22 Reports
Inspection Report — Apr 25, 2025
Follow-Up
Date: Apr 25, 2025
Visit Reason
The inspection was conducted as a partial, unannounced visit due to an incident, with a follow-up on the submitted plan of correction.
Findings
The facility was found to have a deficiency where a resident did not sign their support plan and the home failed to document the resident's inability or refusal to sign. The plan of correction was accepted and fully implemented by the Health and Wellness Coordinator.
Citations (1)
Resident participated in the development of their initial support plan but did not sign it, and the home did not make a notation regarding the resident's inability to sign.
Report Facts
Residents Served: 40
Current Residents in Hospice: 4
Residents Age 60 or Older: 40
Residents with Mobility Need: 1
Residents with Physical Disability: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Health and Wellness Coordinator | Responsible for fixing the support plan deficiency and implementing corrective actions | |
| Health and Wellness Director | Conducts monthly audits of support plans to ensure compliance |
Inspection Report — Jul 17, 2024
Follow-Up
Date: Jul 17, 2024
Visit Reason
The visit was a partial, unannounced inspection triggered by an incident involving alleged inappropriate touching between residents, requiring review and follow-up on the submitted plan of correction.
Complaint Details
The visit was complaint-related due to an incident where Resident 2 reported inappropriate touching by Resident 1. The complaint was substantiated as abuse occurred. Resident 1 was subsequently discharged following a verbal 30-day notice.
Findings
The facility was found to have failed to report an incident of inappropriate touching between residents within the required timeframe and failed to provide a written 30-day discharge notice as stipulated in the resident contract. The submitted plan of correction was accepted and fully implemented by mid-August 2024.
Citations (3)
Failure to report an incident of inappropriate touching between residents to the Department within 24 hours as required.
Resident was touched inappropriately against their wishes by another resident, constituting abuse.
Failure to provide a written 30-day discharge notice to the resident as required by contract; only verbal notice was given.
Report Facts
Residents served: 41
Staffing hours - Total Daily Staff: 41
Staffing hours - Waking Staff: 31
Inspection Report — Feb 28, 2024
Plan of Correction
Date: Feb 28, 2024
Visit Reason
The inspection was a partial, unannounced visit conducted on 02/28/2024 due to an incident at the facility. The report documents the review and acceptance of the facility's plan of correction.
Findings
The facility had a deficiency related to the resident's support plan not being updated to reflect renewed physical therapy services following a fall that resulted in serious injury and rehabilitation stay. The submitted plan of correction was fully implemented and compliance was maintained.
Citations (1)
Resident's support plan was not updated to reflect the reason for renewed physical therapy services after a fall and rehabilitation stay.
Report Facts
Residents Served: 37
Total Daily Staff: 37
Waking Staff: 28
Current Hospice Residents: 1
Residents 60 Years or Older: 37
Residents Diagnosed with Mental Illness: 1
Residents with Physical Disability: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Health and Wellness Director (HWD) | Retrained on community policy and conducted audits related to support plan documentation | |
| Health and Wellness Coordinator (HWC) | Retrained on community policy and responsible for conducting audits of resident therapy documentation | |
| Executive Director (ED) | Provided retraining to HWD and HWC on support plan policy |
Inspection Report — Nov 21, 2023
Follow-Up
Date: Nov 21, 2023
Visit Reason
The inspection was conducted as a follow-up review of the submitted plan of correction for the facility.
Findings
The facility was found to have corrected the previously identified deficiency regarding uncovered trash receptacles in the women's bathroom. Compliance was verified through audits and staff retraining, with ongoing monitoring planned.
Citations (1)
Trash can in the common women's bathroom/shower room was uncovered and had a broken lid.
Report Facts
Residents Served: 43
Current Hospice Residents: 3
Staffing Hours - Resident Support Staff: 0
Staffing Hours - Total Daily Staff: 44
Staffing Hours - Waking Staff: 33
Audit Frequency: 4
Inspection Report — Sep 6, 2023
Renewal
Date: Sep 6, 2023
Visit Reason
The inspection was conducted as a renewal review of the facility's license and compliance with regulatory requirements.
Findings
The inspection identified multiple deficiencies related to resident record confidentiality, hospice care informed consent and fire drill procedures, resident personal equipment safety, surface hazards, soap dispenser labeling, evacuation procedures, fire drill timing and designated meeting places, smoking area safety, and record log completeness. Plans of correction were accepted and implemented for all deficiencies.
Citations (13)
Electronic resident records were left unlocked and accessible on a medication cart computer.
No written informed consent from Resident #1 regarding non-evacuation during fire drills.
Staff did not inform Resident #1 or responsible staff that the fire drill alarm was a drill, not an actual fire.
Staff responsible for evacuating Resident #1 did not use a safe mode of transportation during fire drill simulation.
Staff did not reasonably simulate the level of effort required to move Resident #1 during fire drill evacuation.
Required hospice documentation was not kept with the fire drill record for Resident #1.
Grab assist bar on Resident #2's bed was not securely attached, posing entrapment hazard.
A green rug outside shower in Room #2 lacked slip resistant backing, posing fall hazard.
Unlabeled bar of soap found in shared bathroom of Room #18.
Evacuation times recorded only included residents in fire affected zone, not entire building.
Residents did not evacuate to designated meeting places during fire drills; some only evacuated to doorways.
Smoking area contained combustible materials including propane tanks and nylon chairs without fire-resistant tags.
Destroyed records log did not include residents' dates of birth.
Report Facts
Residents served: 40
Current hospice residents: 5
Residents age 60 or older: 40
Residents with intellectual disability: 1
Residents with mobility need: 3
Inspection Report — Mar 15, 2023
Complaint Investigation
Date: Mar 15, 2023
Visit Reason
The inspection was conducted as a complaint investigation at the facility on 03/15/2023.
Complaint Details
The inspection was complaint-driven and no deficiencies or citations were found, indicating the complaint was not substantiated.
Findings
No regulatory citations or deficiencies were identified as a result of this complaint inspection.
Report Facts
Total Daily Staff: 41
Waking Staff: 31
Residents Served: 38
Current Hospice Residents: 2
Residents Age 60 or Older: 38
Residents with Mobility Need: 3
Inspection Report — Jun 7, 2022
Renewal
Date: Jun 7, 2022
Visit Reason
The inspection was an unannounced full renewal inspection conducted on 06/07/2022 and 06/08/2022 to review compliance with licensing requirements.
Findings
The inspection identified several deficiencies including lack of exterior lighting at a door, presence of a dented can of food, incomplete menu posting, medication storage and documentation issues, and medication administration concerns. All deficiencies had plans of correction implemented and verified by the Department Representative.
Citations (5)
No exterior lighting at the door exiting from the home to the garden area.
A dented can of spaghetti sauce was stored in the home’s pantry.
Menus were only posted up until 6/11/2022, not a full week in advance.
Resident 3’s glucometer reading was documented incorrectly in the MAR; Resident 4’s PRN medication was not available on the medication cart at time of inspection.
Medications were sometimes left for residents on their nightstand or in their room, contrary to policy; repeat violation from 6/29/2021.
Report Facts
Residents Served: 45
Total Daily Staff: 50
Waking Staff: 38
Current Hospice Residents: 1
Residents 60 Years or Older: 44
Residents with Mobility Need: 5
Residents with Physical Disability: 1
Notice — Jun 30, 2021
Date: Jun 30, 2021
Visit Reason
The document serves as a license renewal approval for the Brookdale Bloomsburg 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 advised that an onsite inspection will be conducted within the next twelve months to ensure compliance with applicable regulations.
Report Facts
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary, Office of Long-term Living | Signed the renewal approval letter |
Inspection Report — Jun 29, 2021
Renewal
Date: Jun 29, 2021
Visit Reason
The inspection was conducted as a renewal inspection of the facility license.
Findings
The facility was found to have deficiencies related to emergency telephone numbers not posted near a resident's phone and a missed medication administration. The submitted plan of correction was determined to be fully implemented.
Citations (3)
Resident room #21 did not have the required emergency numbers posted near or by the phone as required.
Resident #1 was administered a 8:00 AM dose of treatment by staff person 'A' on 6/30/21 but the 8 AM dose was unused and not ensured to be completed as prescribed.
Resident #1 did not receive their 8:00 AM dose of treatment as prescribed by the prescriber.
Report Facts
Residents Served: 35
Total Daily Staff: 35
Waking Staff: 26
Notice — May 5, 2020
Date: May 5, 2020
Visit Reason
The document serves as a renewal notification for the license to operate the Personal Care Home and informs that an annual inspection will be conducted within the next twelve months as required by regulation.
Findings
No inspection findings are reported in this document; it is a license renewal notice with a certificate of compliance.
Report Facts
Inspection Report — May 15, 2019
Renewal
Date: May 15, 2019
Visit Reason
The inspection was an unannounced renewal visit conducted by the Department’s Bureau of Human Services Licensing to assess compliance with 55 Pa. Code Chapter 2600 for Personal Care Homes.
Findings
Two violations were found: expired batteries in carbon monoxide detectors and an uncovered trash receptacle in a resident bathroom. Both issues were addressed with corrective actions including replacement, retraining, and ongoing audits.
Citations (2)
Regulation 2600.18: The batteries for two carbon monoxide detectors were dated 12/1/17, indicating they had not been changed within the required timeframe.
Regulation 2600.85d: The trash receptacle in the bathroom of resident room 41 was not covered with a lid, violating sanitation requirements.
Report Facts
Residents Served: 37
Staffing Hours - Resident Support Staff: 4
Staffing Hours - Total Daily Staff: 45
Staffing Hours - Waking Staff: 34
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Julie Heeter | Executive Director | Named in plan of correction and retraining related to carbon monoxide detector maintenance and trash receptacle compliance |
Notice — Apr 5, 2019
Date: Apr 5, 2019
Visit Reason
This document serves as a renewal notification and license issuance for the Personal Care Home facility Brookdale Bloomsburg, confirming the renewal application 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 an administrative license renewal notice.
Inspection Report — Jun 8, 2018
Complaint Investigation
Date: Jun 8, 2018
Visit Reason
The inspection was conducted as a complaint investigation triggered by an incident at the facility.
Complaint Details
The visit was complaint-related due to an incident. Specific substantiation status is not stated.
Findings
Two violations were found related to incomplete pre-admission screening and an outdated resident assessment service plan (RASP). Plans of correction were submitted addressing documentation and staff training.
Citations (2)
Regulation 55 Pa.Code §2600.224(a): Resident #1's pre-admission screening was incomplete with no noted level of supervision or mobility.
Regulation 55 Pa.Code §2600.227(d): Resident #1's RASP dated 5/31/18 was not updated after a 5/20/18 incident and did not reflect suicidal ideations or the home's plan to meet resident needs.
Report Facts
Number of Residents Served: 38
Total Daily Staff: 38
Waking Staff: 29
Number of Residents 60 Years or Older: 37
Number of Current Hospice Residents: 2
Number of Hospice Residents in Past Year: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Julie Heeter | Administrator / Executive Director | Named in relation to plan of correction signatures and responses. |
| Ryan Novak | Department Representative / Inspector | Conducted the on-site inspection. |
Inspection Report — May 10, 2018
Renewal
Date: May 10, 2018
Visit Reason
The inspection was a renewal survey conducted by the Department's Bureau of Human Services Licensing on May 10, 2018, to assess compliance with 55 Pa. Code Chapter 2600 for Personal Care Homes.
Findings
The inspection identified multiple violations related to posting of license inspection summaries, confidentiality of resident records, quality management plan reviews, food labeling, fire drills, transportation safety, medication management, and compliance with prescriber directions. Plans of correction were partially implemented with adequate progress noted.
Citations (10)
Regulation 2600.3(c): The home did not post the current and previous License Inspection Summary reports in a conspicuous and public area visible to the public.
Regulation 2600.17: Resident records contained resident and staff privacy coding sheets, violating confidentiality requirements.
Regulation 2600.26(a): Quality management meetings did not include review of License Inspection Summary violations from 5/18/17.
Regulation 2600.103(e): The home stored unlabeled, outdated frozen foods in the freezer, including chicken cutlets and sausage links.
Regulation 2600.132(e): The home failed to ensure all residents evacuated during fire drills held on 11/16/17 and 4/30/18.
Regulation 2600.132(h): Management staff were retrained on fire drill procedures and evacuation policies with scheduled audits planned.
Regulation 2600.171(b)(5): The first aid kit in the home's vehicle lacked eye coverings required for resident transportation safety.
Regulation 2600.183(d): Resident #1 had an opened Novolog pen not discarded after 28 days, with medication administered beyond expiration dates.
Regulation 2600.185(a): Glucometers were not calibrated with correct date and time; readings were inconsistent and improperly recorded.
Regulation 2600.187(d): Resident #3 did not have blood glucose readings taken as ordered on specified dates, missing required monitoring.
Report Facts
Number of Residents Served: 37
Number of Current Hospice Residents: 3
Number of Hospice Residents in past year: 11
Number of Residents Age 60 or Older: 36
Number of Residents with Mobility Need: 2
Number of Frozen Food Bags: 8
Number of Frozen Italian Sausage Links: 1
Number of Frozen Breaded Crab Patties: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Julie Heeter | Executive Director | Named as legal entity representative and responsible for compliance and corrective actions |
| Amy Deluca | Department representative present during inspection | |
| Cybil Bomberger | Department representative present during inspection |
Inspection Report — Apr 17, 2018
Renewal
Date: Apr 17, 2018
Visit Reason
The document is a renewal license issued to Brookdale Bloomsburg Personal Care Home following receipt of a renewal application dated March 26, 2018. The Department advises 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 serves as a license renewal notification and confirmation of the facility's authorized capacity.
Inspection Report — Nov 28, 2017
Complaint Investigation
Date: Nov 28, 2017
Visit Reason
The inspection was conducted as a complaint investigation at Brookdale Bloomsburg Personal Care Home on November 28, 2017.
Complaint Details
The inspection was triggered by a complaint. The violations found were related to medication administration and resident confidentiality. Partial implementation of corrective actions was noted as of April 12, 2018.
Findings
Multiple violations of 55 Pa.Code Chapter 2600 were found related to resident confidentiality, medication self-administration, medication administration, and medication record documentation. Plans of correction were initiated with partial implementation progress noted.
Citations (4)
Regulation 2600.17: The narcotic book was left unlocked and accessible to unauthorized persons at 9:00am upon entering the facility.
Regulation 2600.181(c): Resident #1 was left with medications in a cup at bedside and cannot self-administer medications as indicated on the DME.
Regulation 2600.182(c): Staff Person A left Resident #1's medications on a table at bedside; Resident #1 is unable to self-administer medications.
Regulation 2600.187(a): Resident #25's Medication Administration record was not initialed after medications were administered on 11-23-17 at 10:00pm.
Report Facts
Number of Residents Served: 37
Resident Age 60 or Older: 36
Number of Current Hospice Residents: 1
Number of Hospice Residents in Past Year: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Julie L. Heeter | Executive Director | Named as Legal Entity Representative and involved in plan of correction approvals. |
| Cindy Yellenic | Department representative on-site during inspection. |
Inspection Report — May 18, 2017
Renewal
Date: May 18, 2017
Visit Reason
The inspection was a renewal licensing inspection conducted to assess compliance with 55 Pa.Code Chapter 2600 for the Personal Care Home Brookdale Bloomsburg.
Findings
The inspection identified multiple violations related to staffing, emergency procedures, safety hazards, medical evaluations, medication administration, training documentation, and resident records. Plans of correction were submitted with timelines for compliance and ongoing monitoring.
Citations (11)
55 Pa.Code §2600.60(a) Staffing shall be provided to meet the needs of the residents as specified in the resident's assessment and support plan. The home has insufficient staff during overnight hours to meet residents' mobility needs and transfer assistance requirements.
55 Pa.Code §2600.96(a) The first aid kit in the wellness office/record room does not include a working thermometer. The one in the first aid kit is not operable.
55 Pa.Code §2600.107(b) The home's written emergency procedures have not been reviewed since 1/5/16 and require annual review and submission to the local emergency management agency.
55 Pa.Code §2600.121(a) Stairways, hallways, doorways, passageways and egress routes must be unlocked and unobstructed. The egress path outside the emergency exit is blocked by overgrown shrubs, preventing immediate egress in an emergency.
55 Pa.Code §2600.124 The home failed to notify the local fire department of changes in resident room numbers and mobility needs since 12/20/16.
55 Pa.Code §2600.125(a) Combustible and flammable materials were stored near the home's hot water heater, posing a fire hazard.
55 Pa.Code §2600.141(a)(2) The medical evaluation for resident #1 dated 1/13/17 does not include the required medication addendum section.
55 Pa.Code §2600.185(a) The home did not implement procedures for safe medication use. Resident #2's PRN medication was unavailable and a loose pill was found in the medication cart.
55 Pa.Code §2600.190(c) Annual practicum training documentation for med tech staff was incomplete and missing signatures and dates.
55 Pa.Code §2600.227(d) Resident #3's support plan lacks documentation of interventions for 12 falls and does not indicate service frequency or responsible providers.
55 Pa.Code §2600.252 Resident #2's records lack a current photograph less than 2 years old; the most recent photo is dated 10/3/14.
Report Facts
Number of Residents Served: 47
Number of Current Hospice Residents: 4
Number of Residents who Are 60 Years of Age or Older: 47
Number of Residents who Have Mental Illness: 1
Number of Residents who Have an Intellectual Disability: 1
Number of Residents who Have a Mobility Need: 7
Number of Residents who Receive Supplemental Security Income: 2
Number of Falls for Resident #3: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Julie L Heeter | Executive Director | Named as legal entity representative signing plans of correction and involved in findings |
| Gerald Dumas | Department representative on-site during inspection | |
| Kimberli Foulkes | Department representative on-site during inspection |
Inspection Report — Apr 10, 2017
Renewal
Date: Apr 10, 2017
Visit Reason
This document is a renewal application and license issuance for the Personal Care Home Brookdale Bloomsburg. The Department of Human Services will conduct an onsite inspection within the next twelve months as required by regulation.
Findings
No inspection findings are reported in this document. It serves as a license renewal confirmation and notification of future inspection requirements.
Notice — Jul 10, 2016
Date: Jul 10, 2016
Visit Reason
This document serves as a license renewal notification and certificate of compliance for Brookdale Bloomsburg Personal Care Home, confirming the facility's authorized capacity and renewal application status.
Findings
No inspection findings are reported. The document confirms the issuance of a regular license and states that an onsite inspection will be conducted within the next twelve months as required by regulation.
Report Facts
Inspection Report — May 24, 2016
Renewal
Date: May 24, 2016
Visit Reason
The inspection was a full renewal inspection of the Brookdale Bloomsburg Personal Care Home conducted by the Pennsylvania Department of Human Services on May 24, 2016.
Findings
Multiple violations of 55 Pa.Code Chapter 2600 were found, including issues with resident confidentiality, contract clarity on smoking policies, towel labeling, exit door functionality, fire alarm system signaling, fire drill evacuation procedures, pre-admission screening documentation, and resident support plan signatures. Plans of correction were submitted with partial implementation status.
Citations (8)
Regulation 2600.17: Resident privacy coding document was improperly posted exposing confidential information.
Regulation 2600.25(c)(8): Resident contracts did not specify whether the home permits smoking.
Regulation 2600.102(k): Use of a common towel was prohibited; towels were not labeled to identify ownership.
Regulation 2600.121(a): Exit door labeled G would not open immediately when pushed, preventing immediate egress in an emergency.
Regulation 2600.130(e): Resident with hearing impairment lacked a signaling device approved by a fire safety expert.
Regulation 2600.132(h): Not all residents evacuated to a designated safe area during a fire drill.
Regulation 2600.224(a): Pre-admission screening for resident #2 did not indicate if the home could meet the resident's needs.
Regulation 2600.227(h): Resident #4's support plan did not document inability or refusal to sign the plan.
Report Facts
Number of Residents Served: 47
Number of Current Hospice Residents: 3
Number of Hospice Residents in Past Year: 6
Residents 60 Years or Older: 47
Residents with Supplemental Security Income: 2
Residents with Intellectual Disability: 1
Residents with Mobility Need: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Marita Menghini-Spock | Executive Director | Named in multiple plans of correction and signature on all pages. |
| Jason Harvey | Inspector conducting the inspection on May 24, 2016. | |
| Ryan Novak | Inspector conducting the inspection on May 24, 2016. |
Inspection Report — Feb 19, 2016
Enforcement
Date: Feb 19, 2016
Visit Reason
The Department of Human Services issued a notice of intent to assess a fine for regulatory violations related to advertising as an Assisted Living residence when the facility is licensed as a Personal Care Home.
Findings
Brookdale Bloomsburg was found to be advertising assisted living services without being licensed as an assisted living residence, violating 55 Pa.Code §2600.18. A fine was assessed for this uncorrected violation.
Citations (1)
55 Pa.Code §2600.18: The facility advertised assisted living services but is not licensed as an assisted living residence.
Report Facts
Fine per day: 153
Total Fine Assessment: 2295
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jacob Herzing | Enforcement Manager | Named as contact for appeals and inspection |
| Matthew J. Jones | Director | Signed enforcement letter |
| Kristin A. Ferge | Executive VP and Treasurer | Named as contact for facility |
| Marita Menghini-Spoch | Executive Director | Named as contact for facility and signed Plan of Correction |
Inspection Report — Jan 29, 2016
Date: Jan 29, 2016
Visit Reason
The inspection was an interim document review conducted off-site to assess compliance with licensing requirements related to the use of the term 'Assisted Living' in facility materials.
Findings
The facility was found to be in violation of 55 Pa.Code Chapter 2600 for advertising as an assisted living residence without proper licensure. The Department required removal of the term 'Assisted Living' from all materials and submission of a plan of correction to avoid fines.
Citations (1)
55 Pa.Code § 2600.18: The facility advertised assisted living services without being licensed as an assisted living residence, violating state regulations.
Report Facts
Fine per resident per day: 3
Calculated Fine per day: 153
Mandated Correction Period: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Matthew J. Jones | Director | Signed letter regarding enforcement and plan of correction. |
| Jacob Herzing | Enforcement Manager | Contact person for submitting plan of correction and off-site inspector on January 29, 2016. |
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