21 Reports
Inspection Report — May 21, 2026
Follow-Up
Date: May 21, 2026
Visit Reason
This was a partial, unannounced follow-up inspection triggered by a complaint and incident review to verify the implementation of a previously submitted plan of correction.
Complaint Details
The inspection was complaint-related and involved substantiation of issues including denial of access to records and failure to report incidents and medication errors.
Findings
The inspection found multiple deficiencies related to failure to provide timely access to records, failure to report incidents and medication errors to the Department, unsanitary conditions in a resident's bathroom, and medication administration and documentation errors. The facility has implemented education and monitoring plans to address these issues.
Citations (6)
Regulation 2600.5a: The administrator or designee failed to provide immediate access to the home's 24 hour report book and an incident report to Department agents upon request.
Regulation 2600.16c: The home failed to report a resident's hospitalization incident to the Department within 24 hours as required.
Regulation 2600.85a: Sanitary conditions were not maintained; a resident's bedroom toilet was found splattered with dried feces.
Regulation 2600.187b: Medication administration records were inaccurately documented with incorrect times and dates of administration.
Regulation 2600.187d: The home failed to follow prescriber's orders by not administering prescribed medications as directed, resulting in medication errors.
Regulation 2600.188b: Medication errors were not immediately reported to the resident, designated person, or prescriber as required.
Report Facts
Residents Served: 53
Current Hospice Residents: 10
Total Daily Staff: 63
Waking Staff: 47
Inspection Report — Oct 28, 2025
Renewal
Date: Oct 28, 2025
Visit Reason
The inspection was conducted as a renewal, complaint, and provisional licensing visit to assess compliance with Personal Care Homes regulations.
Findings
Multiple deficiencies were found related to staff qualifications, medication administration, sanitary conditions, safety, and documentation. The facility was issued a second provisional license with required plans of correction.
Citations (24)
2600.19.e The home did not post the waiver for non-medically licensed staff administering medications in a conspicuous place.
2600.52 Staff Member B lacked a required FBI background check due to not living in Pennsylvania for the past 2 years.
2600.54.a Staff Member B did not have a high school diploma, GED, or active registry status on the Pennsylvania nurse aide registry.
2600.60.a The home lacked certified staff to administer routine and PRN medications during specified shifts.
2600.63.a No staff certified in both CPR and First Aid were present during multiple shifts despite 43 residents being present.
2600.65.f Staff Member A did not receive training in safe management techniques or care for residents with mental illness or intellectual disability during 2024.
2600.85.a Unsanitary conditions included use of resident glucometer for another resident, trash and soiled items near dumpsters, and fecal matter on toilet seats.
2600.85.d A kitchen trashcan lacked a lid and was nearly full of trash.
2600.85.e Trash outside the home was in uncovered dumpsters with open doors and bees present.
2600.88.a Exposed electrical wires were accessible near the maintenance room.
2600.91 Emergency telephone numbers were not posted in a resident's room with a cell phone.
2600.103.e Multiple food items in resident and kitchen refrigerators and pantries were unlabeled or undated.
2600.132.h Resident #1 had not participated in fire drills for at least six months.
2600.171.b The home's first aid kit in the transport van was missing scissors, a thermometer, and a breathing shield.
2600.182.c Staff Member E did not ensure a resident ingested a medication; a medication cup with cream was left untouched in a resident's bathroom.
2600.183.b Prescription medications and syringes were unlocked and accessible in a resident's bathroom without assessment for self-administration.
2600.184.b OTC medications and CAM were not labeled with the resident's name in a resident's bathroom.
2600.185.a Discrepancies existed between blood sugar readings on glucometer and documented MAR; medication for foley catheter was unavailable.
2600.187.d Medications were not administered as ordered due to unavailability; some medications were held without orders.
2600.190.a Multiple staff administered medications without successfully completing the Department-approved medication administration course.
2600.190.c Medication administration training records lacked documentation of completion dates and observations for some staff.
2600.224.a Resident preadmission screening forms lacked determinations that resident needs could be met and missing date of birth.
2600.225.c Resident assessments lacked behavioral and cognitive needs documentation.
2600.251.b Correction fluid was used on a resident's preadmission screening form.
Report Facts
Residents Served: 43
Current Residents Hospice: 9
Staff Count: 55
Waking Staff: 41
Residents Served: 45
Current Residents Hospice: 12
Staff Count: 56
Waking Staff: 42
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff Member A | Named in abuse and medication administration findings; terminated for abuse and privacy violations | |
| Staff Member B | Named in findings for lack of FBI background check and direct care staff qualifications | |
| Staff Member C | Named in medication administration and privacy violation findings; terminated for privacy violation | |
| Staff Member D | Named in medication administration findings | |
| Staff Member E | Named in medication administration and training record findings | |
| Staff Member F | Named in medication administration findings | |
| Staff Member G | Named in medication administration findings | |
| Staff Member H | Named in medication administration and insulin injection findings; training records reviewed | |
| Staff Member I | Named in accommodation violation interview | |
| Executive Director | Named in multiple findings and plans of correction | |
| Director of Nursing | Named in multiple findings and plans of correction | |
| Regional Director of Operations | Provided education on regulations and clarifications |
Notice — Jun 3, 2025
Date: Jun 3, 2025
Visit Reason
The document is a response to a facility's request for a waiver to allow unlicensed direct care staff to administer subcutaneous injections of GLP-1 agonist medications under specified training conditions.
Findings
The waiver outlines training requirements including successful completion of a Department-approved medication administration course, in-person training by licensed healthcare professionals, and annual training hours related to GLP-1 agonist medications and diabetes management. The facility must develop policies for administration, monitoring, and have a clinical contact available at all times.
Inspection Report — May 27, 2025
Enforcement
Date: May 27, 2025
Visit Reason
The inspection was conducted due to an incident and licensing inspections on May 27 and May 29, 2025, resulting in violations of 55 Pa. Code Ch. 2600 related to Personal Care Homes.
Findings
Multiple violations were found including failure to meet resident care needs, inadequate staff qualifications, failure to provide certified CPR assistance during an emergency, incomplete medication records, and deficiencies in resident support plans. The facility's license was revoked and replaced with a first provisional license contingent on correction of violations.
Citations (6)
Resident #1's support plan did not include a plan to meet service needs despite multiple falls and injuries.
Staff member A lacked a high school diploma, GED, or active registry status on the Pennsylvania nurse aide registry.
Staff member A, certified in obstructed airway techniques, failed to render assistance to resident #2 during an aspiration incident.
Resident #1's May 2025 medication administration record did not indicate the diagnosis or purpose for prescribed medications.
Resident #2's January 2025 medication administration record did not include the initials of the staff person who administered Nitroglycerin.
Resident #1's support plan did not document how medical, dental, vision, hearing, mental health or other behavioral care services needs would be met.
Report Facts
Residents Served: 43
Total Daily Staff: 58
Waking Staff: 44
Current Residents on Hospice: 7
Residents with Mobility Need: 15
Residents Diagnosed with Intellectual Disability: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff member A | Named in findings related to failure to provide CPR assistance during aspiration incident and lacking required qualifications. | |
| Juliet Marsala | Deputy Secretary, Office of Long-term Living | Signed enforcement and licensing correspondence. |
Inspection Report — Oct 29, 2024
Renewal
Date: Oct 29, 2024
Visit Reason
The inspection was conducted as a renewal visit to review compliance and verify the submitted plan of correction was fully implemented.
Findings
The inspection identified multiple deficiencies including sanitary conditions, food storage violations, refrigerator/freezer temperature issues, emergency procedure submission delays, evacuation drill timing exceeding limits, medication cart errors, and incomplete preadmission screening forms. All deficiencies had plans of correction accepted and were implemented by December 9, 2024.
Citations (7)
Pungent odor of urine detected in common bathroom near reception desk.
Cases of food and supplies stored on the floor in dry food storage area.
Freezer temperature in 200-hall kitchenette was above required temperature (2°F and 3°F).
Written emergency procedures had not been reviewed and submitted to local emergency management agency since 1/28/21.
Evacuation drill exceeded maximum safe evacuation time by 8 seconds.
Discontinued medication remained in medication cart after discontinuation date.
Resident's preadmission screening form lacked determination that needs could be met by the home.
Report Facts
Residents Served: 53
Freezer Temperature: 2
Freezer Temperature: 3
Evacuation Time: 908
Inspection Report — Jun 5, 2024
Complaint Investigation
Date: Jun 5, 2024
Visit Reason
The inspection was conducted as a complaint investigation at the facility on 06/05/2024.
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 during this unannounced partial inspection.
Report Facts
Total Daily Staff: 49
Waking Staff: 37
Residents Served: 44
Current Hospice Residents: 10
Residents Age 60 or Older: 44
Residents Diagnosed with Intellectual Disability: 2
Residents with Mobility Need: 5
Inspection Report — Feb 15, 2024
Follow-Up
Date: Feb 15, 2024
Visit Reason
The inspection was a partial, unannounced follow-up visit conducted due to an incident, with a focus on verifying the implementation of a previously submitted plan of correction.
Findings
The facility was found to have fully implemented the submitted plan of correction related to a confidentiality violation where resident records were left unattended and accessible in an unlocked office. Continued compliance is required.
Citations (1)
Resident's Medication Administration Record (MAR) and additional resident information were unattended and accessible in the unlocked Executive Director's office.
Report Facts
Residents Served: 52
Current Hospice Residents: 12
Residents 60 Years or Older: 49
Residents Diagnosed with Intellectual Disability: 3
Residents with Mobility Need: 7
Total Daily Staff: 59
Waking Staff: 44
Inspection Report — Oct 31, 2023
Renewal
Date: Oct 31, 2023
Visit Reason
The inspection was a renewal visit conducted to review compliance with licensing regulations and verify the implementation of a previously submitted plan of correction.
Findings
The submitted plan of correction was found to be fully implemented. Several deficiencies were identified related to contract rescission rights, resident compensation for labor, trash receptacle coverage, bathroom ventilation, refrigerator/freezer temperature monitoring, and medication storage, all of which have been corrected or addressed with plans of correction.
Citations (6)
2600.25e Resident contracts did not include the right to rescind the contract within 72 hours after signing.
2600.42q A resident was observed performing labor tasks without compensation, violating labor laws.
2600.85d A full, uncovered, unattended trash can was found in the kitchen.
2600.86b The bathroom in bedroom 229 lacked an operable window or ventilation fan.
2600.103f The walk-in refrigerator in the kitchen lacked a thermometer.
2600.183e Three loose pills were found in the 100-hall medication cart.
Report Facts
Residents Served: 50
Current Hospice Residents: 8
Residents 60 Years or Older: 50
Residents Diagnosed with Intellectual Disability: 3
Residents with Mobility Need: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Juliet Marsala | Deputy Secretary | Signed letter confirming plan of correction implementation |
| Director of Nursing | Removed loose pills from medication cart and involved in medication storage correction | |
| Assistant Director of Nursing | Involved in education and medication cart audits | |
| Maintenance Director | Replaced trashcan lid and repaired bathroom ventilation fan | |
| Administrator | Responsible for education on regulations and oversight of corrective actions |
Inspection Report — May 31, 2023
Enforcement
Date: May 31, 2023
Visit Reason
The inspection was conducted as an interim partial inspection with an unannounced notice to assess compliance and follow up on a plan of correction submission.
Findings
The facility was found to have multiple violations related to medication administration, including failure to report medication errors timely, incomplete medication records lacking diagnosis or purpose, failure to follow prescriber's orders, and failure to report medication errors to residents and prescribers. The Department revoked the certificate of compliance and issued a first provisional license with fines pending if violations are not corrected.
Citations (4)
Failure to report medication errors to the Department within 24 hours as required.
Medication administration records did not contain diagnosis or purpose of prescribed medications for multiple residents.
Failure to follow prescriber's orders, including not administering prescribed Vitamin D3 and blood sugar checks.
Failure to immediately report medication errors to the resident, designated person, and prescriber.
Report Facts
Residents Served: 55
Fine per violation per resident per day: 5
Calculated Fine per violation: 275
Mandated Correction Date: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jessica Williams | Personal Care Home Administrator | Named as submitter of plan of correction and involved in oversight |
| Jason McCloskey | Lead Inspector | Conducted on-site inspection and reviewed plan of correction |
| Jennifer Brown | Regional Director of Operations | Added diagnoses to medication records during plan of correction |
Inspection Report — Mar 29, 2023
Complaint Investigation
Date: Mar 29, 2023
Visit Reason
The inspection was conducted as a complaint investigation following allegations of violations related to Personal Care Homes regulations.
Complaint Details
The visit was complaint-related and substantiated by findings of multiple medication errors, failure to report incidents, neglect in emergency response, and incomplete documentation.
Findings
Multiple violations were found including failure to report medication errors, failure to follow prescriber's orders, incomplete medication records, and failure to provide CPR in accordance with training. Several medication errors involving Resident 1 were not reported to the resident, designated persons, or physicians.
Citations (10)
2600.16c The home failed to report multiple medication errors involving Resident 1 to the Department within 24 hours as required.
2600.25b Resident-home contracts for Residents 1 and 2 were not signed by the residents as required.
2600.42b The home neglected Resident 1 by failing to provide CPR and misidentifying DNR status during a medical emergency.
2600.63d Staff failed to provide CPR to Resident 1 in accordance with training during a medical emergency.
2600.183b Prescription medications and syringes were not kept locked; a medication cart was found unlocked and unattended.
2600.187d Resident 1 did not receive prescribed medications on multiple occasions because they were unavailable in the home.
2600.188b Medication errors involving Resident 1 were not immediately reported to the resident, designated person, or prescriber.
2600.187a Medication administration records for Residents 2, 3, and 4 lacked diagnosis or purpose for prescribed medications.
2600.187d Resident 1 did not receive prescribed Vitamin D3 and blood sugar checks as ordered, and these errors were not reported timely.
2600.188b Medication errors involving Resident 1 in April 2023 were not reported to the resident, designated person, or prescriber.
Report Facts
Residents Served: 49
Fine Amount: 275
Inspection Report — Nov 9, 2022
Renewal
Date: Nov 9, 2022
Visit Reason
The inspection was conducted as a renewal and complaint investigation visit to evaluate compliance with licensing requirements and complaint allegations.
Findings
The inspection identified multiple deficiencies including failure to report an incident to the Department, inadequate quality management reviews, incomplete fire safety orientation for staff, unclean kitchen surfaces, missing bedside furniture and lighting for a resident, incomplete fire drill records, lack of smoking signage, medication administration failures, insulin injections by untrained staff, and incomplete or unsigned resident support plans. Plans of correction were accepted and implemented by December 2022.
Citations (12)
Failure to report a resident fall incident to the Department within 24 hours.
Only one quality management review held this year instead of monthly as required.
Staff person did not complete first day fire safety orientation.
Kitchen walls and trashcan lid were soiled with food and dried ketchup.
No bedside table or shelf beside Resident 7's bed.
Resident 7 did not have access to operable lamp or bedside lighting.
Fire drill records had '0' listed for evacuation time and exit routes on multiple dates.
No smoking signage posted near facility entrances despite being a designated smoking facility.
Medications were not administered to residents #2, #3, #4, and #5 on specified dates due to unavailability.
Staff person B administered insulin without completing required diabetes education within last 12 months.
Resident #6 eloped and support plan did not reflect supervision needs; residents #2 and #3 support plans incomplete.
Resident #2's support plan was not signed or dated by staff; Resident #3's support plan was not dated by resident.
Report Facts
Residents Served: 55
Current Hospice Residents: 7
Residents Age 60 or Older: 55
Residents with Intellectual Disability: 3
Residents with Mobility Need: 5
Total Daily Staff: 60
Waking Staff: 45
Inspection Report — Jul 14, 2021
Renewal
Date: Jul 14, 2021
Visit Reason
The document is a renewal license issued in response to the April 20, 2021 renewal application to operate the Personal Care Home, Elmcroft of Dillsburg. The Department advises that an onsite inspection will be conducted within the next twelve months as required by regulation.
Findings
A regular license is being issued for the facility. The Department will conduct an inspection within the next twelve months and will take enforcement action if noncompliance is found.
Report Facts
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary | Signed the renewal license letter |
Inspection Report — May 24, 2021
Renewal
Date: May 24, 2021
Visit Reason
The inspection was conducted as a renewal and complaint investigation visit to assess compliance and address specific complaints.
Complaint Details
The visit included a complaint investigation as part of the renewal inspection.
Findings
The submitted plan of correction was determined to be fully implemented. Multiple deficiencies were identified related to resident contracts, fire safety orientation, first aid kit contents, medication administration records, resident assessments, and support plan signatures, all with corrective actions planned and completed by specified dates.
Citations (6)
Resident #1's resident-home contract was not signed by the resident.
Staff Person A did not receive orientation in general fire safety and emergency preparedness on the first day of work.
The first aid kit in the 2020 Chevy Bus used to transport residents did not include a thermometer, tweezers, or eye coverings.
Resident #3's medication administration record showed a blood glucose level recorded without a glucometer reading.
Resident #1's initial assessment was not completed within 15 days of admission.
The RASP for Resident #1 and Resident #2 did not include all required signatures.
Report Facts
Residents Served: 40
Current Hospice Residents: 2
Residents Age 60 or Older: 40
Residents with Intellectual Disability: 3
Residents with Mobility Need: 30
Residents with Physical Disability: 0
Staff Total Daily: 70
Staff Waking: 53
Inspection Report — Jan 27, 2021
Renewal
Date: Jan 27, 2021
Visit Reason
The inspection was conducted as part of the Pennsylvania Department of Human Services, Bureau of Human Service Licensing's licensing inspections of the facility.
Findings
No regulatory citations were identified as a result of this inspection.
Inspection Report — Dec 22, 2020
Renewal
Date: Dec 22, 2020
Visit Reason
The inspection was conducted as a 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 — Apr 27, 2020
Routine
Date: Apr 27, 2020
Visit Reason
The Department’s Bureau of Human Services Licensing Representative conducted an inspection of the facility on April 27, 28, 30, 2020 and May 11 and 15, 2020.
Findings
No regulatory citations with 55 Pa. Code Ch. 2600 (relating to Personal Care Homes) were identified as a result of this inspection.
Inspection Report — May 29, 2019
Renewal
Date: May 29, 2019
Visit Reason
The inspection was a full, unannounced renewal licensing inspection conducted on May 29, 2019, to assess compliance with 55 Pa.Code Ch. 2600 relating to Personal Care Homes.
Findings
The inspection identified multiple violations related to staff training, emergency medical plan orientation, training documentation, and food refrigeration temperature controls. Plans of correction were submitted and partially implemented with adequate progress as of June 11, 2019.
Citations (5)
63a - First Aid/CPR Training: Only one staff member with First Aid and CPR certification was present during the night shift despite 56 residents being present on 5/19/2019.
65b - Rights/Abuse 40 Hours: Staff Member A did not receive training on the Emergency Medical Plan and Reportable Incidents within the first 40 hours of work since September 2018.
65f - Training Topics: The 2018 training for Staff Members B and C did not include instruction specific to medical evaluation as required.
65i - Training Record: The 2018 training record did not document the instructor's name for trainings provided to Staff Members B and C in Resident Rights and The Older Adult Protective Services Act.
103f - Refrigerator/Freezer Temps: The freezer in the kitchen had an internal temperature of 25°F on 5/29/2019, exceeding the required maximum of 0°F for frozen food storage.
Report Facts
Residents Served: 67
Current Hospice Residents: 6
Total Daily Staff: 75
Waking Staff: 56
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tara Neal | Executive Director | Named as Administrator and signer of plans of correction |
Inspection Report — Apr 15, 2019
Renewal
Date: Apr 15, 2019
Visit Reason
The document is a renewal application and license issuance for Elmcroft of Dillsburg, a Personal Care Home, indicating the facility's renewal of its license to operate.
Findings
No inspection findings are reported in this document. It confirms the license issuance and states that the Department will conduct an annual inspection within the next twelve months.
Inspection Report — Nov 27, 2018
Complaint Investigation
Date: Nov 27, 2018
Visit Reason
The inspection was conducted as a complaint investigation at Elmcroft of Dillsburg to assess compliance with 55 Pa.Code Chapter 2600 relating to Personal Care Homes.
Complaint Details
The inspection was triggered by a complaint. Specific violations involved unsigned resident contracts and unsafe oxygen equipment procedures. No repeat violations were noted.
Findings
Violations were found related to unsigned resident contracts and inadequate procedures for safe use of oxygen equipment. Plans of correction include auditing resident files for signatures and updating care plans for oxygen use.
Citations (2)
55 Pa.Code §2600.25(b) - The contract for Resident 1 is not signed by the resident.
55 Pa.Code §2600.185(a) - The home failed to develop and implement procedures for safe storage, access, security, distribution, and use of medications and medical equipment by trained staff.
Report Facts
Number of Residents Served: 57
Number of Current Hospice Residents: 5
Number of Hospice Residents in Past Year: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tara Neil | Administrator | Named as administrator in report and plan of correction |
| Jason McCloskey | Department representative conducting inspection | |
| Dale Rosenblat | Department representative conducting inspection |
Inspection Report — Jun 13, 2018
Original Licensing
Date: Jun 13, 2018
Visit Reason
The inspection was conducted as a licensing inspection for a new legal entity operating a Personal Care Home.
Findings
The facility was found to be in substantial compliance with applicable regulations, but the licensing inspector was unable to complete a full inspection due to the newness of the legal entity.
Notice — June 10, 2020
Date: June 10, 2020
Visit Reason
The document serves as a renewal notification and license issuance for the Personal Care Home 'Elmcroft of Dillsburg' following receipt of a renewal application dated May 22, 2020.
Findings
The Department issued a regular license in response to the renewal application and advised that an onsite annual inspection will be conducted within the next twelve months to ensure compliance with applicable regulations.
Report Facts
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