Inspection Reports for
Colonial Courtyard at Bedford
220 Donahue Manor Road, Bedford, PA 15522, Bedford, PA, 15522
Back to Facility Profile21 Reports
Inspection Report — Sep 23, 2025
Renewal
Date: Sep 23, 2025
Visit Reason
The inspection was conducted as a renewal inspection of the Colonial Courtyard at Bedford facility to review compliance with licensing requirements and regulations.
Findings
The facility was found to have multiple deficiencies including unsigned resident contracts, unsecured resident equipment, unlocked medications, improper medication storage and documentation, failure to follow prescriber's orders, and lack of required documentation for secured dementia care unit admissions. Plans of correction were accepted and implemented with target completion dates mostly in October 2025.
Citations (7)
Resident-home contracts for residents #3, #4, and #7 were not signed by the residents.
An enabler bar was not securely attached to resident #1's bed creating a hazard.
Medications including Nystatin cream, Nystop powder, and insulin cartridges were found unlocked and accessible in resident rooms.
Prescription GB Diabetic cream was not available in the medication cart; blood sugar documentation discrepancies for resident #4.
Resident #2's prescribed wound treatments were not utilized as ordered.
Staff member administered insulin injections without completing required Department-approved diabetes patient education program training.
No documentation that residents #3 and #7 and their designated persons did not object to admission to the secured dementia care unit.
Report Facts
Residents Served: 73
Residents Served in Secure Dementia Care Unit: 14
Staffing Hours: 103
Waking Staff: 77
Residents with Mobility Need: 30
Residents with Physical Disability: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Juliet Marsala | Deputy Secretary | Signed the certificate of compliance and licensing letter. |
| Staff member A | Administered insulin injections without completing required training. |
Inspection Report — May 29, 2025
Complaint Investigation
Date: May 29, 2025
Visit Reason
The inspection was conducted as a complaint investigation to review compliance with regulations and to verify the submitted plan of correction for the facility.
Complaint Details
The visit was complaint-related as indicated by the inspection information section stating the reason as 'Complaint'.
Findings
The inspection identified three main deficiencies: a breach of resident record confidentiality due to a staff member posting a video revealing confidential information, failure to provide required assistance with eating/feeding to a resident as per their support plan, and unsecured medication found on the floor in the dining room. Corrective actions including staff termination, education, and monitoring were implemented.
Citations (3)
Resident records confidentiality was breached when a staff member posted a video on social media showing confidential resident information.
A resident did not receive required assistance with eating/feeding during mealtimes as indicated in their support plan.
A prescription medication pill was found unsecured on the floor of the main dining room.
Report Facts
Residents Served: 72
Secured Dementia Care Unit Residents Served: 14
Hospice Current Residents: 8
Residents Age 60 or Older: 72
Residents with Mobility Need: 32
Residents with Physical Disability: 1
Inspection Report — Apr 1, 2025
Complaint Investigation
Date: Apr 1, 2025
Visit Reason
The inspection was conducted as a complaint investigation with an unannounced partial inspection on 04/01/2025.
Complaint Details
The inspection was triggered by a complaint; however, no deficiencies or citations were found.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Residents Served: 73
Secured Dementia Care Unit Residents Served: 15
Current Hospice Residents: 7
Residents Age 60 or Older: 73
Residents with Mobility Need: 40
Residents with Physical Disability: 1
Inspection Report — Jan 7, 2025
Complaint Investigation
Date: Jan 7, 2025
Visit Reason
The inspection was conducted as a complaint investigation with an unannounced partial inspection.
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 as a result of this inspection.
Report Facts
Residents Served: 74
Secured Dementia Care Unit Residents Served: 14
Current Hospice Residents: 6
Residents Age 60 or Older: 74
Residents with Mobility Need: 37
Inspection Report — Nov 13, 2024
Complaint Investigation
Date: Nov 13, 2024
Visit Reason
The inspection was conducted as a complaint investigation at the facility.
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 as a result of this inspection.
Report Facts
Residents Served: 78
Secured Dementia Care Unit Residents Served: 14
Hospice Current Residents: 6
Resident Mobility Need: 37
Total Daily Staff: 115
Waking Staff: 86
Inspection Report — Aug 15, 2023
Renewal
Date: Aug 15, 2023
Visit Reason
The inspection was conducted as a renewal review of the facility's license to ensure continued compliance with regulatory requirements.
Findings
The report found multiple deficiencies related to criminal background checks, medical evaluations, medication storage procedures, and support plan documentation. The facility submitted plans of correction which were accepted and implemented by early September 2023.
Citations (6)
Staff members did not have Pennsylvania State Police background checks completed until the inspection date.
Medical evaluation for resident #1 was not completed within 60 days prior to admission.
Resident #4's annual medical evaluation was not completed as required.
The glucometer for resident #3 was not calibrated correctly, resulting in incorrect blood glucose measurements recorded on the Medication Administration Record.
Resident #3's support plan was not revised within 30 days upon completion of the annual assessment or changes in needs.
The support plan for resident #2 lacked signatures of participants who developed the plan.
Report Facts
Residents Served: 60
Secured Dementia Care Unit Residents Served: 13
Current Hospice Residents: 9
Residents with Mobility Need: 17
Total Daily Staff: 77
Waking Staff: 58
Inspection Report — Apr 5, 2023
Follow-Up
Date: Apr 5, 2023
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 related to abuse, criminal background checks, and staff orientation deficiencies. Continued compliance is required.
Citations (4)
A resident was verbally abused and demeaned by a staff person, with the staff remaining on shift for approximately one more hour after the incident.
Criminal background checks were not completed for four staff persons, including missing Pennsylvania State Police and FBI checks as required.
Four staff persons did not receive required orientation on fire safety and emergency preparedness topics prior to or during their first work day.
Four staff persons who completed 40 hours of work did not receive orientation on resident rights, emergency medical plan, mandatory abuse reporting, and reporting of reportable incidents.
Report Facts
Residents Served: 59
Secured Dementia Care Unit Residents Served: 11
Hospice Current Residents: 7
Residents Age 60 or Older: 59
Residents with Mobility Need: 16
Total Daily Staff: 75
Waking Staff: 56
Notice — Mar 22, 2023
Date: Mar 22, 2023
Visit Reason
The document serves to grant a waiver to Colonial Courtyard at Bedford allowing additional time for their personal care home administrator to complete the required 100-hour standardized training course and competency test.
Findings
The waiver is granted with conditions including supervision requirements and documentation of training. The Department will review compliance with these conditions during the annual inspection.
Report Facts
Training course duration: 100
Inspection Report — Jul 12, 2022
Renewal
Date: Jul 12, 2022
Visit Reason
The inspection was conducted as a renewal inspection of the facility license.
Findings
The inspection identified multiple deficiencies including failure to post current licensing summaries, failure to report resident abuse timely, improper financial record keeping, incomplete staff training, unsafe storage of poisonous materials and medications, failure to conduct monthly fire drills, and incomplete resident assessments. Plans of correction were accepted and implemented for all deficiencies.
Citations (17)
The home's most current licensing summaries issued by the Department were not posted in a conspicuous and public place.
The home did not immediately report an allegation of resident-to-resident abuse to Older Adult Protective Services.
The home did not report a resident-to-resident abuse incident to the Department within required timeframes.
Quarterly financial reviews for residents' funds were not completed timely.
Direct care staff provided unsupervised ADL services before completing Department-approved training and competency testing.
Poisonous materials were not stored in original labeled containers and were accessible to residents.
Lint was accumulated in the lint trap of the clothes dryer, posing a fire hazard.
An unannounced fire drill was not held during the month of April 2022.
Resident did not evacuate to a designated meeting place during a fire drill.
Smoking policy signs were not posted at the home's entrances.
The designated smoking area did not provide fireproof receptacles and ashtrays.
Prescription medications and syringes were found unlocked and accessible in residents' rooms.
Discontinued and expired medications were found in residents' possession.
Controlled substance administration was not properly documented by staff.
Medication administration records (MAR) lacked documentation of special precautions and proper dosage amounts.
Medications and treatments were not always administered following prescriber's orders.
Resident assessments did not include all care needs and medical diagnoses as required.
Report Facts
Residents Served: 42
Current Hospice Residents: 5
Total Daily Staff: 53
Waking Staff: 40
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Executive Operations Officer | Named in multiple findings related to plan of correction implementation, staff education, and monitoring. | |
| Wellness Director | Named in multiple findings related to staff education, medication administration, abuse reporting, and assessment completion. | |
| Maintenance Supervisor | Named in findings related to poisonous materials storage, fire safety, and smoking area compliance. | |
| Administrator | Responsible for reviewing incident reports and conducting audits as part of corrective actions. | |
| Regional Director | Provided education and training related to financial management and staff training. | |
| ASD (Assistant Service Director) | Involved in financial management training and record keeping. |
Inspection Report — Jun 5, 2021
Renewal
Date: Jun 5, 2021
Visit Reason
The document is a renewal application and license issuance for the Personal Care Home 'Colonial Courtyard at Bedford' pursuant to Title 55, PA Code, Chapter 2600.
Findings
A regular license is being issued in response to the renewal application. The Department will conduct an onsite inspection within the next twelve months to ensure compliance with applicable regulations.
Report Facts
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary | Signed the renewal license letter |
Inspection Report — Nov 24, 2020
Renewal
Date: Nov 24, 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 — May 11, 2020
Complaint Investigation
Date: May 11, 2020
Visit Reason
The inspection was conducted as a complaint investigation triggered by an incident involving alleged mistreatment of a resident.
Complaint Details
The complaint was substantiated based on witness statements and investigation. Staff Member B was suspended immediately and later terminated for discourteous conduct toward a resident.
Findings
The investigation found that on 5/10/2020, a staff member yelled at a resident in the bathroom, violating the regulation requiring residents to be treated with dignity and respect. The staff member was suspended and subsequently terminated, and corrective actions including staff training were implemented.
Citations (1)
Regulation 2600.42(c) requires residents to be treated with dignity and respect. A staff member yelled at a resident on 5/10/2020 while the resident was preparing for bed.
Report Facts
Residents Served: 55
Current Residents in Hospice: 9
Residents Age 60 or Older: 55
Residents with Mobility Need: 24
Residents with Physical Disability: 2
Residents Diagnosed with Mental Illness: 1
Residents Receiving Supplemental Security Income: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Belinda McQuaide | Executive Operations Officer | Named in the plan of correction and investigation related to the violation. |
Inspection Report — Jun 19, 2019
Renewal
Date: Jun 19, 2019
Visit Reason
The inspection was an annual renewal inspection conducted by the Department’s Bureau of Human Services Licensing on June 19 and 20, 2019 to assess compliance with 55 Pa.Code Ch. 2600 relating to Personal Care Homes.
Findings
The inspection identified multiple violations including insufficient staff trained in CPR/first aid during certain hours, incomplete staff training records, an unlabeled soap dispenser in a resident bathroom, and a resident not signing their support plan. Plans of correction were submitted addressing these issues.
Citations (4)
2600.63a - At least one staff person for every 50 residents must be trained in first aid and CPR at all times. On 6/13 and 6/14/2019, only one staff person was trained during required hours when two were needed.
2600.65i - The home's record of direct care staff training did not include documentation of 2018 annual fire safety training for Staff Member A.
2600.102i - A dispenser with soap must be provided within reach of each bathroom sink and bar soap must be clearly labeled. An unlabeled used bar of soap was found in Room 101.
2600.227g - Individuals participating in the development of a support plan must sign and date it. Resident #1 did not sign the support plan developed on 6/7/19.
Report Facts
Residents Served: 70
Current Hospice Residents: 11
Residents aged 60 or older: 69
Residents with mobility need: 34
Residents with physical disability: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tressia Day | Executive Operations Officer | Signed multiple plans of correction related to deficiencies |
Notice — Feb 22, 2019
Date: Feb 22, 2019
Visit Reason
The document serves as a renewal notification and license issuance for the Personal Care Home 'Colonial Courtyard at Bedford' following receipt of a renewal application dated February 19, 2019. It also advises that an annual onsite inspection will be conducted within the next twelve months as required by state code.
Findings
No inspection findings are reported in this document. It is a licensing and renewal notice without compliance or deficiency information.
Report Facts
Inspection Report — Jun 12, 2018
Renewal
Date: Jun 12, 2018
Visit Reason
The inspection was conducted as an annual licensing inspection on June 12 and June 13, 2018, for renewal of the facility license.
Findings
Violations of 55 Pa.Code Chapter 2600 related to Personal Care Homes were found, including missing emergency procedures, inadequate exit signage, and incomplete annual medical evaluations. Plans of correction were submitted and approved with some fully implemented and others partially implemented.
Citations (3)
55 Pa.Code §2600.123(b) - The home's emergency procedures are not posted in a conspicuous and public place in the home.
55 Pa.Code §2600.133(a)(2) - The 500 hallway lacks a direct visual line to the nearest exit and has no signs marking the line of travel to the exits. The home served 64 residents on 6/13/2018.
55 Pa.Code §2600.141(b)(1) - Resident 1's most recent medical evaluation was on 1/12/2018, Resident 2's on 8/29/2017, both missing the required annual evaluation.
Report Facts
Number of Residents Served: 61
Residents served on 6/13/2018: 64
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Danielle Foor | Executive Director | Signed plans of correction on multiple violations. |
Inspection Report — Mar 21, 2018
Renewal
Date: Mar 21, 2018
Visit Reason
The document is a renewal license issued in response to the March 15, 2018 renewal application for the Personal Care Home Colonial Courtyard at Bedford. The Department advises that an annual onsite inspection will be conducted within the next twelve months as required by regulation.
Findings
No inspection findings are reported in this document. It serves as a license renewal certificate and notification letter confirming the renewal and outlining future inspection requirements.
Report Facts
Inspection Report — Mar 9, 2018
Complaint Investigation
Date: Mar 9, 2018
Visit Reason
The inspection was conducted as a partial, unannounced visit triggered by an incident.
Complaint Details
The visit was complaint-related, triggered by an incident. No repeat violations were noted. The plan of correction was partially implemented with adequate progress as of 4/6/18.
Findings
The inspection found violations related to medical evaluations, assessments, and support plans for Resident #1, including delays in annual medical evaluations and support plan revisions.
Citations (3)
Regulation 55 Pa.Code 2600 2600.141(b)(1) - Resident #1's medical evaluation dated 12/17/16 was completed more than a year after the prior evaluation dated 7/13/15.
Regulation 55 Pa.Code 2600 2600.225(c) - The initial assessment for Resident #1 was dated in 2015. The next annual assessment was completed on 12/25/16, later than required.
Regulation 55 Pa.Code 2600 2600.227(c) - The initial support plan for Resident #1 was dated in 2015. The annual support plan was not revised until 12/25/16.
Report Facts
Number of Residents Served: 66
Number of Current Hospice Residents: 8
Number of Hospice Residents in past year: 20
Number of Residents 60 Years or Older: 66
Number of Residents with Mental Impairment: 1
Number of Residents with Mobility Needs: 19
Number of Residents with Physical Disability: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Danielle Foor | Executive Director | Signed plan of correction documents related to violations. |
Inspection Report — Jun 27, 2017
Renewal
Date: Jun 27, 2017
Visit Reason
The inspection was conducted as part of the Department of Human Services' annual licensing renewal inspections on June 27 and 28, 2017 for Colonial Courtyard at Bedford.
Findings
Violations of 55 Pa.Code Chapter 2600 related to Personal Care Homes were found and specified in the enclosed License Inspection Summary. The facility must correct all violations by the specified dates and maintain compliance with the code.
Citations (2)
55 Pa.Code §2600.63(a) requires at least one staff person trained and certified in first aid and CPR to be present at all times. Between 8/5/17 and 6/23/17, only one staff member was trained and certified during night hours despite seventy-three residents being present.
55 Pa.Code §2600.141(a)(2) requires medical evaluations to include specific data. Documentation for Resident #1 and Resident #2 was missing data for height, pulse rate, blood pressure, and temperature.
Report Facts
Number of Residents Served: 73
Total Daily Staff: 95
Waking Staff: 71
Number of Current Hospice Residents: 8
Number of Hospice Residents in Past Year: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Danielle Foor | Administrator | Named as facility administrator on page 2. |
| Stacey Frederick | Acting Executive Director | Signed plan of correction documents related to violations. |
Inspection Report — Jul 6, 2016
Renewal
Date: Jul 6, 2016
Visit Reason
The inspection was conducted as an annual licensing renewal inspection of the Personal Care Home facility Colonial Courtyard at Bedford on July 6 and 7, 2016.
Findings
Multiple violations of 55 Pa.Code Chapter 2600 were found, including insufficient trained staff present during certain hours, improper food storage, incomplete resident assessments, and missing support plans. Plans of correction were submitted and partially or fully implemented by August 2016.
Citations (7)
2600.63(a) - At least one staff person for every 50 residents trained in first aid and certified in obstructed airway techniques and CPR was not present at all times. On July 2-4, 2016, 71 residents were present but no or only one trained staff was present during specified times.
2600.103(g) - Food was not stored in closed or sealed containers. Three 1.5 quart plastic storage containers in the kitchen had broken lids, leaving opened and unsealed food products.
2600.225(a) - The home did not complete an initial assessment for Resident 1 within 15 days of admission as required.
2600.225(c) - Resident 3's most recent assessment was completed on 8/3/15, but the previous assessment was from 7/10/14, indicating missing required annual assessments.
2600.227(a) - Resident 1 was admitted but the home did not develop a required written support plan within 30 days of admission.
2600.227(g) - Support plans for Residents 2 and 4 were not signed by the staff persons who developed them.
2600.227(h) - Resident 2's support plan was not signed by the resident and did not contain a notation of refusal or inability to sign.
Report Facts
Number of Residents Present: 71
Number of Residents Served: 74
Number of Current Hospice Residents: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Danielle Foor | Administrator | Named as facility administrator on page 2. |
| Jason McCloskey | Department Representative/Inspector | Conducted on-site inspections on July 6 and 7, 2016. |
| Danielle Foor | Executive Director | Signed plans of correction and responsible for corrective actions. |
Notice — Mar 22, 2016
Date: Mar 22, 2016
Visit Reason
The document serves as a renewal notice and certificate of compliance for the Personal Care Home 'Colonial Courtyard at Bedford' following receipt of a renewal application.
Findings
The Department confirms issuance of a regular license in response to the renewal application and advises that an onsite annual inspection will be conducted within the next twelve months as required by regulation.
Report Facts
Notice — June 12, 2020
Date: June 12, 2020
Visit Reason
This document serves as a renewal notification and issuance of a regular license for the Personal Care Home 'Colonial Courtyard at Bedford' following receipt of the renewal application dated June 9, 2020.
Findings
The Department advises that an onsite inspection will be conducted within the next twelve months as required by regulation. No findings or deficiencies are reported in this document.
Report Facts
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