17 Reports
Inspection Report — Mar 23, 2026
Complaint Investigation
Date: Mar 23, 2026
Visit Reason
The inspection was conducted as a complaint investigation following allegations related to resident care and abuse at Autumn House East.
Complaint Details
The complaint investigation substantiated violations involving neglect and abuse of a resident, including failure to report incidents and inadequate wound care. The resident suffered multiple falls resulting in serious skin tears and infections.
Findings
The inspection found violations related to incident reporting and abuse, including failure to report a resident's injury to the Department and inadequate assessment and care for wounds. The facility's certificate of compliance was revoked and replaced with a first provisional license pending correction of violations.
Citations (2)
2600.16c The home failed to report a resident's incident involving multiple falls and skin tears to the Department within 24 hours as required.
2600.42b A resident was neglected and abused, including inadequate wound assessment and failure to properly monitor and care for injuries sustained during falls.
Report Facts
Residents Served: 103
Residents Served in Dementia Unit: 29
Hospice Current Residents: 9
Inspection Report — Oct 15, 2025
Follow-Up
Date: Oct 15, 2025
Visit Reason
The visit was a follow-up review conducted on October 15-16, 2025, to verify that the submitted plan of correction for previous violations was fully implemented.
Complaint Details
The inspection was complaint-related, triggered by a complaint and interim exit conference was held on 10/16/2025. The submitted plan of correction was found to be fully implemented.
Findings
The facility was found to have implemented the plan of correction fully. Several deficiencies were noted in the prior inspection, including issues with resident confidentiality, compliance with health and safety laws, infestation, and sanitary conditions, all of which were addressed with corrective actions and education.
Citations (30)
Resident medication lists were unlocked and accessible in a common area.
Carbon monoxide detector was missing on the first floor of the secured dementia care unit.
Evidence of rodent infestation with a mouse seen in a resident's room.
Influenza awareness poster was not posted in a public place.
Carbon monoxide alarms were not audible in certain hallways and had outdated batteries.
Resident contracts were not signed by residents.
Staff member without required high school diploma or registry status.
Insufficient number of staff certified in first aid and CPR during night shifts.
Direct care staff did not receive required annual training on multiple topics.
Poisonous materials were unlocked and accessible in a resident's room without proper assessment.
Unsanitary conditions including uncovered urinal and fecal matter in resident areas.
Exposed electrical wires and missing door threshold creating hazards.
Freezer lid did not close properly due to ice buildup; leaking faucet in resident bathroom.
Elevators lacked current certificates of operation.
Unlabeled and undated leftover food containers in kitchen.
No thermometer in kitchen chest freezer.
Food stored improperly, including uncovered snacks and refrigerated items stored at room temperature.
Exit door partially blocked by wheelchair and walker.
Fire drill during sleeping hours not conducted within required 6-month period.
Resident medical evaluation not completed within required timeframe after admission.
Cigarettes found in non-designated smoking area in secured dementia care unit courtyard.
Resident self-administering medications without required assessment by authorized medical professional.
Medications stored unlocked and unattended in resident's room.
Resident medication record did not include all medications present in resident's room.
Medications and syringes found unlocked and unattended on floors in resident areas.
Expired medications and unlabeled insulin pens found in medication storage.
Prescription medication lacked current order from authorized prescriber.
Medication prescribed was not administered due to unavailability in the home.
Staff administered medications without completing required Department-approved medication administration course and competency testing.
Directions for operating key-locking devices on secured dementia care unit doors were not conspicuously posted.
Report Facts
Residents Served: 120
Residents Served in Secured Dementia Care Unit: 31
Hospice Residents: 15
Total Daily Staff: 177
Waking Staff: 133
Inspection Report — Oct 15, 2025
Complaint Investigation
Date: Oct 15, 2025
Visit Reason
The inspection was conducted as a complaint and interim review of the facility on 10/15/2025 and 10/16/2025 to determine compliance with regulations and verify the submitted plan of correction.
Complaint Details
The inspection was complaint-related and interim in nature. The submitted plan of correction was reviewed and determined to be fully implemented.
Findings
The inspection found violations related to resident record confidentiality, compliance with health and safety laws including carbon monoxide detector placement, and evidence of rodent infestation. Plans of correction were accepted and implemented for all deficiencies.
Citations (3)
Resident medication lists were unlocked, unattended, and accessible in the A-hall kitchenette, violating confidentiality requirements.
A carbon monoxide detector was not present on the first floor of the secured dementia care unit, and installed alarms could not be heard from this area.
Evidence of rodent infestation was found when a mouse ran out from underneath a resident's closet and disappeared beneath the baseboard heater.
Report Facts
Residents Served: 120
Residents Served in Secured Dementia Care Unit: 31
Current Hospice Residents: 15
Residents with Mobility Need: 57
Residents Age 60 or Older: 120
Residents with Physical Disability: 2
Total Daily Staff: 177
Waking Staff: 133
Inspection Report — Apr 29, 2025
Follow-Up
Date: Apr 29, 2025
Visit Reason
The visit was a follow-up review of the facility's submitted plan of correction after previous incidents and violations, including an incident and fine.
Findings
The facility was found to have implemented the submitted plan of correction fully, with education provided to staff and administrators on abuse reporting, medication documentation, and resident care. Several deficiencies related to abuse reporting, medication storage, and following prescriber's orders were identified and addressed with corrective actions.
Citations (5)
Failure to immediately report suspected financial abuse of a resident and delay in submitting the Act 13 Mandatory Abuse Reporting form.
Failure to report an incident or condition to the Department within 24 hours as required.
Resident-to-resident abuse resulting in injury, with inadequate timely reporting and monitoring.
Discrepancies between blood sugar readings in resident's glucometer and medication administration record (MAR).
Failure to follow prescriber's orders for blood sugar testing as prescribed.
Report Facts
Residents Served: 120
Residents Served in Secured Dementia Care Unit: 29
Current Hospice Residents: 16
Residents Age 60 or Older: 120
Residents with Mobility Need: 55
Residents with Physical Disability: 1
Total Daily Staff: 175
Waking Staff: 131
Inspection Report — Apr 2, 2025
Complaint Investigation
Date: Apr 2, 2025
Visit Reason
The inspection was conducted as a complaint investigation during an unannounced partial licensing inspection of the facility.
Complaint Details
The inspection was complaint-related, but no deficiencies or citations were found, indicating no substantiated issues.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Total Daily Staff: 168
Waking Staff: 126
Resident Support Staff: 0
Secured Dementia Care Unit Residents Served: 31
Hospice Current Residents: 13
Residents Served: 116
Residents Age 60 or Older: 116
Residents with Mobility Need: 52
Residents with Physical Disability: 2
Inspection Report — Dec 11, 2024
Renewal
Date: Dec 11, 2024
Visit Reason
The inspection was conducted as part of a renewal, provisional, and incident licensing inspection of Autumn House East.
Findings
The inspection identified multiple violations related to resident confidentiality, financial management, abuse, staff orientation and training, sanitary conditions, medication administration, fire safety, resident assessments, and record keeping. Numerous plans of correction were proposed but not yet implemented as of the report date.
Citations (31)
2600.17 Resident records were not kept confidential as a bright orange sign displaying Resident #2's care level was visible on Resident #14's bedroom door.
2600.20.b.3 The home failed to obtain written receipts from residents for cash disbursements for Residents #1, #5, and #7.
2600.20.b.8 The home did not provide residents and their designated persons with itemized accounts of financial transactions on a quarterly basis.
2600.42.b Resident #1 was physically abused when thrown from a wheelchair, resulting in injury and delayed medical treatment.
2600.65.a Staff Member A did not receive required fire safety orientation on their first day of work until after starting.
2600.65.b Staff Member A did not complete required orientation on resident rights, emergency medical plan, and abuse reporting within 40 scheduled hours.
2600.85.a Resident #3's blood glucose testing was performed using another resident's glucometer.
2600.89.b Hot water temperature in a kitchenette sink measured 122.4°F, exceeding the 120°F limit.
2600.101.j Resident #3's fitted bedsheet contained feces stains near the head of the bed.
2600.102.i Unlabeled bars of soap were found in multiple shared shower and tub rooms used by residents.
2600.103.d Food items including oranges, green pepper, and shredded cheese were stored on the floor of the kitchen walk-in refrigerator.
2600.105.g Lint accumulation approximately baseball-sized was found in the lint trap of a dryer in the activities room.
2600.107.d The home failed to submit written emergency procedures annually to the local emergency management agency on time.
2600.132.c Fire drill records lacked documentation of the number of residents in the home and participating in drills.
2600.141.b.1 Resident #3's annual medical evaluation did not include medications the resident can self-administer.
2600.144.c.1 Residents smoked in non-permitted areas without proper fire-safe receptacles and policy enforcement.
2600.182.b Staff Member D, not licensed or waived, administered Trulicity injection to Resident #3.
2600.183.b Medications and syringes were unlocked and accessible in Resident #3's bedroom while the resident was absent.
2600.183.e Expired medications were found in the home's medication cart for Residents #11 and #12.
2600.184.a Pharmacy labels for medications of Residents #3 and #13 did not match prescribed dosage and instructions.
2600.185.a Resident #13's blood glucose levels were not properly recorded or monitored according to physician orders.
2600.187.a Medication records for Residents #3 and #7 lacked frequency of administration and diagnosis or purpose for medications.
2600.187.d The home did not follow prescriber's orders for medication administration timing and dosage for Residents #1 and #13.
2600.190.a Several staff members failed to complete required medication administration training and requalification within the past 2 years.
2600.190.b Staff administered insulin without completing required diabetes patient education within the past 12 months.
2600.225.a Resident assessments and support plans lacked documentation of device needs, financial management, and diagnoses for multiple residents.
2600.225.c Resident assessments and support plans were not updated annually or after significant condition changes for Residents #1, #7, and #10.
2600.227.e Resident #7's support plan did not accurately document ability to self-administer medications.
2600.227.g Resident #10's assessment and support plan were not signed or dated by the assessor or resident.
2600.251.a Resident #8's fall and incident record was improperly included in Resident #1's record.
2600.251.b Correction tape was used to alter Resident #9's preadmission screening document, obscuring dates and sensory needs.
Report Facts
Fine amount: 540
Fine amount: 324
Fine amount: 324
Fine amount: 324
Fine amount: 324
Fine amount: 540
Fine amount: 540
Inspection Report — Mar 19, 2024
Renewal
Date: Mar 19, 2024
Visit Reason
The inspection was conducted as part of a renewal and incident review of the Personal Care Home facility, Autumn House East, including multiple onsite and offsite visits between March and May 2024.
Findings
The inspection identified multiple violations related to resident abuse reporting, instrumental activities of daily living assistance, contract signatures, abuse incidents, staff training, resident personal equipment safety, sanitary conditions, bathroom ventilation, emergency telephone postings, lighting, food storage temperatures, fire drill documentation, medical evaluations, smoking area guidelines, medication labeling and storage, medication administration, support plan documentation, record keeping, and confidentiality of resident information. Plans of correction were accepted with various completion dates, some not yet implemented as of the report date.
Citations (23)
Failure to immediately report suspected resident abuse to appropriate agencies.
Resident did not receive required supervision leading to elopement.
Resident contracts not signed by residents.
Resident-to-resident abuse incidents not properly managed or reported.
Insufficient staff with current CPR and first aid certification during multiple shifts.
Direct care staff hired without completing required training and competency test.
Resident personal equipment posed entrapment risk due to improper covering.
Dead mouse found in tub room indicating poor sanitary conditions.
Inoperable exhaust fan in resident bathroom without window.
Emergency telephone numbers missing near telephone in kitchenette area.
Resident bedside lamp not operable or accessible.
Food stored above safe refrigeration temperatures and improperly labeled.
Fire drill records incomplete, missing resident counts and evacuation details.
Residents failed to evacuate properly during fire drills.
Resident medical evaluations incomplete or not timely.
Smoking occurred in prohibited areas with cigarette butts found on porch.
Medications not labeled with current orders or instructions.
Medications prescribed were not present in the home.
Blood sugar readings inconsistently documented and discrepancies between glucometer and MAR.
Verbal medication orders not obtained or documented by licensed staff.
Prescriber’s orders not consistently followed including medication administration and resident monitoring.
Support plans missing required signatures or not signed by residents without notation.
Resident records contained correction tape and were not maintained confidentially.
Report Facts
Residents Served: 119
Residents Served: 121
Residents Served in Dementia Unit: 30
Residents Served in Dementia Unit: 32
Current Hospice Residents: 15
Current Hospice Residents: 18
Total Daily Staff: 176
Waking Staff: 132
Total Daily Staff: 178
Waking Staff: 134
Deficiencies Cited: 28
Inspection Report — Jul 19, 2023
Complaint Investigation
Date: Jul 19, 2023
Visit Reason
The inspection was conducted as a complaint investigation and due to a change in legal entity at the facility.
Complaint Details
The inspection was complaint-driven and also involved a change in legal entity. Violations were found as detailed in the inspection summary.
Findings
Multiple violations were found including unlabeled carbon monoxide alarms, unsecured poisonous materials accessible to residents, sanitary issues such as mold in the ice machine, inoperable exhaust fans, missing mirrors and operable lamps in resident rooms, improper medication storage, and incomplete resident support plans. Plans of correction were proposed and partially implemented by the follow-up date.
Citations (14)
Battery operated carbon monoxide alarms in kitchen and basement were not labeled with date of installation.
Resident #3 was observed with bowel on body and bedding due to refusal of personal care.
Poisonous materials were unlocked and accessible to residents in the secured dementia care unit shower room.
Mold observed inside kitchen ice machine.
Exhaust fan in resident bathroom E8 was inoperable and bathroom D10 was dusty.
Screen door in laundry room had holes and tears.
Resident room A3 did not have a mirror.
Residents #1 and #2 did not have access to operable bedside lamps.
Unlabeled used bar of soap found in shared F-Hall shower room.
Home did not maintain a 3-day supply of emergency drinking water.
Written emergency procedures not reviewed or submitted to local emergency management agency since 3/21/2022.
Medications and syringes were not locked and were accessible in resident rooms without self-administration orders.
Resident #3's support plan did not include refusal of personal care.
Directions for operating key-locking devices were not conspicuously posted near the secured dementia care unit exit.
Report Facts
Residents Served: 115
Residents Served in Secured Dementia Care Unit: 28
Total Daily Staff: 172
Waking Staff: 129
Deficiency Counts: 14
Residents Served: 127
Residents Served in Secured Dementia Care Unit: 29
Total Daily Staff: 213
Waking Staff: 160
Residents Served: 125
Gallons of Emergency Drinking Water Required: 375
Gallons of Emergency Drinking Water Available: 348
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Juliet Marsala | Deputy Secretary | Signed the provisional license letter. |
| Administrator | Named in multiple findings related to education, training, and implementation of corrections. | |
| Director of Wellness | Named in findings related to resident care, medication storage, and audits. | |
| Assistant Director of Wellness | Named in findings related to resident support plans and audits. | |
| Maintenance Director | Named in findings related to maintenance issues, repairs, and audits. | |
| Memory Care Coordinator | Named in findings related to secured dementia care unit and audits. | |
| Dementia Care Director | Named in findings related to secured dementia care unit and audits. | |
| Dietary Manager | Named in findings related to food safety and labeling. | |
| Cook | Named in findings related to food safety and labeling. |
Inspection Report — Feb 8, 2022
Renewal
Date: Feb 8, 2022
Visit Reason
The inspection was conducted as a renewal visit to assess compliance and verify the submitted plan of correction was fully implemented.
Findings
The facility was found to have several deficiencies including issues with bathroom ventilation, hot water temperature, medication storage procedures, medication administration documentation, refusal of medication documentation, and annual assessments. The submitted plans of correction were accepted and implemented with completion dates ranging from March to May 2022.
Citations (6)
Bathroom in Resident 2's bedroom lacks an operable outside window and ventilation fan is inoperable.
Hot water temperature in E hall's bath/shower room measured at 126.3 degrees Fahrenheit, exceeding the 120°F limit.
Discrepancies found in medication and medical equipment storage and documentation, including missing glucometer readings and mismatched blood sugar readings.
Medication administration records (MAR) for multiple residents did not include initials of staff administering medications at specified dates and times.
Resident 7 refused to take prescribed medication on multiple dates and times; refusals were not documented in the MAR.
Resident 1's annual assessment was not completed timely; POA did not take resident to physician when assessment was due.
Report Facts
Residents Served: 116
Secured Dementia Care Unit Residents Served: 26
Hospice Current Residents: 8
Resident Mobility Need: 43
Blood Sugar Readings: 5
Notice — Aug 31, 2021
Date: Aug 31, 2021
Visit Reason
The document serves as a renewal notification and license issuance for the Personal Care Home 'Autumn House East' following receipt of the renewal application dated July 8, 2021. It also informs the facility that an annual onsite inspection will be conducted within the next twelve months as required by regulation.
Findings
No inspection findings are reported in this document. It confirms issuance of a regular license and advises that enforcement action will be taken if noncompliance is found during future inspections.
Report Facts
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary, Office of Long-term Living | Signed the renewal notification letter |
Inspection Report — Feb 26, 2021
Renewal
Date: Feb 26, 2021
Visit Reason
The inspection was conducted as part of licensing inspections on multiple dates in late February and early March 2021 to assess compliance with regulatory requirements for the facility.
Findings
No regulatory citations or deficiencies were identified as a result of these inspections.
Document — Oct 8, 2020
Date: Oct 8, 2020
Visit Reason
The document serves as a certificate of compliance and approval for a revised license to add a Secure Dementia Care Unit with a capacity of 32 beds to the existing Personal Care Home facility.
Findings
The Department approved the capacity revision request to add a Secure Dementia Care Unit with 32 beds, maintaining the total facility capacity at 150 residents. The license expiration date remains unchanged.
Report Facts
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary | Signed the approval letter and certificate |
Notice — Sep 9, 2020
Date: Sep 9, 2020
Visit Reason
The document serves as a license renewal notification and informs the facility that an annual onsite inspection will be conducted within the next twelve months as required by state regulations.
Findings
No inspection findings are reported in this document. It confirms issuance of a regular license following the renewal application.
Report Facts
Inspection Report — Jun 15, 2020
Renewal
Date: Jun 15, 2020
Visit Reason
The inspection was conducted as a licensing inspection of the facility by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing.
Findings
No regulatory citations were identified as a result of the inspection conducted on 06/15/2020, 06/16/2020, and 06/18/2020.
Inspection Report — Aug 26, 2019
Annual Inspection
Date: Aug 26, 2019
Visit Reason
The inspection was an annual licensing inspection conducted on August 26 and 27, 2019, to assess compliance with 55 Pa.Code Ch. 2600 relating to Personal Care Homes.
Findings
Multiple violations were found related to staff training, facility maintenance, and safety regulations. Plans of correction were submitted addressing issues such as CPR training, bathroom ventilation, window repairs, grab bars installation, and smoking area safety.
Citations (5)
2600.63a At least one staff person for every 50 residents must be trained in first aid and CPR. On 8/24/19, only two staff members had current First Aid training for 112 residents present.
2600.86b Bathrooms must have an operable outside window or exhaust fan. The common bathroom at end of E-Hall and Resident #1's bathroom lacked ventilation fans.
2600.92 Windows and screens must be in good repair and securely screened. Two windows in the E-wing lounge were in poor repair, including a cracked glass pane with a hole.
2600.102d Toilet and bath areas must have grab bars or assist bars. The common bathroom at end of E-Hall near the rear entrance lacked grab or assist bars.
2600.144c Smoking areas must have fire safety policies and fire-resistant furnishings. Two metal benches in the designated smoking area had cushions not labeled as fire resistant.
Report Facts
Residents Served: 126
Current Residents Hospice: 5
Staff: 148
Waking Staff: 111
Notice — Jun 27, 2019
Date: Jun 27, 2019
Visit Reason
This document serves as a renewal notification and license issuance for the Personal Care Home facility Autumn House East, confirming the facility's authorized capacity and informing about 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 notice and certificate of compliance.
Report Facts
Inspection Report — Sep 19, 2018
Original Licensing
Date: Sep 19, 2018
Visit Reason
The inspection was conducted as a new licensing inspection for Autumn House East, a personal care home, to assess compliance with 55 Pa.Code Chapter 2600.
Findings
The facility was found to be in substantial compliance with regulations but had several violations documented in the License Inspection Summary. All violations required correction by specified dates to maintain compliance.
Citations (5)
55 Pa.Code §2600.93(a) - Each ramp, interior stairway and outside steps must have a well-secured handrail. A 6-inch step outside the front door at exit #127 lacked a handrail.
55 Pa.Code §2600.103(d) - Food shall be stored off the floor. A box of white rolls was found sitting on the floor of the walk-in freezer.
55 Pa.Code §2600.104(e) - Breakfast, midday and evening meals shall be served in a dining room except in specified situations. Breakfast was not served in the dining room; it was delivered to residents in their rooms.
55 Pa.Code §2600.123(b) - Copies of emergency procedures must be posted in a conspicuous and public place. The home's emergency procedures were not posted in a conspicuous and public place.
55 Pa.Code §2600.126(a) - Furnaces must be inspected annually by a professional or trained maintenance staff. Inspection certifications expired on 8/10/18 for the A and C Hall boilers.
Report Facts
Number of Residents Served: 127
Number of Current Hospice Residents: 5
Number of Hospice Residents in past year: 20
Staffing Hours - Total Daily Staff: 140
Staffing Hours - Waking Staff: 105
Box of rolls count: 12
Date of inspection: Sep 19, 2018
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Amanda L. Palmer | Administrator | Named in multiple violation findings and plan of correction signatures |
| Douglas Hoover | On-site inspector for the inspection |
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