, potential for more than minimalD1100.0%E—F—
No harm, potential for minimalA—B—C—
CMS’s current file: 1 of the 4 citations on record.

In the surveyor’s words

From the most serious findings on record at Rehabilitation Center at Brethren Village LLC, in the surveyor’s own words.

  • No harm, potential for more than minimal, isolatedF689Jul 6, 2023

    Based on a review of clinical records and facility documentation and staff interview, it was determined that the facility failed to ensure appropriate supervision was provided to prevent a fall of one of the eight residents reviewed (Resident 3) Findings include: A review of Resident 3's diagnosis list revealed Parkinson's Disease, repeated falls, and a left humerus fracture. A review of Resident 3's Initial Minimum Data Set (MDS- A standardized assessment tool that measures health status in long-term care residents) dated June 19, 2023, revealed resident required extensive with two people assistance with transferring. […]

  • No harm, potential for more than minimal, isolatedF686Aug 12, 2021

    Based on observation, clinical record review, and staff interview, it was determined that the facility failed to comprehensively assess and administer medication to a wound; and timely administer wound treatment to a sacral wound for one of seven residents reviewed. (Resident 11). Findings include: Review of Resident 11's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 11's Minimum Data Set (MDS- assessment tool used to facilitate the management of care) dated August 3, 2021, revealed that the resident required extensive of two- person assistance with bed mobility. […]

Read all 4 findings in full →

Every survey on record

FindingsAt actual harm or above

  • Jul 6, 2023Standard1 finding
  • Aug 12, 2021Standard1 finding
  • Jan 23, 2020Standard1 finding
  • Jan 12, 2018Standard1 finding

Surveys that found no deficiencies are not in CMS’s files and do not appear here.

Comparable facilities

The nearest facilities to this one in the same peer group, by weighted findings.

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