38 Reports
Inspection Report — Jan 28, 2026
Renewal
Date: Jan 28, 2026
Visit Reason
The inspection was conducted as a renewal inspection combined with complaint and incident investigations to assess compliance with licensing regulations.
Findings
Multiple deficiencies were identified including unsecured poisonous materials, unsanitary conditions, inadequate water temperature, missing emergency telephone numbers, furniture and equipment issues, medication administration errors, and incomplete resident assessments. Plans of correction were accepted and implemented with ongoing monitoring.
Citations (13)
82c - Poisonous materials were unlocked and accessible in resident #1's medicine cabinet, posing a safety risk.
85a - Rear hallway to dumpster area was littered with trash and some trash bins lacked lids, compromising sanitary conditions.
89a - Hot water temperature in showers of residents #2 and #3 measured 69°F, preventing proper showering.
91 - Emergency telephone numbers were not posted near the telephone by the Life Guidance kitchen.
95 - Water heater in basement was leaking and a resident room heater was not operating correctly.
101j7 - Resident #4 did not have access to an operable lamp or lighting source at bedside.
103f - Life Guidance kitchen refrigerator temperature was 44°F, exceeding the required maximum of 40°F.
121a - Stairways and emergency exits were obstructed by icy snow and a locked emergency exit door.
182b - Staff administered medications without completing required medication administration training.
183b - Prescription medications and syringes were unlocked and accessible in resident #4's room, who cannot self-administer medications.
185a - Thirteen oxygen tanks were unsecured and accessible in room 101, and a blood sugar reading was inaccurately logged.
187a - Resident #5's medication record erroneously indicated three insulin injections per day instead of four.
225c - Resident #4's assessment did not document the need for two bedside mobility devices in use.
Report Facts
Residents Served: 148
Secured Dementia Care Unit Residents Served: 23
Hospice Current Residents: 4
Residents 60 Years or Older: 148
Residents with Mobility Need: 52
Oxygen Tanks Unsecured: 13
Inspection Report — Sep 4, 2025
Follow-Up
Date: Sep 4, 2025
Visit Reason
The inspection visit on 09/04/2025 was a partial, unannounced follow-up inspection triggered by an incident and monitoring related to a plan of correction submission.
Findings
The facility was found to have fully implemented the submitted plan of correction related to an abuse violation involving theft of residents' property by a direct care staff member. The staff member was suspended and subsequently terminated for failure to comply with the investigation. The facility conducted internal investigations, filed a police report, provided staff training, reimbursed the residents, and implemented ongoing monitoring of corrective actions.
Citations (1)
Violation of abuse regulation 42b involving theft of residents' property by a direct care staff person in the secure dementia care unit.
Report Facts
Residents Served: 111
Secured Dementia Care Unit Residents Served: 21
Hospice Current Residents: 5
Residents Age 60 or Older: 111
Residents with Mental Illness: 3
Residents with Intellectual Disability: 1
Residents with Mobility Need: 45
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director | Conducted internal investigation, filed police report, suspended staff person A, provided in-service training, reimbursed residents, and led corrective actions | |
| Community Business Director | Participated in suspension of staff person A during investigation | |
| Life Guidance Director | Provided in-service training to Life Guidance Resident Services Assistants | |
| Direct Care Staff Person A | Alleged to have stolen residents' iPads, denied theft, failed to provide written statement, suspended and terminated |
Inspection Report — May 28, 2025
Follow-Up
Date: May 28, 2025
Visit Reason
The inspection visit on 05/28/2025 was conducted as a follow-up to verify the implementation of a previously submitted plan of correction related to complaint and incident issues at the facility.
Complaint Details
The inspection was complaint-related as indicated by the reason 'Complaint, Incident' and was a follow-up to verify correction of cited deficiencies.
Findings
The submitted plan of correction was determined to be fully implemented as of the inspection date. Several deficiencies related to posting of telephone numbers, staff qualifications, training, medication administration, and medication records were addressed with corrective actions and ongoing monitoring plans.
Citations (6)
Telephone numbers of the Department's personal care home regional office, local ombudsman, protective services, and complaint hotline were not posted in a conspicuous and public place in the secure dementia care unit.
Direct care staff person A did not have a valid high school diploma, GED, or active registry status on the Pennsylvania nurse aide registry; nurse aide certificate was expired.
Direct care staff person B did not receive required medication self-administration training during the training year.
Staff person A administered medications without completing required medication administration training as specified in regulations.
Medication administration record for a resident did not accurately reflect the prescribed medication schedule.
Direct care staff persons A and B, working in the Secure Dementia Care Unit, had only 3.5 hours of required 6 hours annual dementia care training during the training year.
Report Facts
Residents served: 118
Total daily staff: 159
Waking staff: 119
Residents served in secured dementia care unit: 21
Current hospice residents: 8
Residents aged 60 or older: 118
Residents with mobility need: 41
Residents diagnosed with intellectual disability: 1
Hours of dementia care training completed: 3.5
Hours of required dementia care training: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff person A | Named in deficiencies related to expired nurse aide certificate, medication administration without proper training, and insufficient dementia care training | |
| Staff person B | Named in deficiencies related to lack of medication self-administration training and insufficient dementia care training | |
| Executive Director | Executive Director | Conducted walkthroughs, in-service trainings, employee townhall meetings, and oversaw plan of correction implementation |
| Community Business Director | Community Business Director | Conducted audits of direct care staff qualifications and medication administration training |
| Resident Services Director | Resident Services Director | Participated in in-service trainings and audits related to medication administration and staff training |
| Resident Services Supervisor | Resident Services Supervisor | Participated in in-service trainings and audits related to medication administration and staff training |
| Life Guidance Director | Life Guidance Director | Sent notifications to responsible parties and participated in training audits |
Inspection Report — Jan 30, 2025
Renewal
Date: Jan 30, 2025
Visit Reason
The inspection was conducted as part of a renewal, provisional, incident, and monitoring review of the facility to ensure compliance with 55 Pa. Code Chapter 2600 relating to Personal Care Homes.
Findings
The facility was found to be in compliance overall, but several deficiencies were cited including missing carbon monoxide detectors, incomplete resident contracts, elopement risk due to alarm failures, privacy violations due to missing signage, incorrect posted telephone numbers, lack of criminal background checks for hospice workers, incomplete fire safety training, missing bedside tables and operable lamps for some residents, refrigerator temperature violations, medication storage and administration issues, incomplete resident assessments and support plans, and incomplete preadmission screening and consent documentation for secured dementia care residents.
Citations (18)
No Carbon Monoxide detector in kitchen using gas equipment.
Resident-home contracts not signed timely or missing signatures.
Resident eloped from secured dementia care unit due to alarm system failure.
Missing signage indicating video recording in elevator vestibule.
Incorrect telephone number posted for local ombudsman.
No criminal background checks for hospice workers providing services.
Staff did not receive required fire safety training by a fire safety expert.
No bedside table or shelf beside beds of residents #4 and #6.
Residents #4 and #6 did not have operable lamps or lighting at bedside.
Kitchen refrigerator temperature exceeded 40°F.
Tears in medication blister packs making medication unsanitary.
Medication (Motrin 800 MG) not available for resident #7.
Missed medication administrations due to prior authorization delay for resident #6.
Resident #5 initial assessment not completed within 15 days of admission.
Resident support plans missing required medical, dental, behavioral care documentation.
Residents #1 and #8 did not sign their support plans.
Resident #3 preadmission cognitive screening incomplete for secured dementia care unit.
Resident #9 consent form for secured dementia care unit signed late by resident and designated person.
Report Facts
Residents Served: 126
Secure Dementia Care Unit Residents Served: 19
Hospice Residents: 4
Residents Age 60 or Older: 122
Residents with Intellectual Disability: 1
Residents with Mobility Need: 44
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Juliet Marsala | Deputy Secretary | Signed licensing letter and certificate. |
| Executive Director | Named in multiple plans of correction related to compliance and training. | |
| Maintenance Director | Named in plan of correction for carbon monoxide detector installation. | |
| Community Business Director | Named in plan of correction for resident contract audits. | |
| Resident Services Director | Named in medication and assessment related findings and plans of correction. | |
| Resident Service Supervisor | Named in medication audit and training plans. | |
| Assistant Director Culinary Services | Named in refrigerator temperature violation plan of correction. | |
| Regional Care Director | Named in training and education plans of correction. | |
| Life Guidance Director | Named in elopement protocol training and consent documentation plans. | |
| Resident Medication Assistants | Named in medication storage and administration training. | |
| Wellness Nurse | Named in elopement incident and medication training. |
Inspection Report — Nov 25, 2024
Date: Nov 25, 2024
Visit Reason
The inspection was a licensing inspection conducted by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing on 11/25/2024.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Residents Served: 110
Secured Dementia Care Unit Residents Served: 20
Hospice Current Residents: 4
Residents Age 60 or Older: 110
Residents Diagnosed with Intellectual Disability: 1
Residents Diagnosed with Mental Illness: 0
Residents with Mobility Need: 36
Residents with Physical Disability: 8
Resident Support Staff: 0
Total Daily Staff: 146
Waking Staff: 110
Inspection Report — Aug 15, 2024
Follow-Up
Date: Aug 15, 2024
Visit Reason
The inspection visit on 08/15/2024 was conducted as a follow-up to verify that the submitted plan of correction was fully implemented following previous deficiencies.
Findings
The submitted plan of correction was determined to be fully implemented as of the inspection date. Deficiencies related to annual medical evaluations and medication storage and administration were addressed with corrective actions and training.
Citations (3)
Resident medical evaluations were not completed annually as required.
Medications stored in resident bedrooms were found unlocked and unattended, including alprazolam 1mg tablets.
Resident self-administering medications was unable to remember medication details and was not safely self-administering medications.
Report Facts
Residents Served: 114
Secured Dementia Care Unit Residents Served: 11
Hospice Current Residents: 4
Residents Age 60 or Older: 114
Residents with Mobility Need: 32
Total Daily Staff: 146
Waking Staff: 110
Inspection Report — Jun 17, 2024
Complaint Investigation
Date: Jun 17, 2024
Visit Reason
The inspection was conducted as a complaint investigation following allegations at the facility, Atria Center City, on June 17, 2024.
Complaint Details
The inspection was complaint-driven, triggered by allegations at the facility. The report documents multiple repeated violations and deficiencies related to medication management, resident assessments, and documentation.
Findings
Multiple violations were found related to medication management, resident assessments, support plans, and preadmission screening. Several deficiencies were repeated from prior inspections, and a provisional license was issued due to non-compliance.
Citations (13)
Resident #1’s most recent medical evaluation was not current.
Discontinued medications were found in the medication cart for resident #2.
Pharmacy label for resident #2's Melatonin did not match prescribed dosage.
Resident #2's medication administration record did not list diagnosis or purpose for Memantine.
Resident #3 was administered medications at incorrect times and received half the prescribed dose of Enalapril.
Resident #4’s preadmission screening form was not completed timely prior to admission.
Assessment and support plan for resident #1 were not signed by participants.
Support plan for resident #2 did not address agitation despite medication for agitation.
On 8/5/2024, medication was found in the home without a current order for resident #3.
Resident #4's medication packaging was torn in multiple spots.
Resident #3’s prescribed medication Tramadol was not available in the home.
Resident #1’s initial support plan was not completed within 30 days of admission.
Resident #4 and #5’s written cognitive preadmission screening was not completed within 72 hours prior to admission to the secured dementia care unit.
Report Facts
Residents Served: 128
Residents Served in Secure Dementia Care Unit: 13
Fine Per Resident Per Day: 5
Calculated Fine Per Day: 645
Staffing Hours - Resident Support Staff: 151
Staffing Hours - Waking Staff: 113
Inspection Report — Feb 1, 2024
Monitoring
Date: Feb 1, 2024
Visit Reason
The inspection was a monitoring visit conducted by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing on 02/01/2024.
Findings
No regulatory citations or deficiencies were identified during this inspection.
Report Facts
Resident Support Staff: 175
Waking Staff: 131
Residents Served: 137
Secured Dementia Care Unit Residents Served: 20
Residents Age 60 or Older: 137
Residents Diagnosed with Mental Illness: 1
Residents with Mobility Need: 38
Residents with Physical Disability: 1
Inspection Report — Nov 27, 2023
Renewal
Date: Nov 27, 2023
Visit Reason
The inspection was conducted as a renewal visit for the facility license, including a full unannounced inspection on 11/27/2023 and 11/28/2023.
Findings
The inspection identified multiple deficiencies related to resident record confidentiality, contract signatures, privacy violations, inadequate staff training, unsafe bedside mobility devices, emergency preparedness, prohibited portable space heaters, incomplete medical evaluations, medication storage and labeling issues, improper medication administration documentation, resident rights education, preadmission screening delays, incomplete support plans, and incomplete resident record content.
Citations (18)
A book with residents' toileting schedule/checks was unsecured in the memory care closet, which was unlocked.
Resident-home contract for resident #1 was not signed by the resident.
Resident #1's record did not contain a signed statement acknowledging receipt of resident rights and complaint procedures.
Medication technician was observed administering meds to a resident in the home's Bistro, violating privacy.
Direct care staff person B received only 2.5 hours of annual training in 2022, lacking required training topics.
Bedside mobility device for resident #2 was not compliant with FDA guidelines and not documented in support plan.
Bedside mobility device used by resident #3 slid under mattress and was not secured to bed frame, creating entrapment hazard.
Staff person E did not have a copy of the emergency preparedness plan for the local municipality.
Portable space heater was in use in resident room #320.
Medical evaluations for residents #4 and #5 were incomplete, missing medication list and body positioning information.
Medical evaluations for residents #1, #4, #6, #7, #8, and #9 were not completed within the required annual timeframe.
Medications for residents #4, #10, and #11 were improperly stored or labeled, including undated insulin pens and expired nasal spray.
Glucometers for residents #4, #10, and #12 were not calibrated correctly or documentation was incomplete.
Resident #1 was not educated on the right to refuse medication if a medication error is suspected.
Resident #14's preadmission screening form was completed after admission date.
Support plans for residents #2 and #3 did not document or address the use of bedside mobility devices (enablers).
Written cognitive preadmission screening for residents #5 and #15 were incomplete or not timely.
Resident records for #8, #16, and #17 were missing required demographic information, photographs, or preadmission screening.
Report Facts
Residents Served: 126
Total Daily Staff: 164
Waking Staff: 123
Secured Dementia Care Unit Residents Served: 18
Residents Diagnosed with Mental Illness: 2
Residents with Mobility Need: 38
Residents Aged 60 or Older: 126
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Medication Technician | Observed administering medication inappropriately outside resident apartment |
| Staff Person B | Received insufficient annual training and training on required topics | |
| Staff Person C | Did not receive required annual training on multiple topics | |
| Staff Person D | Did not receive required annual training on resident rights and protective services | |
| Staff Person E | Did not have copy of emergency preparedness plan |
Inspection Report — May 16, 2023
Follow-Up
Date: May 16, 2023
Visit Reason
The inspection visit on 05/16/2023 was conducted as a follow-up to verify the implementation of a previously submitted plan of correction related to support plan signatures.
Findings
The facility was found to have fully implemented the plan of correction regarding support plan signatures, ensuring that residents participate in and sign their support plans as required by state regulation.
Citations (1)
Resident #1 did not have a signature on the support plan or any indication that the resident was unable or declined to sign or participate in the support plan.
Report Facts
Residents Served: 135
Secured Dementia Care Unit Residents Served: 20
Current Hospice Residents: 4
Residents Age 60 or Older: 135
Residents with Mobility Need: 43
Total Daily Staff: 178
Waking Staff: 134
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Resident Services Director | Named in plan of correction and responsible for ensuring compliance with support plan signature regulation | |
| Regional Care Director | Provided additional training to Executive Director and Resident Services Director on support plan signature requirements | |
| Executive Director | Received training and met weekly with Resident Services Director to review support plans for compliance |
Inspection Report — Apr 10, 2023
Plan of Correction
Date: Apr 10, 2023
Visit Reason
The inspection was conducted as a complaint and incident investigation with an unannounced partial inspection on 04/10/2023.
Complaint Details
The visit was complaint-related and involved an incident where Resident #1 was hospitalized with seizure-like activity. The home submitted an initial incident report but did not submit the required final report to the Department.
Findings
The facility failed to submit a final incident report to the Department following a resident's hospitalization due to seizure-like activity. The plan of correction was accepted and fully implemented by 06/12/2023.
Citations (1)
Failure to submit a final incident report to the Department following a resident's hospitalization.
Report Facts
Residents Served: 134
Secured Dementia Care Unit Residents Served: 22
Residents Age 60 or Older: 134
Residents with Intellectual Disability: 2
Residents with Physical Disability: 2
Residents with Mobility Need: 42
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Resident Services Director | Named in plan of correction for submitting initial and final incident reports | |
| ED | Named in plan of correction for retraining and auditing incident reports | |
| RSD | Named in plan of correction for retraining on reporting requirements | |
| RVP | Responsible for retraining ED and RSD on reporting requirements |
Inspection Report — Mar 2, 2023
Complaint Investigation
Date: Mar 2, 2023
Visit Reason
The inspection was conducted as a complaint investigation following a complaint received by the Pennsylvania Department of Human Services.
Complaint Details
The visit was complaint-related, triggered by a complaint regarding neglect and failure to provide required care to resident 1, including failure to report an incident and inadequate assistance with Foley bag management. The complaint was substantiated by the findings.
Findings
The inspection found multiple deficiencies including failure to report an unwitnessed fall incident to the department, inadequate assistance with activities of daily living such as Foley bag management, neglect in checking on a resident leading to a fall in the shower, and failure to ensure direct care staff met qualification requirements. Plans of correction were accepted and implemented.
Citations (5)
Failure to report an unwitnessed fall incident to the department within 24 hours.
Failure to provide assistance with activities of daily living as indicated in the resident’s assessment and support plan, specifically Foley bag management.
Neglect of resident leading to a fall in the shower with the water running and flooding the bathroom.
Direct care staff person did not have a high school diploma, GED, or active registry status on the Pennsylvania nurse aide registry.
Resident support plan did not document dates, times, or staff names for assistance provided, and resident did not sign the support plan as required.
Report Facts
Residents Served: 130
Secured Dementia Care Unit Residents Served: 19
Current Hospice Residents: 4
Total Daily Staff: 169
Waking Staff: 127
Resident with Mobility Need: 39
Resident Age 60 or Older: 130
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Resident Services Director | Named in multiple findings related to monitoring communication logs, training, and auditing incident reports and support plans. | |
| Executive Director | Named in multiple findings related to training, auditing, and ensuring compliance with incident reporting and support plans. | |
| Regional Care Director | Named in findings related to providing training and education to staff on incident reporting and support plans. | |
| Manager on Duty | Named in monitoring communication logs and incident reporting. | |
| Staff member A | Reported failure to check on resident leading to fall incident. |
Inspection Report — Oct 18, 2022
Date: Oct 18, 2022
Visit Reason
The inspection was conducted as a partial, unannounced visit related to an incident.
Findings
No regulatory citations or deficiencies were identified during the inspection.
Report Facts
Residents Served: 136
Secured Dementia Care Unit Residents Served: 18
Residents 60 Years or Older: 136
Residents with Mobility Need: 41
Total Daily Staff: 177
Waking Staff: 133
Inspection Report — Aug 17, 2022
Follow-Up
Date: Aug 17, 2022
Visit Reason
The visit was conducted as a follow-up to review the submitted plan of correction after an incident at the facility.
Findings
The facility was found to have deficiencies related to insufficient direct care staffing hours for residents with mobility needs and incomplete orientation and training of a staff person on fire safety, resident rights, and abuse reporting. The submitted plan of correction was determined to be fully implemented.
Citations (3)
Direct care staff hours were insufficient to provide at least 2 hours per day of personal care services to residents with mobility needs; 154.5 hours provided versus 160 hours required.
A staff person did not receive required orientation on fire safety and emergency preparedness topics on their first day of work.
A staff person did not complete training within 40 scheduled working hours on resident rights, emergency medical plan, mandatory reporting of abuse and neglect, and reporting of reportable incidents and conditions.
Report Facts
Residents served: 136
Residents with mobility needs: 41
Direct care staffing hours provided: 154.5
Direct care staffing hours required: 160
Staffing audit period: 90
Training completion timeframe: 10
Inspection Report — Jul 19, 2022
Renewal
Date: Jul 19, 2022
Visit Reason
The inspection was conducted as a renewal review of the facility's compliance with regulatory requirements.
Findings
Multiple deficiencies were identified including failure to timely report incidents, missing resident contract signatures, incomplete criminal background checks, unqualified direct care staff, unsanitary conditions, improper lighting in resident rooms, improper food storage, failure to submit emergency procedures annually, improper medication storage, inaccurate glucometer calibration, and late preadmission screening for secured dementia care unit residents. Corrective actions and training plans were submitted and accepted.
Citations (12)
Failure to report incidents to the department within 24 hours as required.
Resident-home contract not signed by resident due to cognitive impairment.
Staff person A lacked FBI criminal background check prior to hire.
Direct care staff person B lacked required high school diploma, GED, or registry status.
Direct care staff persons B and C lacked documentation of completion and passing of Department-approved direct care training.
Strong fecal odor and fecal matter found in secured dementia care unit; unsanitary use of resident glucometer.
Residents #9 and #10 lacked operable lamp or source of lighting at bedside.
Food stored in opened and unsealed containers in dry food pantry.
Written emergency procedures not submitted annually to local Emergency Management Agency.
Loose pills observed in nursing/diabetic treatment cart.
Resident #7's glucometer not calibrated to correct time; multiple inaccurate glucose log readings for residents #7 and #8.
Resident #9 admitted to secured dementia care unit without timely preadmission cognitive screening.
Report Facts
Residents served: 120
Residents served in secured dementia care unit: 19
Current hospice residents: 7
Residents age 60 or older: 120
Residents with mobility need: 43
Residents with physical disability: 4
Inspection Report — May 6, 2022
Follow-Up
Date: May 6, 2022
Visit Reason
The inspection was a partial, unannounced follow-up review conducted due to an incident involving medication errors and related compliance issues at the facility.
Findings
The facility failed to fully implement its plan of correction related to medication administration errors, incident reporting delays, and communication failures. Multiple deficiencies were identified including failure to report incidents timely, improper medication order clarifications, missed medication doses, and failure to notify prescribers of medication refusals.
Citations (7)
Failure to provide immediate access to the home, residents, and records to Department agents upon request.
Failure to report a medication error incident to the Department within 24 hours as required.
Failure to follow medication procedures including triple check physician verification and clarification of unclear orders.
Changes in medication orders were not properly documented or communicated, including discontinuation without written or verbal order.
Medication administration records lacked diagnoses or purpose for prescribed medications.
Failure to document and report resident refusals of medication to prescribers within 24 hours.
Failure to follow prescriber's orders resulting in missed administration of prescribed medication on specified dates.
Report Facts
Residents Served: 128
Residents Served in Dementia Unit: 16
Residents with Mobility Need: 41
Medication Refusal Dates: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Claire Mendez | Human Services Licensing Supervisor | Signed the letter regarding plan of correction implementation. |
| Resident Services Director | Named in multiple findings related to medication errors, incident reporting, and staff training. | |
| Executive Director | Named in findings related to communication failures and training on incident reporting and medication procedures. | |
| Regional Care Director | Provided training to Executive Director and Resident Services Director on policies and procedures. |
Notice — Sep 13, 2021
Date: Sep 13, 2021
Visit Reason
The document serves as a renewal notification and license issuance for the Personal Care Home 'Atria Center City' following receipt of the renewal application dated August 17, 2021.
Findings
The Department advises that an onsite annual inspection will be conducted within the next twelve months to ensure compliance with applicable regulations; no inspection findings are reported in this document.
Report Facts
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary | Signed the renewal notification letter. |
Inspection Report — Apr 5, 2021
Renewal
Date: Apr 5, 2021
Visit Reason
The inspection was conducted as a renewal review of the Atria Center City personal care home to verify compliance with state regulations and licensing requirements.
Findings
The inspection identified multiple deficiencies including missing posted documents, incomplete resident contract signatures, lack of staff training documentation, improper storage and labeling of medications, and issues with emergency procedures and facility maintenance. Plans of correction were accepted and documented for all deficiencies.
Citations (23)
The home did not have a copy of the current license inspection summary or Personal Care Homes regulation book posted in a conspicuous and public place.
The home did not post required influenza information year-round as required by the Influenza Awareness Act.
Residents #1, #2, and #3 did not sign the Atria Senior Living contract and there was no documentation of refusal or inability to sign.
Residents #1, #2, and #3's records did not contain a signed statement acknowledging receipt of resident rights and complaint procedures.
Direct care staff persons A, B, C, and D lacked documentation of required qualifications including high school diploma, GED, or active registry status.
Staff persons B and D did not have documentation of required fire safety and emergency preparedness orientation on their first day.
Staff persons B and D did not have documentation of training within 40 scheduled working hours on resident rights, emergency medical plan, mandatory reporting of abuse and neglect, and reporting of reportable incidents.
Direct care staff persons B and D did not complete and pass the Department-approved direct care training course.
Three large trash cans and two rectangular trash cans were uncovered and without lids in the kitchen.
The first aid kit in the administrative area lacked a thermometer, tweezers, and scissors.
Apartments # and # did not have a source of light that can be turned on/off at the bedside.
There was no toilet paper in bathroom 236.
Two thermometers in the SDCU kitchenette refrigerator measured above required temperatures (46°F and 50°F).
Two tubs of ice cream in the kitchen freezer were uncovered.
The home’s written emergency procedures had not been submitted to the local emergency management agency since 11/4/2019.
The home’s emergency procedures were not posted in a conspicuous and public place.
The home's menu for the week of 4/5/21 was not posted on the SDCU.
Resident #6's medication label for MAPAP was inconsistent with the prescribed dosage instructions.
Resident #3's prescribed Acetaminophen medication was not available in the home on 4/6/21.
Resident #1's prescribed Vitamin D3 was not administered on 4/5/21 or 4/6/21 due to medication unavailability.
The home did not provide documentation that residents #1, #2, and #3 were educated on their right to refuse medication.
An initial assessment was not completed within 15 days of admission for resident #5.
A support plan was not completed within 30 days of admission for resident #5.
Report Facts
Residents Served: 80
Secured Dementia Care Unit Residents Served: 15
Hospice Current Residents: 4
Residents Age 60 or Older: 79
Residents with Mobility Need: 61
Residents with Physical Disability: 7
Staff Total Daily: 141
Staff Waking: 106
Uncovered Trash Cans: 5
Thermometers in Refrigerator: 2
Inspection Report — Feb 12, 2021
Complaint Investigation
Date: Feb 12, 2021
Visit Reason
The inspection was conducted as a complaint investigation at the facility.
Complaint Details
The inspection was complaint-related, but no deficiencies or citations were found.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Residents Served: 115
Secured Dementia Care Unit Residents Served: 20
Residents Age 60 or Older: 115
Residents Diagnosed with Mental Illness: 1
Residents with Mobility Need: 28
Resident Support Staff: 0
Total Daily Staff: 143
Waking Staff: 107
Inspection Report — Jan 26, 2021
Follow-Up
Date: Jan 26, 2021
Visit Reason
The inspection was a partial, unannounced follow-up review conducted due to an incident at the facility on January 26 and 27, 2021.
Findings
The submitted plan of correction related to resident abuse allegations was determined to be fully implemented. The facility was found to have complied with the required corrective actions, including staff training and supervision plans.
Citations (3)
Staff person A escorted resident #1 roughly by holding the resident's arm and pushed the resident in the back, constituting abuse.
The home did not develop and implement a plan of supervision or suspend the staff person involved in the alleged abuse incident in a timely manner.
The home failed to report the abuse incident to the Department's personal care home regional office within the required timeframe.
Report Facts
Residents Served: 97
Current Residents in Hospice: 2
Residents with Mobility Need: 25
Residents Age 60 or Older: 97
Residents Served in Dementia Unit: 7
Inspection Report — Nov 24, 2020
Complaint Investigation
Date: Nov 24, 2020
Visit Reason
The inspection was conducted as a complaint investigation with unannounced partial inspections on 11/24/2020, 11/25/2020, and 12/03/2020.
Complaint Details
The inspection was complaint-related as indicated by the reason 'Complaint' in the inspection section. No deficiencies or citations were found.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Residents Served: 115
Secured Dementia Care Unit Residents Served: 20
Notice — Oct 21, 2020
Date: Oct 21, 2020
Visit Reason
The document serves as a renewal license approval for Atria Center City Personal Care Home and notifies that an annual inspection will be conducted within the next twelve months as required by regulation.
Findings
The Department issued a regular license in response to the renewal application and stated that an onsite inspection will be conducted within the next year. Enforcement action will be taken if noncompliance is found during the inspection.
Report Facts
Inspection Report — Jul 27, 2020
Follow-Up
Date: Jul 27, 2020
Visit Reason
The visit was a follow-up inspection to verify the implementation of a previously submitted plan of correction for the facility.
Findings
The submitted plan of correction was determined to be fully implemented. Several deficiencies related to resident records access, staffing hours, support plans, and documentation were identified but subsequently addressed with corrective actions and in-services.
Citations (13)
2600.5a.1 - The administrator did not provide immediate access to resident records; documents were delayed until the next day after request.
2600.57b - Direct care staff hours were below the required minimum of 1 hour per day per mobile resident on two days.
2600.57c - Direct care staff hours were below the required minimum of 2 hours per day for residents with mobility needs on two days.
2600.225a - Resident #3's initial assessment was not documented within 15 days of admission; duplicate assessments with different admission dates were found.
2600.227d - Support plans for Residents #1, #3, and #5 did not document how behavioral health and medication management needs would be met.
2600.227g - Residents #2, #4, and #5 participated in support plan development but did not sign their plans.
2600.227h - No notation of refusal or inability to sign support plans was documented for Residents #2, #4, and #5.
2600.231c - Resident #5's written cognitive preadmission screening for the secured dementia care unit was not provided.
2600.231e - No documentation that Resident #5 or designated person objected to admission or transfer to the secured dementia care unit.
2600.234a - Resident #5's initial support plan within 72 hours of admission to the secured dementia care unit was not provided.
2600.234b - The facility's support plan form lacked required details and did not specify medication assistance or contact information for Resident #5.
2600.234c - Resident #5's support plan did not identify the individual responsible for addressing the resident's needs.
2600.252 - Resident #1's record did not contain a copy of the official death certificate.
Report Facts
Residents served: 115
Direct care staffing hours required: 151
Direct care staffing hours provided: 149.25
Direct care staffing hours provided: 146.75
Inspection Report — Mar 25, 2020
Plan of Correction
Date: Mar 25, 2020
Visit Reason
The inspection was conducted due to an incident as indicated by the 'Reason: Incident' on page 2. The report reviews the submitted plan of correction following the incident.
Findings
The plan of correction submitted by the facility was fully implemented as of August 3, 2020. The report details incidents involving residents, delayed reporting of incidents, and outlines corrective actions including staff training and auditing procedures.
Citations (2)
The facility failed to timely report incidents involving Resident #1 and Resident #2 to the Department, with delays ranging from several days to over a week. Resident #1 experienced multiple falls and injuries that were not reported promptly.
Resident #1 was found bleeding from her head after waiting over an hour for assistance, and call bell requests were not answered for over an hour despite policy requiring timely emergency responses.
Report Facts
Residents Served: 115
Secured Dementia Care Unit Residents Served: 19
Hospice Current Residents: 5
Call bell requests: 24
Time waiting for assistance: 70
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sabrina Codella | Executive Director | Named in relation to plan of correction approval and oversight of corrective actions |
Inspection Report — Oct 8, 2019
Monitoring
Date: Oct 8, 2019
Visit Reason
The inspection was a monitoring visit conducted on October 8, 2019, to assess compliance with applicable regulations and statutes for Atria Center City.
Findings
Multiple violations of 55 Pa. Code Chapter 2600 related to Personal Care Homes were identified, including deficiencies in quality management plan implementation, direct care training, locking poisonous materials, bedroom chairs, annual medical evaluations, and medication storage. Plans of correction were submitted with partial implementation progress noted.
Citations (6)
2600.26.a The home has not implemented its quality management plan and has not conducted a quality management review since May 2018. Meetings are to be held quarterly.
2600.65.d Direct care staff person A did not complete and pass the department-approved direct care orientation prior to providing unsupervised work with residents.
2600.82.c On 7/17/19, poisonous materials including Biotene Fluoride Toothpaste and Purell Hand Sanitizer were found unlocked and accessible to residents in the Life Guidance Room.
2600.101.j Bedroom 406 had no chair for the single resident and bedroom 237 had only one chair for two residents.
2600.141.b.1 Resident #1's most recent medical evaluation was completed on 10/16/18, with the previous evaluation on 8/16/17, not meeting the annual requirement.
2600.183.b On 7/17/19, a bottle of Systane Eye drops was located in an unlocked cabinet in the Life Guidance room accessible to residents.
Report Facts
Residents Served: 116
Secured Dementia Care Unit Residents Served: 20
Hospice Current Residents: 5
Residents Age 60 or Older: 115
Residents Diagnosed with Mental Illness: 1
Residents with Mobility Need: 48
Residents with Physical Disability: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sabrina Codella | Executive Director | Named as Administrator and signer of plans of correction |
Inspection Report — Aug 20, 2019
Renewal
Date: Aug 20, 2019
Visit Reason
The document is a renewal application and license issuance for Atria Center City Personal Care Home. The Department of Human Services will conduct an onsite inspection within the next twelve months as part of the annual inspection requirement.
Findings
No inspection findings are reported in this document. It confirms the issuance of a regular license following the renewal application.
Report Facts
Inspection Report — Sep 18, 2018
Complaint Investigation
Date: Sep 18, 2018
Visit Reason
The inspection was conducted as a complaint investigation by the Department’s Bureau of Human Services Licensing on September 18, 2018, to assess compliance with 55 Pa. Code Chapter 2600 relating to Personal Care Homes.
Complaint Details
The visit was complaint-related and substantiated violations were found regarding documentation of resident support plans.
Findings
Violations of 55 Pa. Code Chapter 2600 were found related to resident support plans, specifically a failure to document a resident's refusal or inability to sign the support plan. A plan of correction was initiated to address these issues.
Citations (1)
Regulation 55 Pa.Code 2600.227(h) requires documentation if a resident or designated person is unable or refuses to sign the support plan. Resident #1 did not sign their support plan, and the home failed to document the resident's inability or refusal to sign.
Report Facts
Number of Residents Served: 121
Number of Current Hospice Residents: 4
Number of Hospice Residents in past year: 10
Number of Residents Age 60 or Older: 13
Number of Residents with Mental Illness: 3
Number of Residents with Intellectual Disability: 1
Number of Residents with Mobility Need: 60
Number of Residents with Physical Disability: 36
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Alex Torres | Administrator | Named as the facility administrator on page 2. |
| Sabrina Freeman | Department Representative | Conducted the on-site inspection on September 18, 2018. |
Notice — Aug 17, 2018
Date: Aug 17, 2018
Visit Reason
This document serves as a renewal notification and license issuance for Atria Center City Personal Care Home. It informs the facility that the Department will conduct an onsite inspection within the next twelve months as required by state regulations.
Findings
No inspection findings are reported in this document. It is a licensing and renewal notice with no deficiencies or compliance issues mentioned.
Report Facts
Inspection Report — Jun 14, 2018
Complaint Investigation
Date: Jun 14, 2018
Visit Reason
The inspection was conducted as a complaint investigation of Atria Center City on June 14, 2018, to assess compliance with 55 Pa. Code Chapter 2600 relating to Personal Care Homes.
Complaint Details
The inspection was complaint-driven. Specific complaints involved missing resident clothing and medication administration issues including availability, refusals, and documentation.
Findings
Multiple violations of 55 Pa. Code Chapter 2600 were found, including issues with resident clothing return, medication availability, medication refusal documentation, and medication administration record audits. Plans of correction were submitted addressing training, audits, and oversight to prevent recurrence.
Citations (4)
Regulation 55 Pa.Code §2600.105(f)(2) - The resident's clean clothing was not returned within 24 hours after laundering; resident #1's clothing was left in the laundry room for approximately three days.
Regulation 55 Pa.Code §2600.185(a) - The home failed to develop and implement procedures for safe storage, access, security, distribution, and use of medications by trained staff; resident #1's prescribed medications were not available for administration on 6/14/18.
Regulation 55 Pa.Code §2600.187(c) - The home did not document refusals of prescribed medications by resident #2 on multiple dates and did not report refusals to the prescriber as required.
Regulation 55 Pa.Code §2600.187(d) - The home failed to follow prescriber directions; resident #2 and #3 had multiple medication administration documentation omissions and no documentation of administration for prescribed medications.
Report Facts
Number of Residents Served: 101
Number of Deficiencies: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Alex Torres | Administrator | Named as legal entity representative and responsible for implementing plans of correction. |
| Monique Carter | Administrator | Listed as facility administrator on page 2. |
| Sabrina Freeman | Department representative conducting the inspection on 06/14/2018. |
Inspection Report — Aug 15, 2017
Complaint Investigation
Date: Aug 15, 2017
Visit Reason
The inspection was conducted due to renewal, complaint, and incident reasons as listed on the violation report for Atria Center City.
Complaint Details
The inspection was complaint-related, with substantiation implied by the violations found and the directed plans of correction.
Findings
Multiple violations of Pennsylvania Code Chapter 2600 were found, including neglect and abuse, failure to evacuate during fire drills, incomplete medical evaluations, improper use of oxygen tanks, and incomplete resident personal property inventories. Directed plans of correction were approved for all violations.
Citations (6)
Regulation 2600.42(b) - A resident was neglected and physically abused during lunch service, with staff failing to respond appropriately to choking and distress. CPR was delayed and improperly administered.
Regulation 2600.132(d) - Residents did not evacuate to a public thoroughfare or fire safe area during the fire drill on 11/19/16.
Regulation 2600.141(a)(2) - Resident 1's medical evaluation dated 01/14/16 lacked documentation of special health or dietary needs and allergies.
Regulation 2600.141(b)(1) - Resident 2's last medical evaluation was completed on 02/15/17, but the 2010 DME was missing from the home record.
Regulation 2600.185(a) - An oxygen tank prescribed for Resident 3 was used to feed Resident 1, violating safe storage and use procedures.
Regulation 2600.252 - Resident 2's records lacked an inventory of personal property as voluntarily declared by the resident upon admission and updates.
Report Facts
Number of Residents Served: 116
Total Daily Staff: 151
Walking Staff: 113
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Alex Torres | Administrator | Signed as legal entity representative approving plans of correction on multiple pages. |
| Patricia Adams | Regional Licensing Director | Signed the cover letter transmitting the violation report. |
Inspection Report — Aug 8, 2017
Renewal
Date: Aug 8, 2017
Visit Reason
The document is a renewal application and license issuance for Atria Center City Personal Care Home, confirming the facility's renewal to operate under Title 55, PA Code, Chapter 2600.
Findings
No inspection findings are reported in this document. It states that the Department will conduct an onsite inspection within the next twelve months as required by regulation.
Report Facts
Inspection Report — Jul 17, 2017
Date: Jul 17, 2017
Visit Reason
The inspection was conducted as a licensing inspection of the Personal Care Home facility to identify violations of 55 Pa.Code Chapter 2600.
Findings
Violations related to the facility's website content describing assisted living were found. The facility submitted a plan of correction to revise its website content to comply with applicable regulations.
Citations (1)
55 Pa.Code §2600.18 requires compliance with applicable laws and regulations. The facility's website incorrectly described assisted living and its costs, which violated this regulation.
Report Facts
Number of Residents Served: 114
Total Daily Staff: 150
Walking Staff: 113
Number of Current Hospice Residents: 4
Number of Hospice Residents in Past Year: 10
Number of Residents Age 60 or Older: 13
Number of Residents with Mental Illness: 3
Number of Residents with Intellectual Disability: 1
Number of Residents with Mobility Need: 36
Number of Residents with Physical Disability: 36
Notice — Jul 10, 2017
Date: Jul 10, 2017
Visit Reason
Issuance of a revised license due to the facility's recent adjustment of the use of physical space, specifically indicating a secured dementia care unit licensed capacity of 25 beds.
Findings
The document confirms the licensed capacity of 165 residents with a secured dementia care unit capacity of 25. It includes demographic data of residents served and notes the license expiration date remains unchanged.
Report Facts
Number of Current Hospice Residents: 6
Number of Hospice Residents in Past Year: 15
Residents Age 60 or Older: 115
Residents with Mental Illness: 3
Residents with Intellectual Disability: 1
Residents with Mobility Need: 37
Residents with Physical Disability: 37
Inspection Report — Apr 21, 2017
Complaint Investigation
Date: Apr 21, 2017
Visit Reason
The inspection was conducted as a complaint investigation triggered by an incident involving alleged undignified treatment of a resident.
Complaint Details
The visit was complaint-related due to an allegation of undignified treatment of resident #1. The complaint was substantiated as violations were found.
Findings
Violations of 55 Pa.Code Chapter 2600 related to Personal Care Homes were found, including failure to provide assistance to a resident having difficulty ambulating, causing bruising and pain. A plan of correction was submitted to address staff training on dignity and respect.
Citations (1)
Regulation 55 Pa.Code §2600.42(c) - A resident shall be treated with dignity and respect. On 2/17/17, staff failed to assist resident #1 with ambulation, causing bruising and pain to the resident's right arm.
Report Facts
Number of Residents Served: 129
Total Daily Staff: 149
Working Staff: 112
Number of Current Hospice Residents: 3
Number of Hospice Residents in past year: 7
Number of Residents Age 60 or Older: 129
Number of Residents with Intellectual Disability: 1
Number of Residents with Mobility Need: 20
Number of Residents with Physical Disability: 3
Inspection Report — Sep 19, 2016
Renewal
Date: Sep 19, 2016
Visit Reason
The inspection was conducted as part of the Department of Human Services' annual licensing inspections on September 19 and 20, 2016, for renewal of the facility license.
Findings
Multiple violations of 55 Pa.Code Chapter 2600 related to Personal Care Homes were found, including issues with resident contracts, staffing hours, annual training, emergency procedures, vaccinations, medical evaluations, medication management, and pre-admission screening. Plans of correction were submitted and partially implemented for all violations.
Citations (14)
55 Pa.Code §2600 - The contract for resident #1 was not signed by the responsible party at admission or inspection.
55 Pa.Code §2600 - Direct care staff hours were insufficient; on inspection days, 129 residents required 120 hours of direct care but only 105 hours were provided.
55 Pa.Code §2600 - At least 75% of personal care service hours must be during waking hours; the home provided 90 waking hours but 112 were required.
55 Pa.Code §2600 - Direct care staff persons did not receive the required 12 hours of annual training in 2015.
55 Pa.Code §2600 - Annual training for direct care staff did not include required topics such as infection control, medication self-administration, and care for residents with dementia or mental illness.
55 Pa.Code §2600 - Written emergency procedures were not reviewed, updated, or submitted to the local emergency management agency since January 14, 2015.
55 Pa.Code §2600 - A resident's calico cat was present without a current rabies vaccination certificate; last vaccination was June 16, 2015.
55 Pa.Code §2600 - Resident #3 lacked a medical evaluation within 60 days prior to admission or within 30 days after admission as of inspection date.
55 Pa.Code §2600 - Medical evaluation for resident #4 was incomplete and missing documentation for diagnoses, treatment, and medications.
55 Pa.Code §2600 - Resident #5 was prescribed 200 mg Meloprolol Succinate but previous order for 100 mg was still in the medication cart at inspection.
55 Pa.Code §2600 - Glucometer reading times for residents #6, #7, and #8 were incorrect, showing times one hour earlier than actual readings.
55 Pa.Code §2600 - Resident #9's prescribed inhaler medication was not administered as ordered; documented use was inconsistent with prescription.
55 Pa.Code §2600 - The home failed to follow prescriber directions for resident #9's medication.
55 Pa.Code §2600 - Pre-admission screening forms for residents #10 and #11 did not include determinations that the home can meet their service needs.
Report Facts
Number of Residents Served: 129
Direct Care Staff Hours Required: 120
Direct Care Staff Hours Provided: 105
Waking Hours Required: 112
Waking Hours Provided: 90
Annual Training Hours Required: 12
Annual Training Hours Received: 6
Annual Training Hours Received: 6
Annual Training Hours Received: 5
Inspection Report — Aug 18, 2016
Renewal
Date: Aug 18, 2016
Visit Reason
The document is a renewal license issued in response to the facility's renewal application. The Department advises 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 primarily serves as a license renewal confirmation and notification of upcoming inspection requirements.
Report Facts
Notice — Feb 11, 2016
Date: Feb 11, 2016
Visit Reason
The document is a response to a waiver request submitted by WG Center City SH, LLC for certain Pennsylvania Personal Care Home regulations related to criminal history checks and staff hiring.
Findings
The Department of Human Services cannot waive certain protective services regulations and outlines the documentation required for compliance with the Supreme Court decision on criminal background checks.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tara Pride | Director of Regulatory Implementation | Signed the waiver response letter. |
Inspection Report — Jan 14, 2016
Complaint Investigation
Date: Jan 14, 2016
Visit Reason
The inspection was conducted as a licensing inspection triggered by complaints and incidents at Atria Center City, a Personal Care Home, on January 14 and January 18, 2016.
Complaint Details
The inspection was complaint-related, triggered by allegations of abuse and failure to report incidents. The complaints were substantiated as violations were found.
Findings
The inspection found multiple violations related to abuse reporting, staff background checks, and resident assessments. The facility submitted plans of correction with partial implementation progress noted.
Citations (4)
Regulation 55 Pa.Code §2600.15(a) - The home failed to immediately report suspected abuse of a resident to the local area agency on aging as required.
Regulation 55 Pa.Code §2600.16(c) - The home failed to report an incident witnessed by staff to the Department's personal care home complaint hotline within 24 hours.
Regulation 55 Pa.Code §2600.502 - The home allowed staff with criminal charges and failed to obtain criminal background checks for private duty aides as required by law.
Regulation 55 Pa.Code §2600.225(c) - The home did not assess residents' needs related to personal possessions, agitation, aggression, judgment, short and long term memory during the most recent assessments.
Report Facts
Number of Residents Served: 126
Number of Violations: 55
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joanna Mansfield | Administrator | Named as the legal entity representative signing plans of correction and administrator on page 2 and subsequent pages. |
| Christine McHale | Department representative conducting inspection on January 14 and 18, 2016. | |
| Natasha Braswell | Department representative conducting inspection on January 18, 2016. |
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