Inspection Reports for
Abington Manor at Morgan Hill
215 CEDAR PARK BOULEVARD,, EASTON, PA, 18042
Back to Facility Profile42 Reports
Inspection Report — May 7, 2026
Renewal
Date: May 7, 2026
Visit Reason
The inspection was a renewal visit conducted as a full, unannounced inspection to review compliance and verify the submitted plan of correction.
Findings
The facility was found to have multiple deficiencies including late incident reporting, incomplete criminal background checks, inaccurate medication labeling, and incomplete resident assessments. The submitted plan of correction was accepted and fully implemented by July 16, 2026.
Citations (9)
Regulation 16c: The facility failed to report a resident's unwitnessed fall and hospital admission within 24 hours to the Department.
Regulation 51: Criminal background checks were not requested timely for a staff member, violating hiring policies.
Regulation 141b1: Resident medical evaluations were incomplete or not current, missing secured dementia indication.
Regulation 183b: Medications and syringes were stored unlocked and unattended in an accessible area.
Regulation 184a: Prescription medication labels did not match physician orders for dosage and administration.
Regulation 185a: Glucometer readings were not recorded on the Medication Administration Record as required.
Regulation 225a: Resident initial assessments were not completed within 15 days of admission.
Regulation 225c: Additional assessments did not document significant changes such as hospice admission.
Regulation 227d: Resident support plans lacked required documentation for medical, dental, and behavioral services and FDA guideline compliance for enabler bars.
Report Facts
Residents Served: 50
Current Hospice Residents: 3
Residents Age 60 or Older: 50
Residents with Mobility Need: 18
Residents with Physical Disability: 1
Total Daily Staff: 68
Waking Staff: 51
Inspection Report — Apr 23, 2026
Complaint Investigation
Date: Apr 23, 2026
Visit Reason
The inspection was conducted as a complaint investigation to review compliance and verify the submitted plan of correction.
Complaint Details
The visit was complaint-related as indicated by the inspection information. The submitted plan of correction was fully implemented and accepted.
Findings
The inspection found expired medications improperly labeled and stored, and incomplete resident assessments failing to capture significant behavioral and care needs. The submitted plan of correction was accepted and fully implemented.
Citations (2)
183e Storing Medications: Expired medications were found labeled with incorrect open dates and not discarded according to manufacturer instructions.
225c Additional Assessment: Resident assessments did not include significant behavioral issues and care needs such as physical aggression, exit seeking, and bladder management.
Report Facts
Residents Served: 47
Current Hospice Residents: 5
Total Daily Staff: 64
Waking Staff: 48
Inspection Report — Feb 3, 2026
Complaint Investigation
Date: Feb 3, 2026
Visit Reason
The inspection was conducted as a complaint investigation during an unannounced partial licensing inspection of the facility.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Residents served: 54
Current Hospice Residents: 3
Residents Age 60 or Older: 49
Residents Diagnosed with Mental Illness: 2
Residents with Mobility Need: 15
Residents with Physical Disability: 2
Inspection Report — Jan 7, 2026
Complaint Investigation
Date: Jan 7, 2026
Visit Reason
The inspection was conducted as a complaint investigation during an unannounced partial licensing inspection of the facility.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Residents Served: 44
Current Hospice Residents: 3
Residents Age 60 or Older: 58
Residents with Mobility Need: 15
Residents with Physical Disability: 1
Inspection Report — Dec 10, 2025
Original Licensing
Date: Dec 10, 2025
Visit Reason
The inspection was conducted due to a change in legal entity and as part of the initial licensing process for the newly licensed personal care home facility.
Findings
The facility was found to be in substantial compliance with applicable regulations but not fully compliant. Several citations were identified related to safety and fire code issues, all of which had corrective action plans with completion dates.
Citations (3)
93a - Handrails: The ground slope outside the 1st floor sunroom exit did not have a well-secured handrail.
121a - Unobstructed Egress: Doors to the 2nd floor balcony, which do not lead to a path of egress, were not labeled with a 'Not an Exit' sign.
131f - Fire Extinguisher Inspection: The fire extinguisher in the outdoor smoking area had not been inspected since 2024.
Report Facts
Residents Served: 44
Current Residents in Hospice: 4
Staffing Hours - Total Daily Staff: 58
Staffing Hours - Waking Staff: 44
Residents Age 60 or Older: 44
Residents with Mental Illness: 1
Residents with Mobility Need: 14
Residents with Physical Disability: 2
Inspection Report — Jul 15, 2025
Follow-Up
Date: Jul 15, 2025
Visit Reason
The inspection visit on 07/15/2025 was a partial, unannounced follow-up triggered by an incident to verify the implementation of a previously submitted plan of correction.
Findings
The facility was found to have fully implemented the plan of correction related to abuse, criminal background checks, direct care staff qualifications, initial direct care training, and annual medical evaluations. The report details corrective actions taken and ongoing monitoring plans to maintain compliance.
Citations (5)
A resident was roughly handled by a staff member causing pain and was denied assistance with handwashing, constituting abuse.
The facility was unable to provide a criminal background check for an employee at the time of hire.
A direct care staff person did not have a high school diploma, GED, or active registry status on the Pennsylvania nurse aide registry.
A direct care staff person had no evidence of passing the direct care competence test required before providing unsupervised ADL services.
A resident's most recent medical evaluation was overdue by more than 1 year and 15 days.
Report Facts
Residents Served: 41
Current Hospice Residents: 4
Resident Support Staff: 14
Total Daily Staff: 69
Waking Staff: 52
Inspection Report — Jul 15, 2025
Complaint Investigation
Date: Jul 15, 2025
Visit Reason
The inspection was an unannounced partial investigation triggered by an incident involving alleged resident neglect and abuse.
Complaint Details
The visit was complaint-related due to an incident of alleged resident neglect and abuse by staff member A. The complaint was substantiated as the investigation confirmed neglect and abuse occurred.
Findings
The investigation found that a staff member neglected and abused a resident by refusing assistance, roughly handling the resident causing pain, and failing to assist with handwashing. Additional deficiencies included missing criminal background checks, unqualified direct care staff, lack of direct care competency testing, and overdue annual medical evaluations for residents.
Citations (5)
42b Abuse: Staff member A neglected and verbally abused a resident by refusing toileting assistance, roughly handling the resident causing pain, and failing to assist with handwashing.
51 Criminal Background Check: The facility was unable to provide a criminal background check for Employee A who was hired without this documentation.
54a Direct Care Staff: Direct care staff person A lacked a high school diploma, GED, or active registry status on the Pennsylvania nurse aide registry.
65d Initial Direct Care Training: Direct care staff person A had no evidence of passing the direct care competence test required before providing unsupervised ADL services.
141b1 Annual Medical Evaluation: A resident's most recent medical evaluation was more than 1 year and 15 days overdue.
Report Facts
Residents Served: 41
Current Hospice Residents: 4
Residents 60 Years or Older: 41
Residents Diagnosed with Mental Illness: 2
Residents with Mobility Need: 14
Residents with Physical Disability: 2
Resident Support Staff: 14
Total Daily Staff: 69
Waking Staff: 52
Inspection Report — Dec 18, 2024
Renewal
Date: Dec 18, 2024
Visit Reason
The inspection was conducted as a full, unannounced visit for renewal, complaint, and incident reasons on 12/18/2024.
Findings
The inspection identified multiple deficiencies including expired batteries in a carbon monoxide monitor, combustible materials near heat sources, untimely medical evaluations, medication labeling errors, medication administration errors, and incomplete resident support plans. All deficiencies had plans of correction accepted and were implemented or scheduled for completion.
Citations (7)
2600.18 - The batteries for the carbon monoxide monitor in the kitchen were due to be replaced by 11/6/24.
2600.125.a - A cloth rag was found behind the 1st floor dryer in the laundry room, posing a combustible storage hazard.
2600.141.a - Resident #1's medical evaluation was completed more than 60 days prior to admission, violating timely evaluation requirements.
2600.184.a - Resident #2's insulin medication container lacked the sliding scale order on the pharmacy label, a repeated violation.
2600.187.d - Resident #2 received an incorrect insulin dose and Resident #3 was given medication despite low blood pressure, repeated violations.
2600.227.d - Resident #4's support plan did not document the need for assistance with showering and dressing.
2600.227.g - Resident #1's support plan was not signed by the person who completed the form.
Report Facts
Residents Served: 45
Total Daily Staff: 65
Waking Staff: 49
Current Hospice Residents: 1
Residents Diagnosed with Mental Illness: 4
Residents with Mobility Need: 20
Residents with Physical Disability: 2
Inspection Report — Oct 30, 2024
Date: Oct 30, 2024
Visit Reason
The inspection was a partial, unannounced visit conducted due to an incident at the facility.
Findings
No regulatory citations or deficiencies were identified during the inspection.
Report Facts
Residents Served: 51
Current Hospice Residents: 3
Residents Age 60 or Older: 51
Residents with Mobility Need: 19
Residents with Physical Disability: 2
Inspection Report — Oct 30, 2024
Complaint Investigation
Date: Oct 30, 2024
Visit Reason
The inspection was conducted as a result of an incident, classified as a complaint investigation, with an unannounced partial inspection type.
Complaint Details
The visit was complaint-related due to an incident; no deficiencies or citations were substantiated.
Findings
No regulatory citations or deficiencies were identified during the inspection.
Report Facts
Residents Served: 51
Current Hospice Residents: 3
Total Daily Staff: 70
Waking Staff: 53
Inspection Report — Jul 3, 2024
Date: Jul 3, 2024
Visit Reason
The inspection was conducted as a partial, unannounced visit due to an incident at the facility on 07/03/2024.
Findings
No regulatory citations or deficiencies were identified during this inspection.
Report Facts
Total Daily Staff: 66
Waking Staff: 50
Residents Served: 45
Current Hospice Residents: 2
Residents Age 60 or Older: 45
Residents Diagnosed with Mental Illness: 4
Residents with Mobility Need: 21
Residents with Physical Disability: 1
Inspection Report — May 7, 2024
Complaint Investigation
Date: May 7, 2024
Visit Reason
The inspection was conducted as a complaint investigation at Abington Manor at Morgan Hill on 05/07/2024.
Complaint Details
The inspection was complaint-related, but no deficiencies were found and no follow-up was required.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Total Daily Staff: 70
Waking Staff: 53
Resident Support Staff: 0
Residents Served: 51
Current Hospice Residents: 2
Residents 60 Years or Older: 51
Residents Diagnosed with Mental Illness: 1
Residents with Mobility Need: 19
Residents with Physical Disability: 1
Inspection Report — Feb 1, 2024
Renewal
Date: Feb 1, 2024
Visit Reason
The inspection was conducted as a renewal inspection of the facility license.
Findings
The inspection found multiple deficiencies related to resident personal equipment safety, medication storage and administration, medication record keeping, and compliance with controlled substance policies. The facility submitted plans of correction which were accepted and fully implemented.
Citations (8)
The enabler bar in Resident #1’s room was not securely attached to the bed frame, posing a safety risk.
Resident #2 self-administers medications stored unlocked on bedside table; door not locked when leaving room.
Medication cart on third floor outside nurse’s station was unlocked and unattended during inspection.
A discontinued medication patch was found in the medication cart for Resident #3.
Resident #5’s medication label had incorrect directions to administer daily instead of once weekly.
Resident #4’s glucometer was not calibrated with the correct date and time; controlled substance count sheets incomplete.
Resident #3’s medication record was incorrectly documented regarding medication administration and holds.
Resident #4 was administered incorrect insulin dose due to MAR reading error.
Report Facts
Residents Served: 51
Current Hospice Residents: 3
Total Daily Staff: 70
Waking Staff: 53
Residents with Mobility Need: 19
Residents Age 60 or Older: 51
Residents with Physical Disability: 1
Residents Using Bed Canes: 14
Inspection Report — Dec 15, 2023
Follow-Up
Date: Dec 15, 2023
Visit Reason
The inspection was a partial, unannounced follow-up visit triggered by an incident to verify the implementation of a previously submitted plan of correction.
Findings
The facility was found to have fully implemented the plan of correction related to the abuse incident involving improper wheelchair transport. Staff were re-educated and the responsible staff member was terminated.
Citations (1)
42b - Abuse: Staff Member A improperly transported a resident in a wheelchair causing injury resulting in a closed fracture requiring surgery. Staff Member A was terminated and all staff were re-educated on proper wheelchair transport procedures.
Report Facts
Residents Served: 40
Current Hospice Residents: 3
Inspection Report — Dec 15, 2023
Plan of Correction
Date: Dec 15, 2023
Visit Reason
The inspection was conducted as a partial, unannounced incident investigation related to an abuse allegation involving a resident injury during wheelchair transport.
Findings
The investigation found that Staff Member A improperly transported a resident in a wheelchair, resulting in the resident sustaining a sprained knee and later a closed fracture requiring surgery. Staff Member A was counseled and subsequently terminated for non-compliance. All staff were re-educated on proper wheelchair transport procedures, and leg bags were ordered to secure residents' legs during transport.
Citations (1)
Staff Member A improperly transported a resident in a wheelchair, causing injury including a sprained knee and a closed fracture requiring surgery.
Report Facts
Residents Served: 40
Current Hospice Residents: 3
Total Daily Staff: 41
Waking Staff: 31
Residents with Mobility Need: 1
Residents with Physical Disability: 1
Inspection Report — Nov 1, 2022
Renewal
Date: Nov 1, 2022
Visit Reason
The inspection was conducted as a renewal visit to review compliance with licensing requirements at Abington Manor at Morgan Hill.
Findings
The inspection identified multiple deficiencies including hot water temperatures exceeding limits, furniture and equipment hazards, fire drill evacuation time issues, smoking area fire safety concerns, medication self-administration assessment lapses, medication labeling errors, storage procedure violations, medication record inaccuracies, follow prescriber order errors, support plan documentation issues, and failure to maintain a records destruction log. All deficiencies had accepted plans of correction and were implemented by the report date.
Citations (13)
89b Hot water temperature in resident-accessible areas exceeded 120°F, measuring 127.5°F in bathrooms of Rooms 124 and 315, and 127.1°F in Room 329.
95 Furniture and equipment hazard: a large block of ice was found on the walk-in freezer floor with frozen water leaking from the ceiling fan.
132d Fire drill evacuation took 13 minutes and 30 seconds, exceeding the expert-approved safe time of 13 minutes.
144c2 Smoking area fire safety: the smoking urn lid was off with combustible materials inside, posing a fire hazard.
181c Resident #1 self-administered medication without a physician assessment of ability to self-administer.
184a Resident #2's prescription medication container lacked staff initials of the person opening the pen.
184b Resident #3's OTC medication capsules were not labeled with the resident's name.
185a Resident #1's medication was not available at the time of inspection, violating storage procedures.
187a Medication record errors for Resident #2 included incorrect MAR strength and dosage documentation.
187d Resident #2's insulin was improperly withheld or administered contrary to prescriber orders on multiple dates.
227d Resident #4's support plan was outdated and did not reflect current care needs including hospice services.
227g Resident #4's support plan was not signed by the resident, and refusal or inability to sign was not documented.
253c The facility failed to maintain a log of resident records destroyed in the last 12 months as required.
Report Facts
Residents Served: 40
Current Residents in Hospice: 3
Fire Drill Evacuation Time: 13.5
Safe Evacuation Time: 13
Inspection Report — Jun 28, 2022
Follow-Up
Date: Jun 28, 2022
Visit Reason
The inspection was a partial, announced follow-up visit due to a change in legal entity, conducted to verify the implementation of a previously submitted plan of correction.
Findings
The submitted plan of correction was determined to be fully implemented, including installation of handrails on egress paths, re-education and scheduling of monthly fire drills, completion of the annual fire safety inspection and fire drill, and improved documentation of fire drill records.
Citations (4)
The exit doors leading from the sunroom had egress paths without handrails, posing a safety risk for residents with walkers.
The home did not conduct a fire drill in December 2021.
The home’s fire safety inspection was not conducted prior to December 31, 2021 as required.
Fire drill logs dated 2/12/22, 04/26/22, and 5/12/22 did not include the exit routes used during the fire drill.
Report Facts
Residents Served: 33
Current Hospice Residents: 4
Total Daily Staff: 34
Waking Staff: 26
Mobility Need: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Michele Moskalczyk | Human Services Licensing Supervisor | Signed the letter confirming plan of correction implementation |
| Director of Services | Named in relation to re-education on fire drills, fire drill documentation, and responsible for scheduling fire safety inspections | |
| Campus Executive Director | Oversees compliance related to fire drills and fire safety inspections | |
| Maintenance Director | Involved in completion of handrail installation |
Inspection Report — Oct 14, 2021
Renewal
Date: Oct 14, 2021
Visit Reason
The inspection was conducted as a renewal visit with an incident review, including an unannounced full inspection on 10/14/2021 and an off-site review on 10/21/2021.
Findings
The facility had multiple deficiencies related to medication administration errors, documentation issues, contract signatures, staff training in CPR/First Aid, fire department notification, smoking policy enforcement, medication storage and labeling, refusal of medication documentation, and resident support plan updates. Plans of correction were accepted and implemented with follow-up reviews scheduled.
Citations (14)
16c - The facility failed to report medication errors involving Resident #1 to the Department within 24 hours as required.
25b - The resident-home contract for Resident #2 was not signed by the resident as required.
63a - No staff certified in First Aid and CPR were present during certain overnight and evening shifts despite serving 35 residents.
124 - The facility incorrectly notified the fire department that 11 residents required evacuation assistance when only 1 resident did.
144c1 - A resident was observed smoking outside the designated smoking area contrary to the facility's smoking policy.
183e - Resident #1’s medication pen lacked the date it was opened, violating manufacturer instructions.
184a - Resident #1’s medication pen lacked the initials of the staff person who opened it.
184b - OTC medications for Residents #1 and #3 were not labeled with the resident's name as required.
184c - Resident #4’s sample medication lacked written directions from the prescriber.
185a - Resident #1’s medications were not available and the blood glucose monitor was not calibrated correctly.
187c - Resident #1 refused medication but the refusals were not reported to the prescriber within 24 hours.
187d - The facility failed to follow prescriber’s orders for Resident #1 and erroneously administered medication to Resident #3 when contraindicated.
188b - Medication errors involving Resident #1 were not immediately reported to the resident, designated person, and prescriber.
227d - Resident support plans for Residents #2 (corrected to #5) and #6 lacked documentation of medical/dietary needs and assistive devices.
Report Facts
Residents served: 35
Staff on duty: 36
Waking staff: 27
Residents with mobility need: 1
Hospice residents: 2
Notice — Sep 7, 2021
Date: Sep 7, 2021
Visit Reason
The document serves as a renewal notification and license issuance for the Personal Care Home 'Abington Manor at Morgan Hill' following receipt of the renewal application dated August 10, 2021.
Findings
The Department issued a regular license in response to the renewal application and advised that an onsite inspection will be conducted within the next twelve months to ensure compliance with applicable regulations.
Report Facts
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary | Signed the renewal notification letter. |
Inspection Report — Apr 20, 2020
Renewal
Date: Apr 20, 2020
Visit Reason
The inspection visits occurred as part of licensing inspections conducted by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing, for the facility's regulatory compliance.
Findings
No regulatory citations were identified as a result of the inspections conducted on multiple dates in April and May 2020.
Inspection Report — Aug 28, 2019
Complaint Investigation
Date: Aug 28, 2019
Visit Reason
The inspection was conducted as a complaint investigation based on concerns raised about the facility's compliance with regulations.
Complaint Details
The inspection was complaint-driven, with the reason for inspection explicitly stated as 'Complaint'. The complaint involved concerns about medication administration, resident assistance, and support plan updates. The submitted plan of correction was fully implemented.
Findings
Multiple violations were found related to resident assistance with activities of daily living, medication administration, documentation of medication refusals, adherence to prescriber's orders, and updating support plans for residents with wandering behaviors. The facility submitted plans of correction which were fully implemented by October 2019.
Citations (6)
23a - Activities of Daily Living Assistance: Resident #1 experienced delayed staff response times to call bells, with documented response times exceeding 17 minutes on multiple occasions.
182c - Medication Administration: Resident #2 was not assessed for self-administering medications, and family members found medications left unsecured in the resident's bedroom.
187b - Date/Time of Medication Administration: Resident #2's eye drops were documented as administered on dates when the medication was not available in the home.
187c - Refusal of Medication: Resident #2 refused multiple medications on various dates, but these refusals were not reported to the prescriber as required.
187d - Follow Prescriber's Orders: Resident #2's eye drops were not administered from 8/14/19 through 8/23/19 due to unavailability in the home.
227d - Support Plan Medical/Dental: Resident #3's support plan was not updated to reflect increased supervision needs related to wandering behaviors.
Report Facts
Residents Served: 48
Current Hospice Residents: 5
Residents Age 60 or Older: 48
Residents with Mobility Need: 14
Residents with Physical Disability: 1
Total Daily Staff: 62
Waking Staff: 47
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Diane Dellocomo | Executive Director | Named in multiple plans of correction and signature on violation reports |
Notice — Aug 12, 2019
Date: Aug 12, 2019
Visit Reason
The document serves as a renewal notification for the operation of a Personal Care Home and informs the owner of the requirement for an annual onsite inspection within the next twelve months.
Findings
No inspection findings are reported in this document. It confirms issuance of a regular license following the renewal application.
Inspection Report — Jul 11, 2019
Complaint Investigation
Date: Jul 11, 2019
Visit Reason
The inspection was conducted as a complaint investigation to assess compliance with 55 Pa. Code Ch. 2600 related to Personal Care Homes.
Complaint Details
The inspection was complaint-driven and unannounced. Specific complaints involved failure to provide assistance with ADLs, delayed call bell responses, incomplete resident documentation, and fire safety concerns.
Findings
Multiple violations were found including failure to provide assistance with activities of daily living, excessive response times to call bells, incomplete resident support plan signatures, outdated resident photographs, and inadequate fire drill exit route practices.
Citations (4)
On 7/2/19, staff refused to open a resident's bottle of water, resulting in the resident not receiving ADL service. Resident #4 waited up to 53 minutes for call bell response on 7/3/19 and 25 minutes on 7/4/19. Resident #5 waited 7 minutes and 12 minutes for toileting assistance on 7/3/19.
The home's fire drill log shows the facility is not alternating exit routes during monthly fire drills, repeatedly using the front exit and fire safe stairwells on multiple dates.
Resident #3's support plan dated 6/20/19 was not signed by the resident and lacked documentation of refusal or inability to sign.
Resident #3 had a photograph dated 6/2017 in their record that was more than two years old, indicating outdated resident documentation.
Report Facts
Residents Served: 56
Current Hospice Residents: 5
Resident #4 call bell wait time: 53
Resident #4 call bell wait time: 25
Resident #5 toileting assistance wait: 7
Resident #5 toileting assistance wait: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Diane Dellacona | Executive Director | Named in Plan of Correction signatures and oversight of compliance |
Inspection Report — May 29, 2019
Complaint Investigation
Date: May 29, 2019
Visit Reason
The inspection was conducted as a complaint investigation to assess compliance with 55 Pa. Code Ch. 2600 relating to Personal Care Homes.
Complaint Details
The inspection was complaint-driven and unannounced. Specific complaints involved treatment record omissions and inadequate updates to resident care plans. The findings were substantiated with citations issued.
Findings
The inspection identified citations related to treatment record documentation and resident care planning, specifically regarding failure to initial treatments and incomplete Resident Assessment and Service Plans (RASP). Plans of correction were submitted addressing staff education and updating resident care plans.
Citations (2)
Treatment records for Resident #1 were not initialed as given on multiple dates, violating documentation requirements.
Resident #1's RASP was not updated to reflect current needs and falls prevention measures, including reminders to use a pendant.
Report Facts
Residents Served: 53
Current Hospice Residents: 5
Staff Counts: 69
Staff Counts: 52
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Diane Dellacono | Executive Director | Signed plans of correction related to treatment record and RASP deficiencies |
| Ryan Novak | On-site Department representative during inspection | |
| Anne Graziano | Human Services Licensing Supervisor | Signed cover letter for inspection report |
Inspection Report — Apr 30, 2019
Complaint Investigation
Date: Apr 30, 2019
Visit Reason
The inspection was conducted as a complaint investigation following an allegation of abuse against staff members at the assisted living facility.
Complaint Details
The complaint investigation was triggered by an allegation of abuse against three staff members. The allegation was substantiated as the plan of supervision was not followed and required training was not completed.
Findings
The investigation found that the approved plan of supervision for staff was not being followed, allowing staff to provide care without proper supervision. Additionally, staff did not receive required annual training under the Older Adult Protective Services Act, and Resident #1's care plan did not identify the need for three staff to assist with transfers.
Citations (3)
Through staff interviews, it was determined that Resident #1 required at least 3 staff to transfer/reposition him while in bed, but the resident's RASP did not identify this need or the home's plan to meet it.
The approved plan of supervision was not followed, allowing Staff persons A and B to provide care to residents without another staff person present at all times.
Staff persons A and B did not receive annual training in the Older Adult Protective Services Act for the 2018 training year.
Report Facts
Residents Served: 50
Current Hospice Residents: 5
Staff Total Daily: 66
Staff Waking: 50
Residents with Mobility Need: 16
Residents 60 Years or Older: 50
Residents with Physical Disability: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Diane Dellocono | Executive Director | Named in plan of correction and supervision oversight |
Inspection Report — Mar 1, 2019
Complaint Investigation
Date: Mar 1, 2019
Visit Reason
The inspection was conducted as a complaint investigation following a complaint received by the Department’s Bureau of Human Services Licensing.
Complaint Details
The inspection was triggered by a complaint. The report does not explicitly state the substantiation status of the complaint.
Findings
The inspection found multiple violations related to medication administration, including medication errors and improper handling of medication carts. Plans of correction were submitted addressing these issues with commitments to staff training and improved medication administration procedures.
Citations (4)
Resident #1's atorvastatin and melatonin were not initialed as administered on 2/22/19 at 9pm.
The electronic EMARS were left open and unattended at 12:10pm, exposing confidential resident information.
Residents #2 and #3's noon medications were pre-poured and left on top of the medication cart while other medications were administered.
Resident #1 did not receive prescribed medications as ordered, and the doctor was not notified of the medication error.
Report Facts
Number of Residents Served: 56
Number of Current Hospice Residents: 6
Number of Hospice Residents in past year: 20
Number of Residents with Mobility Need: 18
Number of Residents with Physical Disability: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Diane Dellocono | Executive Director | Named in multiple plans of correction related to medication administration violations. |
| Ryan Novak | Department representative conducting the inspection. |
Notice — Feb 14, 2019
Date: Feb 14, 2019
Visit Reason
This document serves to notify the facility of a granted waiver related to admission, resident medical evaluation, health care, and preadmission screening under Pennsylvania Code, with conditions and annual review.
Findings
The waiver is granted with conditions requiring the use of specific incident and screening forms. The Department will review compliance with these conditions annually during the facility's annual inspection.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jacqueline L. Rowe | Director | Signed the waiver approval letter |
Notice — Jan 18, 2019
Date: Jan 18, 2019
Visit Reason
The document serves to inform the owner that a previous notice indicating the facility's closure was sent in error and that the license to operate is reinstated.
Findings
No inspection findings are reported as this is a licensing reinstatement notice correcting a prior error.
Report Facts
License Number: 219620
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jacqueline L. Rowe | Director | Signed the reinstatement letter. |
Notice — Jan 7, 2019
Date: Jan 7, 2019
Visit Reason
Notification that the personal care home license number 219620 is no longer operated by Cedar Park Assisted Living, LLC due to a change in legal entity.
Findings
The document confirms that the facility at 215 Cedar Park Boulevard is no longer operated by Cedar Park Assisted Living, LLC as of January 7, 2019, due to a legal entity change.
Inspection Report — Aug 28, 2018
Complaint Investigation
Date: Aug 28, 2018
Visit Reason
The inspection was conducted due to a complaint and incident reported at the facility.
Complaint Details
The visit was complaint-related with substantiated findings of resident abuse, elopement, and inadequate behavior management.
Findings
Violations of 55 Pa. Code Ch. 2600 related to resident care, abuse, elopement, and management of resident behaviors were found. The facility failed to fully implement policies to prevent harm and ensure resident safety.
Citations (6)
Resident #1 was afraid and upset due to staff roughness and mishandling during assistance with undressing and call bell pendant removal.
Resident #3 was missing for approximately two hours due to failure to conduct a full search and notify police promptly, resulting in the resident lying outside in the rain.
Resident #3 was placed in a secured dementia unit after an elopement incident to prevent recurrence.
Resident #5 exhibited aggressive and combative behaviors and had punched Resident #3, requiring increased supervision.
The facility failed to use positive interventions to manage Resident #3's difficult behaviors and did not address the resident's frequent elopement attempts.
Resident #3's behaviors and needs were not addressed in the Resident Assessment and Support Plan (RASP) dated 5/2/2018, and aggressive behaviors were not addressed in the 7/16/2018 RASP.
Report Facts
Number of Current Hospice Residents: 5
Number of Hospice Residents in past year: 8
Number of Residents 60 Years of Age or Older: 52
Number of Residents with Mobility Need: 16
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Susan Sartoretto | Owner | Signed plan of correction documents and referenced as legal entity representative |
Inspection Report — Aug 7, 2018
Renewal
Date: Aug 7, 2018
Visit Reason
The document is a renewal application and license issuance for Abington Manor at Morgan Hill Personal Care Home. The Department of Human Services notifies the facility that an onsite inspection will be conducted within the next twelve months as part of the annual inspection requirement.
Findings
No inspection findings are reported in this document. It serves as a license renewal notification and confirmation of the facility's licensed capacity.
Inspection Report — Sep 26, 2017
Renewal
Date: Sep 26, 2017
Visit Reason
The inspection was an annual licensing inspection conducted as part of the renewal process for Abington Manor at Morgan Hill.
Findings
Multiple violations of 55 Pa.Code Chapter 2600 were found, including missing required posters, lack of carbon monoxide detector, food storage issues, fire hazard risks, medication administration errors, and incomplete resident documentation. Plans of correction were submitted with partial implementation status.
Citations (14)
The facility did not post the Influenza Awareness Act poster in a public and conspicuous place and lacked a carbon monoxide detector in the kitchen as required.
A container in the kitchen storing two 25 lb. bags of sugar did not have a lid.
Opened bags of cereal in the dry food storage room were not dated when opened.
The dryer lint trap in the third floor laundry room had an abundance of lint.
Combustible materials were stored within 2 feet of hot water heaters with gas pilots in the boiler room.
Medication administration errors occurred including improper documentation and administration of prescribed medications for residents.
Expired medication (Spiriva Cap Handihlr) was kept in the home.
The original container for prescription medications lacked proper pharmacy labels including resident name, medication name, prescription date, dosage, and prescriber information.
The home failed to document refusals of prescribed medications and did not report refusals to the prescriber as required.
The home did not follow directions of the prescriber for medication administration, including missed doses and failure to weigh residents as ordered.
The glucometer for a resident was not calibrated to date and time, and some prescribed medications were not available in the home.
The home failed to develop and implement procedures for safe storage, access, security, distribution, and use of medications by trained staff.
The home did not notify the local fire department in writing of the home's capacity as required.
The resident assessment and support plan for a resident was not updated to reflect dietary restrictions and needs.
Report Facts
Number of Residents Served: 51
Total Daily Staff: 60
Waking Staff: 45
Number of Current Hospice Residents: 8
Number of Hospice Residents in Past Year: 23
Employees mentioned
| Name | Title | Context |
|---|---|---|
| David Seng | Administrator | Named in multiple findings and plans of correction |
Notice — Aug 9, 2017
Date: Aug 9, 2017
Visit Reason
This document serves as a renewal notification for the operation of a Personal Care Home pursuant to Title 55, PA Code, Chapter 2600, and informs the facility of the requirement for an annual onsite inspection within the next twelve months.
Findings
No inspection findings are reported in this document. It is a license renewal letter and certificate confirming the facility's authorized capacity and renewal status.
Inspection Report — Jun 21, 2017
Complaint Investigation
Date: Jun 21, 2017
Visit Reason
The inspection was conducted as a licensing inspection triggered by complaint and incident reports at Abington Manor at Morgan Hill.
Complaint Details
The inspection was complaint-related, triggered by incidents involving medication errors and missing medications. Specific complaints included failure to report incidents and medication administration errors.
Findings
Multiple violations related to medication administration, labeling, storage, and reporting were found. The facility failed to report incidents timely and had issues with medication availability and documentation.
Citations (7)
Regulation 55 Pa.Code §2600: The home failed to report a missing blister pack of Oxycodone for Resident #1 to the Department within 24 hours as required.
Regulation 55 Pa.Code §2600.42(l): Residents did not have all prescribed medications in stock, including Tramadol and APAP/Codeine, causing medication availability issues.
Regulation 55 Pa.Code §2600.183(a)(1): Prescription medications were not kept in original labeled containers, risking loss and confusion.
Regulation 55 Pa.Code §2600.184(a): Medication labels lacked required pharmacy information and appeared to be borrowed from other bottles.
Regulation 55 Pa.Code §2600.185(a): Medication administration procedures were not properly documented, including missing signatures and incomplete records.
Regulation 55 Pa.Code §2600.187(a): Medication administration records lacked date, time, and staff initials for multiple doses administered to residents.
Regulation 55 Pa.Code §2600.188(b): Medication errors were not immediately reported to the resident, designated person, and prescriber as required.
Report Facts
Number of Residents Served: 53
Number of Current Hospice Residents: 7
Number of Hospice Residents in past year: 24
Total Daily Staff: 62
Waking Staff: 47
Residents 60 Years or Older: 53
Residents with Mobility Need: 9
Residents with Physical Disability: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| David Seng | Administrator | Named in multiple medication administration and compliance findings |
| Kimberli Foulkes | Department representative on-site during inspection |
Inspection Report — Dec 20, 2016
Complaint Investigation
Date: Dec 20, 2016
Visit Reason
The inspection was conducted as a complaint investigation triggered by an incident involving a resident discharged from a long-term care facility with orders for a wheelchair and gel cushion due to risk for pressure ulcers.
Complaint Details
The investigation was triggered by an incident involving a resident discharged from a long-term care facility with orders for pressure ulcer prevention equipment. The complaint was substantiated as the facility failed to follow physician orders and update the resident's support plan accordingly.
Findings
The facility failed to follow the directions of the prescriber regarding wound care and pressure ulcer prevention for a resident, resulting in a sacral stage II pressure ulcer and other complications. Additionally, the resident's support plan was not updated to reflect wound care needs or repositioning requirements.
Citations (4)
55 Pa.Code §2600.187(d) - The home did not follow the directions of the prescriber for resident care.
A resident was discharged with orders for a wheelchair and gel cushion to prevent pressure ulcers, but the home failed to follow these orders, resulting in a sacral stage II pressure ulcer and other complications.
55 Pa.Code §2600.227(a) - The resident's written support plan was not developed or implemented within 30 days of admission as required.
The resident's support plan was not updated to indicate the need for wound care or who would provide it, nor to indicate repositioning needs to promote wound healing.
Report Facts
Number of Residents Served: 52
Number of Current Hospice Residents: 7
Number of Hospice Residents in Past Year: 7
Total Daily Staff: 57
Walking Staff: 43
Residents Age 60 or Older: 52
Residents with Mobility Need: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| David Seng | Administrator | Named as legal entity representative and administrator in violation report and plan of correction |
| Julienne Rushin | Department of Human Services inspector conducting the investigation | |
| Jason Harvey | Department of Human Services inspector conducting the investigation |
Inspection Report — Sep 1, 2016
Annual Inspection
Date: Sep 1, 2016
Visit Reason
The inspection was an annual licensing inspection conducted by the Pennsylvania Department of Human Services on September 1, 2016, at Abington Manor at Morgan Hill.
Findings
Multiple violations of 55 Pa.Code Chapter 2600 related to personal care home regulations were found, including issues with resident confidentiality, hot water temperature, medical evaluations, medication storage and administration, and resident care planning.
Citations (9)
55 Pa.Code 2600.17 - Resident records were not kept confidential as a resident name was found on a post report sheet visible on the first floor elevator.
55 Pa.Code 2600.89(b) - Hot water temperatures at sinks accessible to residents measured above 120°F, posing a scalding risk.
55 Pa.Code 2600.41(a)(2) - Medical evaluations for residents were incomplete or not properly signed by medical professionals.
55 Pa.Code 2600.183(a)(1) - Prescription medications and OTC drugs were not properly stored or labeled, and medication removal procedures were not followed.
55 Pa.Code 2600.183(d) - Insulin vials were not labeled with the date opened, risking use of expired medication.
55 Pa.Code 2600.185(a) - Medications were not safely stored or accessible only to trained staff, and some medications were not on site as ordered.
55 Pa.Code 2600.225(a) - Resident assessments were incomplete, missing reassessments and bowel management evaluations.
55 Pa.Code 2600.227(a) - Support plans for residents were incomplete or missing required summaries and determinations.
55 Pa.Code 2600.251(b) - Resident records lacked permanent, legible, and signed entries by staff on controlled drug records.
Report Facts
Number of Residents Served: 55
Total Daily Staff: 60
Walking Staff: 45
Number of Current Hospice Residents: 8
Number of Hospice Residents in past year: 10
Residents 60 Years or Older: 55
Residents with Mobility Need: 6
Residents with Physical Disability: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| David Seng | Administrator | Named in multiple plans of correction and responses to violations |
| Jesse Hummel | Department Representative conducting inspection |
Inspection Report — Aug 11, 2016
Renewal
Date: Aug 11, 2016
Visit Reason
The document is a renewal application and license issuance for Cedar Park Assisted Living, LLC to operate Abington Manor at Morgan Hill. The Department will conduct an onsite inspection within the next twelve months as part of the renewal process.
Findings
No inspection findings are reported in this document. It confirms the issuance of a regular license following the renewal application.
Inspection Report — Jun 30, 2016
Date: Jun 30, 2016
Visit Reason
The inspection was conducted as an interim document review related to a licensing enforcement action concerning the improper use of the term 'Assisted Living' by the facility.
Findings
The facility was found in violation of Pennsylvania Code § 2600 for advertising as an assisted living residence without proper licensure. The violation concerns the use of the term 'Assisted Living' in written materials and on the website, which is prohibited unless licensed accordingly.
Citations (1)
55 Pa.Code § 2600.18: The facility advertised assisted living services and identified itself as an 'Assisted Living' residence without being licensed as such, violating state regulations.
Report Facts
Fine per resident per day: 3
Calculated Fine per day: 159
Mandated Correction Date: 15
Inspection Report — Jun 30, 2016
Date: Jun 30, 2016
Visit Reason
The inspection was an interim document review conducted by the Department of Human Services to assess compliance with licensing regulations for the facility.
Findings
The facility was found to be in violation of 55 Pa.Code Chapter 2600 related to the use of the term 'assisted living' in marketing materials, as it is not a licensed assisted living residence. A plan of correction was submitted to address the violation by removing the term from the website and virtual tour.
Citations (1)
55 Pa.Code § 2600.18: The facility improperly used the term 'assisted living' in marketing materials despite not being licensed as an assisted living residence.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| David Seng | Administrator | Signed the plan of correction addressing the violation related to marketing language. |
Inspection Report — Jun 28, 2016
Complaint Investigation
Date: Jun 28, 2016
Visit Reason
The inspection was conducted as a complaint investigation triggered by an incident involving medication errors reported on June 28 and June 29, 2016.
Complaint Details
The investigation was triggered by an incident involving medication errors on 6/28/2016. The provider failed to report the incident timely and had medication administration errors involving residents #1 and #2.
Findings
The provider failed to report medication errors within 24 hours and lacked a system for timely submission of reportable incidents. Medication administration errors occurred involving residents #1 and #2, including improper handling and documentation of medications.
Citations (2)
Regulation 55 Pa.Code §2600.160(b): The home failed to report medication errors within 24 hours and lacked a system for timely submission of reportable incidents.
Regulation 55 Pa.Code §2600.182(c): Medication administration errors occurred involving residents #1 and #2, including incorrect medication handling and failure to follow proper medication procedures.
Report Facts
Number of Residents Served: 57
Number of Current Hospice Residents: 3
Number of Hospice Residents in past year: 11
Number of Residents Age 60 or Older: 57
Number of Residents with Mobility Need: 8
Number of Residents with Physical Disability: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| David Seng | Administrator | Named as legal entity representative and signer of plan of correction related to medication error findings |
Notice — September 7, 2021
Date: September 7, 2021
Visit Reason
This document serves as a license renewal notification and certificate of compliance for Abington Manor at Morgan Hill, a Personal Care Home. It informs the facility that a regular license is being issued and that an annual onsite inspection will be conducted within the next twelve months.
Findings
No inspection findings are reported in this document. It only confirms the issuance of a license and the requirement for a future annual inspection.
Report Facts
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary, Office of Long-term Living | Signed the renewal notification letter. |
Report — November 1, 2018
November 1, 2018
Viewing
Loading inspection reports...
