30 Reports
Inspection Report — May 4, 2026
Renewal
Date: May 4, 2026
Visit Reason
The inspection was an unannounced full renewal inspection conducted to review compliance with licensing regulations and verify correction of previous deficiencies.
Findings
The facility had multiple deficiencies related to staff qualifications, annual training, fire safety evacuation times, medication management, documentation, and resident support plans. Plans of correction were accepted and implemented with proposed completion dates mostly by mid-2026.
Citations (14)
54a Direct care staff person B does not have a high school diploma, GED, or active registry status on the Pennsylvania nurse aide registry.
65g Staff persons C and D did not receive required annual fire safety training completed by a fire safety expert or trained staff during 2025.
132d The home exceeded the maximum safe evacuation time of 15 minutes during fire drills on 11/18/2025 and 3/9/2026, evacuating residents in 18 minutes 19 seconds and 24 minutes 28 seconds respectively.
132h During fire drills on 3/9/2026 and 11/18/2025, not all residents evacuated to a designated meeting place; only 46 of 68 and 67 of 72 residents evacuated respectively.
183d Several medications in the home's medication cart for Residents 1, 2, and 3 were not current or discontinued as of 5/4/2026.
183e Multiple medications for Residents 2, 4, 5, and 6 were opened without dates or expired as of 5/4/2026.
184a Pharmacy labels for Resident 7's Ativan cream lacked dosage instructions and Resident 8's Magnesium Glycinate lacked the resident's name.
184b OTC medication Magnesium Glycinate for Resident 8 was not labeled with the resident's name.
185a Resident 3's glucometer reading was documented incorrectly and the glucometer was not calibrated; Resident 7's prescribed medication was not available on 5/4/2026.
187b Resident 2's medication administration record lacked staff initials for Oxycodone doses on 4/14/2025 and 4/16/2025; Resident 9's medication was recorded as given but was refused on 5/4/2026.
187d Resident 2 was not administered Ferrous Sulfate since 4/23/2026 due to medication unavailability; Resident 7's blood pressure and heart rate were not measured as required before medication administration on multiple occasions.
227g Resident 10 participated in support plan development but did not sign the support plan due to dementia.
231c Resident 10's written cognitive preadmission screening was not completed within 72 hours prior to admission to the secured dementia care unit.
236 Direct care staff person C working in the secured dementia care unit had only 3.75 hours of required 6 hours annual dementia care training during 2025.
Report Facts
Residents Served: 72
Secured Dementia Care Unit Residents Served: 17
Current Hospice Residents: 11
Fire Drill Evacuation Time: 18.32
Fire Drill Evacuation Time: 24.47
Residents Evacuated to Fire Safe Area: 46
Residents Evacuated to Fire Safe Area: 67
Inspection Report — Dec 30, 2025
Complaint Investigation
Date: Dec 30, 2025
Visit Reason
The inspection was conducted as a complaint and provisional review of the facility on 12/30/2025 and 01/30/2026 to verify compliance and plan of correction implementation.
Complaint Details
The inspection was complaint-related and provisional. The submitted plan of correction was reviewed and determined to be fully implemented.
Findings
The inspection identified several deficiencies including obstructed emergency egress, combustible storage near heat sources, missing annual medical evaluations, outdated prescriptions, and unsigned support plans. All deficiencies had corrective plans accepted and were implemented or scheduled for completion.
Citations (5)
121a Unobstructed Egress: A "Sorry, We're Closed" sign blocked egress from the home’s ground floor SDCU emergency exit.
125a Combustible Storage: A large cloth tarp was stored at the base of the boiler in the boiler room.
141b1 Annual Medical Evaluation: Resident's most recent medical evaluation was not completed within the required annual timeframe.
183d Prescription Current: All medications for a resident were located in the Clare Bridge medication cart’s narcotics box, including outdated medications.
227g Support Plan Signatures: Residents and assessors participated in support plan development but did not sign the support plans as required.
Report Facts
Residents Served: 72
Secured Dementia Care Unit Residents Served: 14
Current Hospice Residents: 5
Residents Age 60 or Older: 72
Residents with Mental Illness: 4
Residents with Mobility Need: 27
Residents with Physical Disability: 1
Inspection Report — Jun 2, 2025
Follow-Up
Date: Jun 2, 2025
Visit Reason
The visit was a partial, unannounced inspection conducted as a follow-up to review the submitted plan of correction for an incident reported on 06/02/2025.
Findings
The inspection found multiple deficiencies including failure to timely report an incident, improper labeling of OTC medications, failure to follow prescriber's medication orders, and missing resident signatures on support plans. The facility submitted plans of correction which were accepted and implemented by 08/12/2025.
Citations (4)
Failure to report an incident to the Department within 24 hours as required.
OTC medications and CAM were not labeled with the resident's name.
Failure to follow prescriber's medication orders, including missed doses and unavailable medications.
Resident participated in support plan development but did not sign the support plan.
Report Facts
Residents Served: 71
Secured Dementia Care Unit Residents Served: 12
Current Hospice Residents: 8
Residents Age 60 or Older: 71
Residents with Mobility Need: 17
Residents with Physical Disability: 1
Inspection Report — Mar 31, 2025
Date: Mar 31, 2025
Visit Reason
The inspection was conducted as a licensing inspection by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing, due to an incident.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Residents Served: 75
Secured Dementia Care Unit Residents Served: 14
Current Hospice Residents: 7
Resident Support Staff: 0
Total Daily Staff: 91
Waking Staff: 68
Inspection Report — Apr 11, 2024
Monitoring
Date: Apr 11, 2024
Visit Reason
The visit was an unannounced partial inspection conducted as a monitoring review of the facility's compliance with regulatory requirements.
Findings
The inspection identified several deficiencies including unsigned resident contracts, missing signed statements acknowledging receipt of resident rights, sanitary issues with medication carts, lack of operable bedside lamps for a resident, incomplete menu postings in the memory care unit, improperly stored medications without open dates, unlabeled medication direction changes, and incomplete preadmission cognitive screening documentation for secured dementia care unit residents. Plans of correction were submitted and accepted with ongoing monitoring.
Citations (8)
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.
Three packs of cigarettes and plastic utensils were found in memory care medication cart.
Resident 3 did not have access to an operable lamp or source of lighting at bedside.
Weekly menus for the upcoming week were not posted in a conspicuous and public place in the memory care unit.
Medication belonging to Resident 4 did not have an open date and should have been discarded after 28 days.
Medication direction changes for Residents 1 and 5 were not indicated on medication containers/labels.
Resident 1's written cognitive preadmission screening did not indicate the resident requires secured care due to dementia.
Report Facts
Residents Served: 65
Secured Dementia Care Unit Residents Served: 19
Current Hospice Residents: 5
Residents Age 60 or Older: 65
Residents Diagnosed with Mental Illness: 3
Residents with Mobility Need: 39
Residents with Physical Disability: 1
Inspection Report — Sep 28, 2023
Complaint Investigation
Date: Sep 28, 2023
Visit Reason
The inspection was a partial, unannounced complaint investigation conducted due to a complaint received by the Pennsylvania Department of Human Services.
Complaint Details
The visit was complaint-related, triggered by a complaint. The report does not explicitly state substantiation status.
Findings
The inspection identified multiple deficiencies including failure to submit an incident report for a resident's unwitnessed fall with head injury, breaches in record confidentiality, inadequate staffing leading to delayed resident assistance, incomplete medical evaluation documentation, failure to secure medical care after a head injury, and incomplete preadmission screening documentation. Plans of correction were accepted and implemented.
Citations (6)
Failure to submit an incident report to the Department for a resident's unwitnessed fall resulting in a head injury.
Resident records were left unlocked and accessible to visitors, violating confidentiality requirements.
Resident did not receive toileting assistance as required by assessment and support plan due to lack of available direct care staffing.
Resident's medical evaluation did not include required page 2 information such as special health or dietary needs and medication regimen.
Resident with head injury was not sent to hospital or evaluated by doctor despite unclear speech; failure to secure medical care as required.
Resident's preadmission screening form did not include determination that the resident's needs can be met by the services provided by the home.
Report Facts
Residents Served: 69
Residents Served in Secured Dementia Care Unit: 22
Current Hospice Residents: 8
Residents Diagnosed with Mental Illness: 3
Residents Age 60 or Older: 69
Residents with Mobility Need: 39
Residents with Physical Disability: 1
Total Daily Staff: 108
Waking Staff: 81
Inspection Report — Sep 14, 2022
Renewal
Date: Sep 14, 2022
Visit Reason
The inspection was conducted as a full, unannounced visit for renewal, complaint, incident, and monitoring purposes at the facility.
Findings
The inspection identified multiple deficiencies including failure to post required documents, delayed incident reporting, issues with resident dignity and respect, sanitary and maintenance concerns, medication storage and documentation errors, incomplete resident records, and other regulatory noncompliance. Plans of correction were submitted and accepted with re-education and audits planned or implemented.
Citations (22)
The home's copy of 55 Pa. Code Chapter 2600 was not posted in a conspicuous and public place.
The home did not report multiple incidents involving residents to the Department within 24 hours as required.
Refund check for a deceased resident was not issued within the required timeframe.
A staff person treated a resident without dignity and respect, including physical contact and verbal commands.
Rugs in the dementia unit entrance had large brown stains; emergency food cans were covered in a black substance resembling mold.
Trash outside the home was not properly stored; old pallets, salt bags, and carts were found outside dumpsters.
Furniture in resident rooms was broken and in disrepair, including nightstand drawers and scratched walls.
102 five-gallon jugs of water were stored on the floor, violating food storage requirements.
Unlabeled and undated food items were found in the main kitchen freezer.
Ice cream freezer temperature was above required level (10°F) during inspection.
Food was stored in opened, unsealed, unlabeled, and undated containers in the main kitchen freezer.
Large accumulation of lint was found in the lint trap of clothes dryers.
A dog present at the home did not have a current rabies vaccination certificate.
Emergency procedures were not posted in a conspicuous and public place in the home.
Resident medical evaluation was incomplete, missing special health or dietary needs and medication list.
Loose half pill found in medication cart; tape found on blister card covering a pill.
Medication administration record discrepancies and documentation errors were found.
Preadmission screening forms did not include determination that resident needs can be met by the home.
Resident assessment was not completed within 15 days of admission.
Resident support plan was not signed by the resident.
Resident cognitive preadmission screening was not dated.
Resident records were missing required information including abuse incident reports, race, religion, and face sheets.
Report Facts
Residents Served: 65
Staffing: 104
Waking Staff: 78
Residents with Mobility Need: 39
Residents Diagnosed with Mental Illness: 3
Residents Diagnosed with Physical Disability: 1
Residents Receiving Hospice: 10
Five Gallon Water Jugs Stored on Floor: 102
Medication Count Discrepancy: 1
Inspection Report — Jan 31, 2022
Follow-Up
Date: Jan 31, 2022
Visit Reason
The inspection visit was a partial, unannounced follow-up inspection conducted due to an incident, to verify the implementation of a previously submitted plan of correction.
Findings
The submitted plan of correction for a deficiency related to the support plan revision was fully implemented and compliance was maintained. The facility demonstrated corrective actions including audits and clinical staff retraining.
Citations (1)
Support plan did not document the change for Honey Thick Liquids as required by the resident's nutritional needs.
Report Facts
Residents Served: 61
Residents Served in Secured Dementia Care Unit: 22
Current Residents in Hospice: 5
Residents Age 60 or Older: 61
Residents Diagnosed with Mental Illness: 3
Residents with Mobility Need: 35
Residents with Physical Disability: 1
Resident Support Staff: 0
Total Daily Staff: 96
Waking Staff: 72
Notice — Jul 7, 2021
Date: Jul 7, 2021
Visit Reason
The document serves as a certificate of compliance and notification of license renewal for Brookdale Northampton Personal Care Home, confirming the facility's authorized operation and informing that an annual inspection will be conducted within the next twelve months.
Findings
No inspection findings are reported in this document. It confirms issuance of a regular license following the renewal application and advises that the Department will conduct an inspection within the next year to ensure compliance.
Report Facts
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary | Signed the license renewal notification letter |
Inspection Report — Jun 3, 2021
Renewal
Date: Jun 3, 2021
Visit Reason
The inspection was conducted as a renewal inspection of the facility's license, including multiple on-site and off-site review dates.
Findings
The inspection identified multiple deficiencies related to posting of licensing inspection summary, quality management plan implementation, administrator staffing hours, emergency management procedures, smoke detector repair policy, menu posting, medication self-administration assistance, medication record accuracy, discontinued medication storage, medication availability, support plan content and signatures, and resident record content including outdated photographs. Plans of correction were accepted and implemented for all deficiencies.
Citations (13)
Licensing inspection summary was not posted in a conspicuous and public place in the home.
Quality management plan meeting did not include development and implementation of measures to address identified issues.
Administrator was present in the home an average of 8 hours per week, less than the required 20 hours.
Written emergency procedures were not submitted to the local emergency management agency for calendar year 2020.
Emergency procedures policy did not indicate that repairs to smoke detectors shall be completed within 48 hours of being found inoperative.
Menu for the following week was not posted in a conspicuous and public place in the home.
Failure to provide assistance with medication self-administration as outlined in the support plan, resulting in expired medications present, unavailable prescribed medications, and incomplete medication administration records.
Resident's record did not include a current list of medications for self-administering resident.
Expired medications were stored in the resident's room.
Medication prescribed as needed was not available in the home (repeat violation).
Support plan form did not include spaces to indicate frequency and responsible party, relying on narrative text.
Resident participated in support plan development but did not sign the support plan (repeat violation).
Resident record did not include a photograph no more than 2 years old.
Report Facts
Residents Served: 54
Secured Dementia Care Unit Residents Served: 18
Hospice Current Residents: 5
Residents with Mobility Need: 39
Residents 60 Years or Older: 54
Administrator Staffing Hours: 8
Total Daily Staff: 93
Waking Staff: 70
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Claire Mendez | Department Representative | Signed the initial letter regarding plan of correction implementation. |
| Unnamed Executive Director | Executive Director | Named in multiple findings related to plan of correction implementation and staff training. |
| Health and Wellness Director | Health and Wellness Director | Involved in retraining staff and auditing medication administration and support plans. |
| District Director of Clinical Services | District Director of Clinical Services | Provided training and oversight for support plan revisions and staff education. |
| District Director of Operations | District Director of Operations | Responsible for reviewing administrator coverage schedule. |
| Regional Maintenance Technician | Regional Maintenance Technician | In-serviced maintenance staff on smoke detector repair policy. |
Inspection Report — Aug 24, 2020
Complaint Investigation
Date: Aug 24, 2020
Visit Reason
The inspection was conducted as a complaint investigation with multiple off-site review dates from 08/24/2020 through 09/10/2020 to assess compliance with licensing regulations.
Complaint Details
The inspection was initiated due to a complaint. The findings include substantiated deficiencies related to staffing, training, and staff qualifications.
Findings
The facility was found to have multiple deficiencies related to staff qualifications, staffing levels, training, and orientation. Several direct care staff lacked required documentation, training, or orientation, and staffing was insufficient to meet resident needs at times.
Citations (8)
54a - Direct care staff person A did not have a high school diploma, GED, or active registry status on the Pennsylvania nurse aide registry.
60a - Resident #1 did not receive required instrumental activities of daily living due to lack of available direct care staffing, and call bell response was delayed overnight.
60b - Staffing was insufficient on September 2 with one staff member providing all care for 27 residents on the first floor, impacting quality of care.
65a - Staff person C did not receive orientation on fire safety, emergency preparedness, and related topics prior to or during the first work day.
65d - Direct care staff person A began providing unsupervised ADL services without completing required Department-approved training and competency testing.
65f - Direct care staff persons A and C did not receive required annual training in medication self-administration, dementia care, mental illness, and other required topics during 2019.
65g - Direct care staff persons A and C did not receive required annual training in resident rights, Older Adult Protective Services Act, falls prevention, fire safety, emergency preparedness, and crisis response during 2019.
236 - Direct care staff persons A and D working in the Secure Dementia Care Unit did not complete required dementia care training hours during 2019.
Report Facts
Residents Served: 62
Residents Served in Dementia Unit: 15
Hospice Current Residents: 4
Staffing: 84
Waking Staff: 63
Residents 60 Years or Older: 62
Residents with Mobility Need: 22
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ken Williams | Executive Director | Named in relation to retraining and oversight of corrective actions. |
| David Carrion | Lead Inspector | Lead inspector for the complaint investigation. |
| Claire Mendez | Lead Reviewer | Reviewer of plan of correction and follow-up. |
Notice — Aug 3, 2020
Date: Aug 3, 2020
Visit Reason
This document serves as a renewal notification and issuance of a regular license for Brookdale Northampton Personal Care Home following receipt of the renewal application dated June 2, 2020.
Findings
The Department advises that an onsite annual inspection will be conducted within the next twelve months to ensure compliance with applicable regulations. No findings or deficiencies are reported in this document.
Report Facts
Inspection Report — Jun 4, 2020
Follow-Up
Date: Jun 4, 2020
Visit Reason
The inspection was a partial, unannounced follow-up visit triggered by an incident to verify the implementation of a previously submitted plan of correction.
Findings
The facility was found to have fully implemented the submitted plan of correction. Deficiencies involved treatment of residents with dignity, timely completion of annual assessments, and proper signatures on support plans, all of which were addressed with corrective actions and training.
Citations (3)
42c - Treatment of Residents: Staff member A was unaccounted for 33 minutes and reported to have entered residents' rooms cursing and throwing water, though no physical harm occurred. The staff member was suspended and terminated, and resident rights training was implemented.
225c - Additional Assessment: Resident #1’s annual assessment was completed late due to an inadvertent fax of the wrong document. The facility retrained staff and implemented audits to ensure timely assessments.
227g - Support Plan Signatures: Resident #1 and a facility representative did not sign the support plan due to a filing error. Audits were conducted and quarterly reviews established to ensure proper signatures.
Report Facts
Residents Served: 70
Secured Dementia Care Unit Residents Served: 19
Inspection Report — Mar 9, 2020
Renewal
Date: Mar 9, 2020
Visit Reason
The inspection was a full, unannounced renewal survey conducted on March 9 and 10, 2020 to assess compliance with regulatory requirements for Brookdale Northampton.
Findings
The facility submitted a plan of correction which was determined to be fully implemented as of September 10, 2020. Multiple deficiencies were identified related to resident care, medication administration, training, and safety, all of which had corrective actions completed.
Citations (15)
Resident #1's resident-home contract was not signed by the resident.
On 01/01/2020, resident #2 went missing for over 2 hours due to failure to ensure all door locks were engaged in the Secured Dementia Care Unit.
Direct care staff persons A and B did not receive required training in multiple topics during training year 2019.
Expired food items were found in the home's dry goods storage area.
A chest of drawers blocked the exit door to the stairwell in the home's Secured Dementia Care Unit on 03/09/2020.
Resident #3's initial medical evaluation lacked medical information pertinent to emergency diagnosis and treatment.
Resident #4 was given the wrong dose of Alprazolam on 03/09/2020 by staff.
On 03/10/2020, medications for residents #5 and #6 were not current orders but remained on the medication cart.
Resident #4's Novolog FlexPen was open without an open/discard date specified on 03/10/2020.
Resident #4 and #7's prescribed medications were not available or lacked staff initials on administration records.
Resident #8's medication was not administered as prescribed and staff falsified initials.
Resident #9's medication documentation was incomplete and the home failed to account for misplaced medication.
Direct care staff person B in the Secured Dementia Care Unit had only 2 hours of dementia care training in 2019.
Resident #2's cognitive pre-admission screening was over-written and incomplete.
Operating instructions for the home's locking mechanism were not posted near the exit door or courtyard gate in the Secured Dementia Care Unit.
Report Facts
Residents Served: 75
Secured Dementia Care Unit Residents Served: 21
Hospice Current Residents: 7
Residents 60 Years or Older: 75
Residents Diagnosed with Mental Illness: 3
Residents with Mobility Need: 39
Residents with Physical Disability: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Francie K. Hoch | Executive Director | Signed plan of correction and named in corrective actions |
| Claire Mendez | Human Services Licensing Supervisor | Report author and plan of correction approver |
Inspection Report — May 10, 2019
Complaint Investigation
Date: May 10, 2019
Visit Reason
The inspection was conducted as a complaint and incident investigation at Brookdale Northampton Personal Care Home on April 25, 2019 and May 10, 2019.
Complaint Details
The inspection was triggered by a complaint and incident. The violation involved resident #1 refusing medication due to a suspected medication error, which was substantiated by resident and staff statements.
Findings
The facility was found to have violations related to resident rights, specifically failing to ensure a resident was afforded the right to refuse medication. The Executive Director provided re-training to staff and reviewed policies to prevent recurrence.
Citations (1)
Regulation 2600.191 Resident Right to Refuse requires the home to educate residents on the right to question or refuse medication if a medication error is suspected. The home failed to ensure resident #1 was afforded this right when she refused to take coumadin medication.
Report Facts
Residents Served: 93
Residents Served in Dementia Unit: 21
Current Hospice Residents: 7
Residents Age 60 or Older: 93
Residents with Mobility Need: 40
Residents with Physical Disability: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Francie Hoch | Administrator | Named as Administrator and Executive Director who signed plan of correction |
| Sabrina Freeman | Department representative conducting inspection |
Notice — Apr 9, 2019
Date: Apr 9, 2019
Visit Reason
The document serves as a license renewal certificate and letter confirming receipt of the renewal application to operate the Personal Care Home 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 only confirms the issuance of a regular license following the renewal application.
Report Facts
Inspection Report — Mar 18, 2019
Renewal
Date: Mar 18, 2019
Visit Reason
The inspection was an annual licensing renewal survey conducted on March 18 and 19, 2019, to assess compliance with 55 Pa. Code Chapter 2600 for Personal Care Homes.
Findings
Multiple violations of Pennsylvania Personal Care Homes regulations were identified, including missing resident signatures on contracts, incomplete resident rights acknowledgments, unsecured medications, incomplete medication lists, lack of resident education on medication refusal rights, and incomplete pre-admission screening forms. A plan of correction was submitted addressing these deficiencies with timelines for completion.
Citations (8)
Regulation 2600.25(b): Contracts for residents #1 and #2 were not signed by the residents.
Regulation 2600.41(e): Residents #1 and #2 records lacked signed statements acknowledging receipt of resident rights and complaint procedures.
Regulation 2600.181(d): Resident #3's medication was not stored in a locked or secured medication unit.
Regulation 2600.181(f): Resident #3's record did not include a current list of medications, missing Cymbalta Caps 60 mg.
Regulation 2600.185(a): The home did not have PRN Docusate Sodium Caps 100 mg and Acetaminophen Tabs 325 mg available for resident #4.
Regulation 2600.191: Residents #1 and #2 were not educated on the right to refuse medication if they believed there was a medication error.
Regulation 2600.224(a): Pre-admission screening forms for residents #1 and #2 did not include specific needs or were dated more than 30 days after admission.
Regulation 2600.231(c): Resident #1 did not have a preadmission screening completed in collaboration with a physician or geriatric assessment team within 72 hours prior to admission to secured dementia care unit.
Report Facts
Number of Residents Served: 92
Number of Current Hospice Residents: 7
Number of Hospice Residents in past year: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Francie K. Hoch | Executive Director | Named as Legal Entity Representative signing plans of correction and involved in findings. |
| Tahesia Thomas | Department representative conducting the inspection on March 18 and 19, 2019. | |
| Youn Hie Chung | Department representative conducting the inspection on March 18 and 19, 2019. |
Notice — Apr 19, 2018
Date: Apr 19, 2018
Visit Reason
The document serves as a renewal notification for the Personal Care Home license of Brookdale Northampton, confirming receipt of the renewal application and advising of 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 notice regarding licensing and inspection requirements.
Notice — Aug 15, 2017
Date: Aug 15, 2017
Visit Reason
Response to a request for a waiver of Pennsylvania Code Chapter 2600 requirements related to qualifications for direct care staff persons in a personal care home.
Findings
The waiver request was returned for additional information because the individual’s name did not appear on the Pennsylvania Nurse Aide Registry and the required certificate was not included. Alternatives to meet education requirements were provided.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jill Kachmar | Regulatory Licensing Manager | Signed the waiver request response letter. |
Notice — Jul 24, 2017
Date: Jul 24, 2017
Visit Reason
The document is a response to a waiver request related to qualifications for direct care staff persons at a personal care home.
Findings
The waiver request was returned for additional information. The purpose of the waiver is to ensure qualified staff provide services to personal care home residents. Documentation showed the individual has a high school diploma from Haiti and an expired Pennsylvania Nurse Aide Registry status.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jill Kachmar | Regulatory Licensing Manager | Signed the letter responding to the waiver request. |
Inspection Report — Jun 28, 2017
Renewal
Date: Jun 28, 2017
Visit Reason
The inspection was conducted as a renewal licensing inspection of the Brookdale Northampton Personal Care Home on June 28 and June 29, 2017.
Findings
Multiple violations of 55 Pa.Code Chapter 2600 were found, including staff qualifications, training documentation, equipment maintenance, fire drill procedures, and medication administration errors. Plans of correction were submitted and partially implemented with adequate progress noted.
Citations (6)
Regulation 2600.54(a): Direct care staff person A does not have a high school diploma, GED diploma, or active registration status on the Pennsylvania nurse aide registry.
Regulation 2600.65(d): The home lacks documentation that direct care staff person A, hired 4/12/17, completed the Department-approved direct care training course and passed the competency test.
Regulation 2600.95: The drawer was missing from the cabinet in the Memory Care Unit activity area and the basement exit door was difficult to open and did not close completely.
Regulation 2600.132(f): The central lounge exit was used during fire drills conducted on 6/30/16, 7/29/16, and 8/30/16, contrary to requirements for alternate exit routes.
Regulation 2600.185(a): Glucometers were not calibrated to the correct date and time.
Regulation 2600.187(a): Resident #1 was prescribed Melatonin 5 mg in tablet form, but the electronic medication record lists Melatonin 5 mg in soft gel form.
Report Facts
Number of Residents Served: 91
Number of Residents Served in Secured Dementia Care Unit: 20
Number of Current Hospice Residents: 3
Number of Hospice Residents in Past Year: 9
Number of Residents Age 60 or Older: 91
Number of Residents with Mobility Needs: 32
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Caruso | Executive Director | Named as Executive Director signing plans of correction and involved in retraining and compliance activities. |
| Natasha Braswell | Department representative present on-site during inspection. | |
| Dean Gray | Department representative present on-site during inspection. |
Inspection Report — May 1, 2017
Complaint Investigation
Date: May 1, 2017
Visit Reason
The inspection was conducted as a complaint/incident investigation triggered by an incident at the facility.
Complaint Details
The visit was complaint-related due to an incident on 4/14/17 involving resident #1. Staff person A was suspended and later terminated following investigation.
Findings
A violation of 55 Pa.Code Chapter 2600 was found where a resident was treated without dignity and respect during a rough transfer to the shower. The staff refused the resident's request to turn up the heat in the bedroom.
Citations (1)
Regulation 55 Pa.Code 2600.42(c): A resident was roughly transferred to the shower by staff and the resident's request to increase heat in the bedroom was refused by staff.
Report Facts
Number of Residents Served: 88
Number of Hospice Residents in past year: 17
Number of Residents Served in Secured Dementia Care Unit: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Caruso | Executive Director | Named as administrator and involved in investigation and corrective actions. |
| Lauren Kazimer | Inspector | Conducted on-site inspection on 05/01/2017. |
Inspection Report — Apr 5, 2017
Renewal
Date: Apr 5, 2017
Visit Reason
This document is a renewal notification and license issuance for Brookdale Northampton Personal Care Home. 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 serves as a license renewal confirmation and notification of future inspection requirements.
Notice — Sep 14, 2016
Date: Sep 14, 2016
Visit Reason
The document serves as a waiver approval letter for Brookdale Northampton related to qualifications for direct care staff persons under Pennsylvania Code 55 Pa.Code § 2600.54(a).
Findings
The Department of Human Services granted a waiver for the facility under the authority of 55 Pa.Code § 2600.19, determining that a non-U.S. educational program is similar to U.S. educational requirements.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jacqueline L. Rowe | Director | Signed the waiver approval letter. |
Notice — Jul 14, 2016
Date: Jul 14, 2016
Visit Reason
The document serves as a response to a request for a waiver of Pennsylvania Code Chapter 2600 requirements related to qualifications for direct care staff persons at a personal care home.
Findings
The Department of Human Services granted the requested waiver, determining that the non-U.S. educational program is similar to U.S. educational requirements.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tara Pride | Director of Regulatory Implementation | Signed the waiver approval letter. |
Inspection Report — Jun 29, 2016
Annual Inspection
Date: Jun 29, 2016
Visit Reason
The inspection was conducted as part of the Department of Human Services' annual licensing inspections on June 29 and June 30, 2016, for Brookdale Northampton Personal Care Home.
Findings
Multiple violations of 55 Pa.Code Chapter 2600 were found related to resident dignity, emergency phone postings, resident access to bedrooms, medical evaluations, medication storage and administration, and documentation. Plans of correction were submitted and partially implemented as of August 2016.
Citations (9)
Regulation 2600.42(c): Staff locked a resident's bedroom door and denied access, violating resident dignity and respect.
Regulation 2600.91: Emergency phone numbers were not posted in room #224 as required.
Regulation 2600.101(i): Staff locked a resident's bedroom door, denying access at all times.
Regulation 2600.141(b)(1): Resident #3's medical evaluation was not current; last evaluation was on 7/25/2014.
Regulation 2600.183(e): Resident #4's medication cart contained expired insulin and an opened, undated Novolog insulin.
Regulation 2600.184(a): Medication carts were returned to pharmacy for clarification and relabeling; audits and training were conducted.
Regulation 2600.187(a): Medication administration records lacked required details for residents #6, #8, and #9.
Regulation 2600.187(b): Staff failed to initial medication administration records for resident #4's Novolog insulin.
Regulation 2600.187(d): Resident #4 did not receive Accuchecks as prescribed on specified dates and times.
Report Facts
Number of Residents Served: 79
Number of Residents in Secured Dementia Care Unit: 23
Number of Current Hospice Residents: 8
Number of Hospice Residents in Past Year: 20
Total Daily Staff: 121
Walking Staff: 91
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Caruso | Executive Director | Named in multiple findings and plan of correction signatures. |
Inspection Report — May 6, 2016
Renewal
Date: May 6, 2016
Visit Reason
This document is a renewal license issued to Brookdale Northampton Personal Care Home following their April 4, 2016 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 serves as a license renewal certificate and notification letter confirming the issuance of a regular license.
Report Facts
Inspection Report — Jan 29, 2016
Date: Jan 29, 2016
Visit Reason
The inspection was conducted as an interim document review to assess compliance with licensing requirements related to the use of the term 'Assisted Living' and licensure status.
Findings
The facility was found to be in violation of 55 Pa.Code Chapter 2600 for advertising assisted living services without being a licensed assisted living residence. A fine is proposed unless corrected by the mandated date.
Citations (1)
55 Pa.Code § 2600.18 requires compliance with applicable laws. The facility advertised assisted living services without being licensed as an assisted living residence.
Report Facts
Fine per resident per day: 3
Calculated fine per day: 246
Mandated correction period: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Matthew J. Jones | Director | Signed enforcement letter |
| Jacob Herzing | Enforcement Manager | Contact for plan of correction submission and off-site inspection |
Inspection Report — Jan 29, 2016
Enforcement
Date: Jan 29, 2016
Visit Reason
The Department of Human Services issued a notice of intent to assess a fine for regulatory violations related to personal care homes. The document serves as a fine assessment and enforcement action for uncorrected violations.
Findings
Brookdale Northampton was found to have uncorrected violations under 55 Pa.Code Chapter 2600, specifically a Class III violation. The facility continues to advertise as an Assisted Living residence without proper licensing.
Citations (1)
55 Pa.Code Chapter 2600 Section 18 Class III violation for Brookdale Northampton advertising assisted living services without being a licensed assisted living residence.
Report Facts
Fine Amount: 3690
Fine Per Resident Per Day: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jacob Herzing | Enforcement Manager | Named as contact for appeals and enforcement |
| Matthew J. Jones | Director | Signed enforcement letter |
Notice — August 23, 2017
Date: August 23, 2017
Visit Reason
The document serves as a response to a request for a waiver of Pennsylvania Code qualifications for direct care staff at Brookdale Northampton personal care home.
Findings
The Department of Human Services granted the waiver, determining that the non-U.S. educational program of the staff member is similar to U.S. educational requirements. The facility must keep documentation of this waiver.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jay Bausch | Deputy Director of Administration | Signed the waiver approval letter. |
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