12 Reports
Inspection Report — May 13, 2026
Complaint Investigation
Date: May 13, 2026
Visit Reason
The inspection was conducted as a complaint and incident investigation to review compliance and the submitted plan of correction for the facility.
Complaint Details
The inspection was complaint-driven and incident-related, focusing on failure to report incidents and compliance with resident care assessments. The plan of correction was accepted and fully implemented by June 2026.
Findings
The facility failed to report a fire alarm incident as required, experienced a water pressure issue due to Legionella contamination requiring water system shutdown, and did not properly update resident assessments related to enabler bars. Plans of correction were submitted and accepted with implementation dates in June 2026.
Citations (3)
16c - Written Incident Report: The home did not report a fire alarm incident caused by bacon burning on the stove to the Department's regional office within 24 hours as required.
89a - Water Pressure: The home lacked hot and cold water under pressure from an April to May 2026 period due to Legionella contamination and water system shutdown.
225c - Additional Assessment: A resident's assessment did not document the type of enabler bar installed or whether a protective cover was required, constituting a repeated violation.
Report Facts
Residents Served: 11
Current Hospice Residents: 2
Residents Age 60 or Older: 11
Inspection Report — Aug 28, 2025
Renewal
Date: Aug 28, 2025
Visit Reason
The inspection was conducted as a renewal visit to assess compliance with licensing requirements and verify correction of previous deficiencies.
Findings
The facility was found to have multiple deficiencies including record confidentiality breaches, expired certificates for boiler and stair glide, inadequate awake staff for residents with mobility needs, incomplete medical evaluations, and fire safety documentation issues. All cited deficiencies had plans of correction accepted and were implemented by the follow-up date.
Citations (13)
Record confidentiality was violated when a medication cart laptop was left unlocked and accessible to resident records.
The boiler and stair glide certificates of operation were expired, violating applicable health and safety laws.
An awake direct care staff person was not present overnight despite a resident requiring assistance for transferring.
Staff persons residing in the home overnight were not trained or available to administer PRN medications.
The home’s notification letter to the fire department lacked a general description of residents' mobility needs.
A resident had a portable space heater disguised as a TV stand fireplace, which is prohibited.
The last fire drill and fire safety inspection by a fire safety expert were overdue by nearly a year.
The most recent fire safety expert letter designating safe evacuation time was outdated by one year.
Resident medical evaluations did not include the ability to safely use or avoid poisonous materials.
A resident's glucometer was not calibrated to the current time, risking inaccurate readings.
Medication administration training records for a staff person lacked required signatures and documentation.
A resident’s preadmission screening form was missing the signature of the person completing the screening.
A resident’s support plan did not include details on the use, risks, and safety of an enabler bar device.
Report Facts
Residents Served: 15
Staffing Hours - Resident Support Staff: 16
Staffing Hours - Total Daily Staff: 32
Staffing Hours - Waking Staff: 24
Hospice Residents: 1
Residents Age 60 or Older: 15
Residents with Mobility Need: 1
Inspection Report — Aug 13, 2024
Renewal
Date: Aug 13, 2024
Visit Reason
The inspection was a renewal inspection conducted on 08/13/2024 to review the facility's compliance with licensing requirements.
Findings
The inspection found multiple deficiencies including incomplete annual training hours and topics for a staff member, incomplete training records, lack of a three-day emergency supply of drinking water, an exit door requiring excessive force to open, and missing documented blood glucose readings in a resident's medication administration record. Plans of correction were accepted and implemented by 09/30/2024.
Citations (6)
Staff Member A did not receive 12 hours of annual training in 2023; only 4.75 hours were verified.
Staff Member A did not receive 2023 annual trainings on required topics including medication self-administration and safe management techniques.
Staff Member A’s annual training records did not include the length of training for certain topics.
The home did not have a three-day emergency supply of drinking water onsite or a contract for immediate delivery.
An exit door required excessive force to be opened during physical site inspection.
Resident #2’s Medication Administration Record did not contain the documented blood glucose reading on 8/8/24 at 8am.
Report Facts
Residents Served: 14
Total Daily Staff: 14
Waking Staff: 11
Annual Training Hours Verified: 4.75
Gallons of Water Onsite: 45
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff Member A | Named in deficiencies related to annual training hours, training topics, and training record | |
| Director of Nursing | Named in deficiency related to missing blood glucose documentation and plan of correction | |
| Administrator | Named in deficiencies related to exit door correction and emergency water supply |
Inspection Report — May 19, 2022
Renewal
Date: May 19, 2022
Visit Reason
The inspection was conducted as a renewal inspection of the Birdsboro Lodge facility to assess compliance with licensing requirements.
Findings
The inspection found several deficiencies including failure to review staff training during quality management meetings in 2021, lack of documentation for emergency procedures submission to the local emergency management agency in 2021, failure to conduct a fire drill in April 2022, conducting fire drills only on the last day of the month, and improper labeling of medication storage items. Plans of correction were submitted and accepted for all deficiencies with evidence of implementation.
Citations (5)
The home did not review staff training during the quality management meeting in 2021.
The home did not have documentation that their emergency procedures were reviewed and submitted to the local emergency management agency in 2021.
The home did not conduct a fire drill in the month of April 2022.
The home's last 4 fire drills were conducted only on the last day of the month, not on varied days and times as required.
Medications belonging to resident #1 were not labeled with the date the pens were opened for use, contrary to manufacturer instructions.
Report Facts
Residents Served: 13
Total Daily Staff: 13
Waking Staff: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Responsible for conducting staff training on medication storage and reviewing manufacturers instructions |
| Administrator | Administrator | Responsible for quality management meetings, emergency procedures submission, fire drill compliance, and monitoring ongoing compliance |
Inspection Report — Jun 30, 2021
Renewal
Date: Jun 30, 2021
Visit Reason
The inspection was conducted as a renewal inspection of the Birdsboro Lodge facility to assess compliance with licensing requirements.
Findings
The inspection identified multiple deficiencies including failure to post the current license inspection summary, unsigned resident contracts, outdated quality management meetings, prohibited use of audio monitors, unsafe resident equipment, lack of bedside lighting, failure to test smoke detectors monthly, fire safety hazards in smoking areas, incomplete medication instructions, incomplete narcotic counts, unsigned support plans, and incomplete resident record content. Plans of correction were accepted or implemented for all deficiencies except one medication issue which was initially not accepted but later accepted.
Citations (12)
Licensing inspection summary dated 6/21/19 was not posted in a public conspicuous area.
Resident #1 and Resident #2 contracts were not signed by the residents.
Last quality management meeting was completed on 12/6/19, overdue for annual meeting.
Use of prohibited audio monitors on 1st and 2nd floors.
Grab assist bars attached to beds had uncovered 12 inch slats posing limb entrapment hazard.
Room #2 lacked an operable lamp or other source of lighting accessible from bedside.
Fire alarms and smoke detectors were not tested monthly as required.
Propane gas grill located in designated smoking area posing fire hazard.
Resident #3's sample medication Dulera lacked written instructions from prescriber.
Narcotic counts were not completed at the end of every shift as required.
Resident #2's RASP dated 5/21/21 was not signed by the resident or documented inability to sign.
Resident #1 and Resident #2 records lacked hair color, eye color, and identifying marks.
Report Facts
Residents Served: 15
Total Daily Staff: 16
Waking Staff: 12
Deficiencies cited: 12
Inspection Report — Nov 17, 2020
Date: Nov 17, 2020
Visit Reason
The inspection was conducted as a self-inspection and declaration tool related to an increase in the facility's maximum licensed capacity from 20 to 23 residents.
Findings
The facility was found to be in compliance with all applicable regulations under 55 Pa.Code Chapter 2600 for Personal Care Homes, with no violations noted during the inspection.
Report Facts
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Chris Gregg | Administrator | Facility Inspector and Legal Entity Representative who signed the declaration |
Inspection Report — Nov 12, 2020
Routine
Date: Nov 12, 2020
Visit Reason
The inspection was conducted as a routine licensing inspection by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing.
Findings
No regulatory citations were identified as a result of this inspection.
Inspection Report — Jun 4, 2020
Routine
Date: Jun 4, 2020
Visit Reason
The inspection was conducted as a routine licensing inspection by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing.
Findings
No regulatory citations were identified as a result of this inspection.
Notice — May 15, 2020
Date: May 15, 2020
Visit Reason
The document serves as a renewal notification and license issuance for Birdsboro Lodge, a Personal Care Home, and advises that an annual onsite inspection will be conducted within the next twelve months.
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 — Jun 21, 2019
Renewal
Date: Jun 21, 2019
Visit Reason
The inspection was an annual renewal inspection conducted by the Department’s Bureau of Human Services Licensing to assess compliance with 55 Pa. Code Chapter 2600 for Personal Care Homes.
Findings
Violations of 55 Pa. Code Chapter 2600 were found during the inspection, including issues related to fire drill evacuation times and failure to conduct overnight fire drills during sleeping hours. Plans of correction were partially implemented with adequate progress noted.
Citations (2)
2600.132d - The local fire department determined the fire drill evacuation time exceeded the maximum time designated by the fire safety expert. The previous year's maximum time was 6 minutes 15 seconds, but the drill took 2 minutes 40 seconds longer.
2600.132e - The home did not conduct an overnight fire drill during the required sleeping hours of 11:00 p.m. to 7:00 a.m. within the last 6 months.
Report Facts
Residents Served: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christopher Gregg | Administrator | Named as Administrator and signer of plan of correction |
Inspection Report — Mar 25, 2019
Renewal
Date: Mar 25, 2019
Visit Reason
The document is a renewal application and license issuance for Birdsboro Lodge Personal Care Home. 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 26, 2018
Original Licensing
Date: Jun 26, 2018
Visit Reason
The inspection was conducted as an initial licensing inspection for Birdsboro Lodge, a new legal entity operating a Personal Care Home.
Findings
The facility was found to be in substantial compliance with applicable regulations under 55 Pa. Code Chapter 2600. The licensing inspector was unable to complete a full inspection due to the newness of the legal entity.
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