31 Reports
Inspection Report — Nov 10, 2025
Complaint Investigation
Date: Nov 10, 2025
Visit Reason
The inspection was conducted as a complaint investigation with a partial, unannounced visit to review compliance and the submitted plan of correction.
Complaint Details
The inspection was complaint-driven and the submitted plan of correction was reviewed and accepted as fully implemented.
Findings
The submitted plan of correction was fully implemented and compliance was maintained. One deficiency was noted regarding a resident assessment missing a response to sensory limitations, but it was argued that the section did not apply to the resident and documentation was otherwise adequate.
Citations (1)
Regulation 2600.225c: Resident assessment did not include a response to Sensory Limitations, Section F, 1-6, on the approved assessment form. The facility stated the section did not apply to the resident and provided documentation to support mobility needs.
Report Facts
Residents Served: 70
Secured Dementia Care Unit Residents Served: 22
Hospice Current Residents: 4
Residents Age 60 or Older: 70
Residents Diagnosed with Mental Illness: 2
Residents with Mobility Need: 19
Inspection Report — Sep 11, 2025
Plan of Correction
Date: Sep 11, 2025
Visit Reason
The inspection was a partial, unannounced visit conducted on 09/11/2025 due to an incident and interim review.
Findings
The inspection identified deficiencies including mistreatment of a resident in the secure dementia unit, lack of operable bedside lamps in resident rooms, and medication storage issues where a prescribed as-needed medication was unavailable due to expiration and refill issues. Corrective actions and staff training were implemented with ongoing monitoring.
Citations (3)
Resident in secure dementia unit was mistreated by staff who poured soapy water over the resident's head after the resident refused shower assistance.
Beds in resident rooms did not have access to operable bedside lamps; bulbs were blown or lamps were controlled by wall switches away from the bed.
A prescribed as-needed medication was not available on the medication cart due to expiration and lack of refill authorization.
Report Facts
Residents Served: 54
Residents Served in Secured Dementia Care Unit: 21
Current Hospice Residents: 3
Residents Age 60 or Older: 54
Residents with Mobility Need: 22
Residents with Physical Disability: 1
Total Daily Staff: 76
Waking Staff: 57
Inspection Report — Sep 3, 2025
Date: Sep 3, 2025
Visit Reason
The inspection was conducted as a licensing inspection due to an incident, with an unannounced partial inspection type.
Findings
No regulatory citations or deficiencies were identified during the inspection.
Report Facts
Residents Served: 52
Secured Dementia Care Unit Residents Served: 17
Hospice Current Residents: 2
Residents Age 60 or Older: 52
Residents Diagnosed with Intellectual Disability: 2
Residents with Mobility Need: 22
Residents with Physical Disability: 1
Inspection Report — Jul 16, 2025
Renewal
Date: Jul 16, 2025
Visit Reason
The inspection was conducted as a renewal visit to review compliance with licensing regulations and verify the submitted plan of correction was fully implemented.
Findings
The inspection identified multiple deficiencies including delays in providing requested records, late incident reporting, confidentiality breaches, outdated staff contact lists, unsecured poisonous materials, trash outside the home, inoperable bathroom ventilation, water pressure issues, unsecured light fixtures, lack of bedside lighting, missing freezer thermometers, lack of fire department notification documentation, incomplete fire drill records, incomplete resident evacuation during fire drills, discontinued medications on the medication cart, and missing directions for key-locking devices. All deficiencies had plans of correction accepted and were implemented by September 2025.
Citations (16)
Delay in providing requested medication administration training records.
Incident reports for resident death and smoke detector activation were not reported within required 24 hours.
Resident medical records were accessible on an unlocked medication cart computer and binders.
Outdated staff contact list provided to the Department including staff not employed for over 2 years.
Hand sanitizer with poison warning was unlocked and accessible in the Memory Care Unit Kitchenette.
Trash including cardboard, empty bags, wood pallets, and furniture was found outside the dumpster.
Bathroom in resident room lacked operable window or ventilation fan; fan was inoperable.
No water coming out of bathroom sink faucet in resident room.
Light fixture on porch outside Secure Dementia Care Unit exit was hanging down approximately 2 inches.
Resident room lacked an operable lamp or other source of lighting at bedside.
No thermometer in small freezer in the Secured Dementia Care Unit kitchenette.
No documentation of written notification to local fire department regarding home address, bedroom locations, and evacuation assistance.
Fire drill records lacked am/pm designation, time, number of residents in home, and number evacuated.
During fire drill, one resident did not evacuate to designated meeting place away from building or within fire-safe area.
Discontinued medication found on medication cart.
Directions for operating key-locking devices at Secure Dementia Care Unit exit gate were not conspicuously posted.
Report Facts
Residents Served: 51
Secured Dementia Care Unit Residents Served: 21
Current Hospice Residents: 4
Residents Age 60 or Older: 51
Residents with Mobility Need: 22
Residents with Physical Disability: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director | Executive Director | Named in multiple findings including delay in providing records, incident reporting, confidentiality breaches, and training. |
| Director of Nursing | Director of Nursing | Named in findings related to delay in providing records, incident reporting, confidentiality, training, and monitoring. |
| Memory Care Coordinator | Memory Care Coordinator | Named in findings related to incident reporting, confidentiality, medication audit, and training. |
| Regional Director of Operations | Regional Director of Operations | Provided training on multiple regulations including incident reporting, confidentiality, criminal background checks, and fire safety. |
| Regional Maintenance Director | Regional Maintenance Director | Responsible for repairs and audits related to bathroom ventilation, water pressure, and light fixtures. |
| Dining Director | Dining Director | Involved in training and monitoring related to poisonous materials and trash management. |
Inspection Report — May 22, 2025
Date: May 22, 2025
Visit Reason
The inspection was conducted as a partial, unannounced visit due to an incident at the facility.
Findings
No regulatory citations or deficiencies were identified during this inspection.
Report Facts
Residents Served: 50
Secured Dementia Care Unit Residents Served: 21
Current Hospice Residents: 5
Residents Age 60 or Older: 50
Residents with Mobility Need: 30
Inspection Report — Nov 8, 2024
Date: Nov 8, 2024
Visit Reason
The inspection was conducted as a licensing inspection by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing, with the reason stated as 'Incident'.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Residents Served: 59
Secured Dementia Care Unit Residents Served: 21
Hospice Current Residents: 4
Residents Age 60 or Older: 59
Residents with Mobility Need: 37
Residents with Physical Disability: 3
Resident Support Staff: 0
Total Daily Staff: 96
Waking Staff: 72
Inspection Report — Sep 19, 2024
Renewal
Date: Sep 19, 2024
Visit Reason
The inspection was conducted as a renewal visit for the facility's license, including a full unannounced inspection on 09/19/2024 and 09/25/2024.
Findings
The inspection found multiple deficiencies related to staff qualifications, food safety, medication administration documentation, emergency egress, support plan documentation, and key-locking device signage. All deficiencies had plans of correction accepted and were implemented by 10/22/2024.
Citations (7)
Direct care staff person A lacked documentation of a U.S. high school diploma or GED.
Unlabeled and undated leftover food items found in refrigerators in the 200 and 300 commons areas.
Ice cream freezer temperature was 15 degrees, above the required 0°F.
A walker was blocking the emergency exit to the courtyard, and the 200 hallway exit door required excessive force to open.
A dose of PRN morphine was administered but not documented on the Medication Administration Record (MAR).
Resident #1's support plan did not include required documentation for the use of a Halo Safety Ring device.
Directions for operating an electronic locking device on the courtyard gate were not posted.
Report Facts
Residents Served: 57
Secured Dementia Care Unit Residents Served: 20
Current Hospice Residents: 3
Residents with Mobility Need: 28
Residents 60 Years or Older: 57
Residents with Physical Disability: 3
Inspection Report — Aug 20, 2024
Follow-Up
Date: Aug 20, 2024
Visit Reason
The inspection was a partial, unannounced visit conducted due to an incident, with a focus on reviewing the submitted plan of correction.
Findings
The facility was found to have deficiencies related to incomplete medical evaluations and failure to follow prescriber's orders for medication administration. The submitted plan of correction was determined to be fully implemented as of the follow-up review.
Citations (2)
Resident Document of Medical Evaluation (DME) did not include an indication of mobility need; the section was blank.
Resident's blood sugar was not tested as ordered and medication was not administered according to prescriber's directions.
Report Facts
Residents Served: 59
Memory Care Unit Residents Served: 21
Hospice Current Residents: 4
Residents Age 60 or Older: 59
Residents with Mobility Need: 37
Residents with Physical Disability: 3
Total Daily Staff: 96
Waking Staff: 72
Inspection Report — Jul 31, 2024
Complaint Investigation
Date: Jul 31, 2024
Visit Reason
The inspection was conducted as a complaint and incident investigation during an unannounced partial licensing inspection.
Complaint Details
The inspection was complaint-related and incident-related; no deficiencies or citations were substantiated.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Residents Served: 59
Secured Dementia Care Unit Residents Served: 23
Hospice Current Residents: 7
Residents Age 60 or Older: 59
Residents with Mobility Need: 32
Residents with Physical Disability: 3
Inspection Report — May 9, 2024
Follow-Up
Date: May 9, 2024
Visit Reason
The inspection was a partial, unannounced follow-up visit triggered by an incident to review the submitted plan of correction for the facility.
Findings
The submitted plan of correction was determined to be fully implemented, with continued compliance required. The main deficiency involved incomplete or inadequate documentation of medical evaluations for residents in the secured dementia care unit, specifically lacking the required diagnosis terminology.
Citations (1)
Resident documentation of medical evaluation (DME) form indicating the resident requires secure dementia care was not completed timely and did not indicate the resident has a diagnosis of dementia or Alzheimer's disease as required.
Report Facts
Residents Served: 52
Residents in Secured Dementia Care Unit: 18
Current Hospice Residents: 4
Resident Support Staff: 79
Waking Staff: 59
Residents with Mobility Need: 27
Residents with Physical Disability: 2
Residents 60 Years or Older: 52
Inspection Report — Mar 27, 2024
Date: Mar 27, 2024
Visit Reason
The inspection was conducted as a partial, unannounced licensing inspection with an interim reason on 03/27/2024.
Findings
No regulatory citations or deficiencies were identified during the inspection.
Report Facts
Residents Served: 50
Hospice Current Residents: 4
Residents Age 60 or Older: 50
Residents with Mobility Need: 18
Residents with Physical Disability: 3
Staff Total Daily: 69
Staff Waking: 52
Notice — Mar 25, 2024
Date: Mar 25, 2024
Visit Reason
This letter responds to a request from the facility to use the TruLoo Smart Toilet seat to automate tracking of bowel movements and urinations to identify clinically concerning changes.
Findings
The Department reviewed the submitted information and determined that the informed consent process meets regulatory requirements for resident rights and privacy. The letter does not endorse the device but reminds the facility to maintain compliance with all regulations.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Theresa Hartman | Director, Bureau of Human Services Licensing | Signed the response letter regarding the TruLoo Smart Toilet seat request. |
Inspection Report — Nov 2, 2023
Renewal
Date: Nov 2, 2023
Visit Reason
The inspection was conducted as a renewal inspection of the facility's license.
Findings
The facility had several deficiencies related to annual staff training on Resident Rights, improper food storage, medication storage procedures, and medication record documentation. All deficiencies had accepted plans of correction which were fully implemented by the time of the report.
Citations (5)
Staff person A did not have annual training in the required topic Resident Rights for the 2022 training year.
In the main kitchen's freezer there was a plastic bag of frozen chicken that was not sealed properly.
The home did not have proper procedures implemented for the safe storage, access, security, distribution and use of medications and medical equipment by trained staff persons.
Resident #1's medication administration record had an error in documentation of the 8am medication reading.
Resident #2's medication administration record was not accurately documented when a medication was held as ordered.
Report Facts
Residents Served: 42
Total Daily Staff: 53
Waking Staff: 40
Residents with Mobility Need: 11
Residents 60 Years or Older: 42
Inspection Report — Mar 14, 2023
Complaint Investigation
Date: Mar 14, 2023
Visit Reason
The inspection was conducted as a complaint investigation at the facility on 03/14/2023.
Complaint Details
The inspection was complaint-related; no deficiencies or citations were substantiated.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Residents Served: 43
Current Residents in Hospice: 3
Residents Age 60 or Older: 43
Residents with Mobility Need: 14
Residents with Physical Disability: 2
Total Daily Staff: 57
Waking Staff: 43
Inspection Report — Aug 2, 2022
Renewal
Date: Aug 2, 2022
Visit Reason
The inspection was conducted as a renewal, complaint, and incident review of the facility.
Findings
Multiple deficiencies were identified including staff qualification documentation, fire safety orientation, hot water temperature exceeding limits, outdated food labeling, lack of furnace inspection documentation, fire drill scheduling issues, dietary needs documentation errors, and medication administration training deficiencies.
Citations (11)
Direct care staff person A lacked documentation of high school diploma, GED, or active nurse aide registry status.
Staff persons A, B, and C did not complete first day orientation on fire safety and emergency preparedness.
Hot water temperature measured 125.6°F in a resident room, exceeding the 120°F limit.
Outdated or unlabeled food items found in the reach-in freezer.
No documentation that the gas boiler was cleaned or inspected annually as required.
Fire drills were routinely conducted between the 26th and 31st of the month, not on varied days and times.
Resident #1's dietary needs were not properly documented or followed according to prescribed orders.
Staff person B lacked documentation of completed medication administration training and annual practicum.
Staff person B did not successfully complete Department-approved medication administration course but was scheduled to administer medications.
No medication administration training record for staff person B who administered medications.
Resident #1 and Resident #2's support plans did not indicate they were on special diets as required.
Report Facts
Residents Served: 37
Staffing Hours: 49
Waking Staff: 37
Hot Water Temperature: 125.6
Completion Dates: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff person A | Named in deficiencies related to lack of qualification documentation and incomplete fire safety orientation. | |
| Staff person B | Med-Tech | Named in deficiencies related to medication administration training, insulin injection training, and lack of training records. |
| Staff person C | Named in deficiency related to incomplete fire safety orientation. | |
| Resident #1 | Named in deficiencies related to dietary needs and support plan documentation. | |
| Resident #2 | Named in deficiency related to support plan dietary documentation. |
Inspection Report — Sep 24, 2021
Renewal
Date: Sep 24, 2021
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 — Jul 12, 2021
Renewal
Date: Jul 12, 2021
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.
Notice — Jun 30, 2021
Date: Jun 30, 2021
Visit Reason
The document serves as a renewal notification and license issuance for the Personal Care Home 'Elmcroft of Reading' following receipt of the renewal application dated April 6, 2021.
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
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary, Office of Long-term Living | Signed the renewal notification letter |
Inspection Report — Jun 22, 2021
Renewal
Date: Jun 22, 2021
Visit Reason
The inspection was conducted as a renewal inspection combined with a complaint investigation at Elmcroft of Reading.
Complaint Details
The inspection included a complaint investigation component as indicated by the reason for visit: Renewal, Complaint.
Findings
The inspection identified multiple deficiencies including issues with contract signatures, combustible storage, smoke detector testing, medical evaluation documentation, medication storage procedures, medication record accuracy, following prescriber's orders, preadmission screening, and support plan signatures. Plans of correction were accepted and documented for all deficiencies.
Citations (9)
Resident #1 refused to sign the new resident contract despite not being incapacitated.
A dryer sheet was located behind the dryer near the kitchen, posing a possible fire hazard.
Smoke detectors and fire alarms were not tested monthly for operability as required.
Resident #1’s medical evaluation was incomplete, missing body positioning information.
Resident #3's glucometer was not calibrated with the correct day and time.
Staff incorrectly transcribed Resident #2’s daily weights on the medication administration record on multiple occasions.
Resident #2’s doctor was not contacted despite weight gains meeting parameters requiring notification.
Resident #1’s preadmission screening was incomplete and did not indicate if the home could meet the resident's needs.
Resident #1’s support plan was not signed by the resident, with no indication of refusal or inability to sign.
Report Facts
Residents Served: 31
Total Daily Staff: 42
Waking Staff: 32
Completion Dates: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff Person A | Named in medication record deficiency for incorrectly transcribing Resident #2’s daily weights. | |
| Nurse Manager | Nurse Manager | Re-educated staff on glucometer calibration and medication administration. |
Inspection Report — Mar 23, 2021
Renewal
Date: Mar 23, 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.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Anne Graziano | Signed the inspection report letter |
Inspection Report — Mar 17, 2021
Renewal
Date: Mar 17, 2021
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.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Anne Graziano | Signed the inspection report letter |
Inspection Report — Dec 10, 2020
Renewal
Date: Dec 10, 2020
Visit Reason
The inspection was conducted as part of the licensing inspections by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing for Elmcroft of Reading facility.
Findings
No regulatory citations were identified as a result of the inspections conducted on 12/10/2020 and 12/22/2020.
Inspection Report — Nov 30, 2020
Routine
Date: Nov 30, 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.
Notice — May 5, 2020
Date: May 5, 2020
Visit Reason
The document serves as a renewal notification and license issuance for the Personal Care Home 'Elmcroft of Reading' following receipt of the renewal application dated April 14, 2020. It also 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 confirms issuance of a regular license and outlines the Department's plan to conduct an annual inspection within the next year.
Report Facts
Inspection Report — Mar 11, 2020
Complaint Investigation
Date: Mar 11, 2020
Visit Reason
The inspection was conducted as a complaint investigation to review compliance at Elmcroft of Reading.
Complaint Details
The inspection was complaint-driven and unannounced. The plan of correction was reviewed and determined fully implemented.
Findings
The submitted plan of correction was found to be fully implemented. A deficiency was identified related to failure to revise a hospice resident's support plan to reflect amended needs.
Citations (1)
Regulation 2600.227.c: The facility failed to revise the support plan for a hospice resident to describe amended needs and develop a plan to meet those needs after the resident began receiving hospice services.
Report Facts
Residents Served: 44
Current Hospice Residents: 4
Resident Support Staff: 0
Total Daily Staff: 50
Waking Staff: 38
Residents Age 60 or Older: 40
Residents with Mobility Need: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Heather Hetrick | Executive Director | Signed plan of correction and listed as administrator |
Inspection Report — Jun 20, 2019
Renewal
Date: Jun 20, 2019
Visit Reason
The inspection was a renewal inspection conducted by the Department’s Bureau of Human Services Licensing to assess compliance with 55 Pa. Code Ch. 2600 for Personal Care Homes.
Findings
The inspection identified multiple violations related to resident privacy, staff training, furniture safety, food storage, medication labeling and storage, following prescriber orders, and support plan documentation and signatures. Plans of correction were partially implemented with adequate progress noted.
Citations (9)
2600.17 Resident records confidentiality was violated as the License Inspection Summary dated 3/19/19 was posted with resident privacy coding sheet attached, exposing confidential information.
2600.63.a Staff training deficiency: On 6/15/2019 from 9pm to 11pm, only 1 staff person was certified in First Aid and CPR, below the required ratio.
2600.95 Furniture and equipment safety issue: Halo safety rings on beds in rooms 218 and 412 lacked covers to prevent entrapment.
2600.103.i Food safety violation: A jar of peanut butter with a Best By date of 2/19/19 was found in the home's food storage area.
2600.183.e Medication storage violation: Flexpen and Advair diskus were not labeled with the date opened.
2600.184.a Medication labeling error: Pharmacy label on Levothyroxine .112mg bottle did not match the prescribed dosage schedule.
2600.187.d Medication administration error: Resident #4's medication was held incorrectly on multiple dates, not following prescriber orders.
2600.227.d Support plan deficiency: Resident #5's and #6's Resident Assessment and Support Plans were not updated to reflect current services.
2600.227.g Support plan signatures were missing for four residents, including Resident #5 and #7, compromising documentation of participation.
Report Facts
Residents Served: 58
Current Hospice Residents: 8
Residents Age 60 or Older: 57
Residents Diagnosed with Mental Illness: 2
Residents with Mobility Need: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Doreen S. Hoos | Executive Director | Named in multiple findings and plans of correction signatures |
Inspection Report — May 8, 2019
Complaint Investigation
Date: May 8, 2019
Visit Reason
The inspection was conducted as a complaint investigation to assess compliance with 55 Pa. Code Ch. 2600 for Personal Care Homes.
Complaint Details
The inspection was triggered by a complaint, and violations were substantiated as detailed in the violation report.
Findings
Multiple violations were found including excessive wait times for assistance, non-functioning water faucet, wet towels causing hazards, unattended medications, medication administration errors, failure to follow prescriber orders, and incomplete support plan revisions.
Citations (7)
2600.23.a. The home’s preferred standard wait time is 7-10 minutes, but resident #1 waited significantly longer on multiple occasions, up to 1 hour and 9 minutes.
2600.89.a. The faucet in the kitchenette of the common area in hallway 300 did not function.
2600.95. Wet towels were found around the base of the toilet in room 318 due to occasional leaking, creating a hazard.
2600.183.b. Two medication carts were left unattended at 9:00 am in the hallway outside the activity room.
2600.187.b. Medication administration records showed that Tramadol 50 mg was administered to resident #1 at 2 pm but documentation errors were noted.
2600.187.d. The home did not follow the prescriber’s directions for Tramadol 50 mg administered at 11 am, which should have been given three times daily.
2600.227.c. Resident #1’s support plan was not updated to reflect needs after hospital admission for a fractured rib.
Report Facts
Residents Served: 54
Current Hospice Residents: 5
Staff Count: 58
Waking Staff: 44
Resident Wait Time: 69
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Doreen S. Hoos | Executive Director | Signed plans of correction and involved in oversight |
| Greg Geesaman | Maintenance Director | Assessed and corrected water faucet issue |
| Vanessa Mendez | Department representative present on-site during inspection |
Notice — Mar 28, 2019
Date: Mar 28, 2019
Visit Reason
This document serves as a renewal notification for the Personal Care Home license of Elmcroft of Reading and informs about the requirement for an annual onsite inspection 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.
Inspection Report — Mar 19, 2019
Complaint Investigation
Date: Mar 19, 2019
Visit Reason
The inspection was conducted as a complaint investigation at Elmcroft of Reading to assess compliance with 55 Pa. Code Chapter 2600 relating to Personal Care Homes.
Complaint Details
The inspection was triggered by a complaint. The report does not state the substantiation status.
Findings
The inspection found violations related to the facility's failure to implement positive interventions for a physically aggressive resident and failure to revise the resident's support plan to address aggressive behaviors. Plans of correction were partially implemented as of May 7, 2019.
Citations (2)
55 Pa.Code §2600.201 - The home failed to implement positive interventions to modify or eliminate a resident's physically aggressive behavior.
55 Pa.Code §2600.227(c) - The resident's support plan did not address aggressive behaviors and was not revised within 30 days of the assessment.
Report Facts
Number of Residents Served: 53
Number of Current Hospice Residents: 3
Number of Hospice Residents in past year: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Doreen Hoos | Administrator | Named as legal entity representative and signer of plan of correction |
| Kristin DeVries | Department representative conducting the inspection | |
| Vanessa Mendez | Department representative conducting the inspection |
Inspection Report — Dec 20, 2018
Complaint Investigation
Date: Dec 20, 2018
Visit Reason
The inspection was conducted as a complaint investigation at Elmcroft of Reading to assess compliance with 55 Pa. Code Chapter 2600 relating to Personal Care Homes.
Complaint Details
The inspection was complaint-driven. Specific violations were found regarding resident care and medical documentation. No substantiation status was explicitly stated.
Findings
The inspection found violations related to inadequate assistance with activities of daily living and incomplete medical evaluations. The facility failed to ensure dressing changes were completed and documented as required, and several resident medical evaluations lacked required health status information.
Citations (2)
55 Pa.Code §2600.23(a) - The home failed to provide required assistance with activities of daily living when a resident's dressing changes were not completed or documented by staff as needed.
55 Pa.Code §2600.141(a)(2) - Medical evaluations for three residents were incomplete, missing key health status and cognitive functioning information.
Report Facts
Number of Residents Served: 54
Total Daily Staff: 57
Waking Staff: 43
Number of Current Hospice Residents: 6
Number of Hospice Residents in Past Year: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Doreen Hoos | Administrator | Named as facility administrator in report header |
| Ryan Novak | Department Representative | Conducted on-site and off-site inspections |
Inspection Report — Jun 5, 2018
Original Licensing
Date: Jun 5, 2018
Visit Reason
The inspection was conducted due to a change in legal entity and to perform licensing inspection for a new legal entity operating the home.
Findings
The facility was found to be in substantial compliance with regulations. Two violations were cited related to fire drill frequency and medication storage, with plans of correction submitted.
Citations (2)
55 Pa.Code §2600.132(e): The home did not conduct sleeping-hour fire drills every six months as required; the last two drills occurred on 10/25/17 and 5/25/18.
55 Pa.Code §2600.183(b): Resident room #403 had unsecured medication accessible to other residents, violating medication storage requirements.
Report Facts
Number of Residents Served: 52
Number of Current Hospice Residents: 6
Total Daily Staff: 58
Waking Staff: 44
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Doreen Hoos | Administrator | Named as legal entity representative and signer of plan of correction |
| Jason Harvey | Inspector conducting the inspection | |
| Anne O'Haire | Inspector conducting the inspection |
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