Inspection Reports for
Colonial Courtyard at Clearfield
1300 Leonard Street, Clearfield, PA 16830, Clearfield, PA, 16830
Back to Facility Profile39 Reports
Inspection Report — Nov 14, 2025
Complaint Investigation
Date: Nov 14, 2025
Visit Reason
The inspection was conducted as a complaint investigation with an unannounced partial inspection to review compliance and follow up on a plan of correction.
Complaint Details
The complaint involved suspected resident abuse due to delayed reporting of a possible narcotic overdose. The local law enforcement agency investigated, but the facility did not report the allegation to the local Area Agency on Aging until hours later.
Findings
The submitted plan of correction was determined to be fully implemented. The report includes a resident abuse violation related to delayed reporting of suspected abuse involving possible narcotic overdose.
Citations (1)
2800.15.a: The residence failed to immediately report suspected abuse of a resident involving possible narcotic overdose. The allegation was not reported to the local Area Agency on Aging until several hours after the incident.
Report Facts
Residents Served: 66
Memory Unit Residents Served: 22
Hospice Current Residents: 7
Residents Age 60 or Older: 66
Residents Diagnosed with Mental Illness: 2
Residents with Physical Disability: 1
Residents with Mobility Need: 28
Inspection Report — Sep 3, 2025
Complaint Investigation
Date: Sep 3, 2025
Visit Reason
The inspection was conducted as a complaint investigation with an unannounced partial inspection on 09/03/2025.
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 the inspection.
Report Facts
Residents Served: 64
Special Care Unit Residents Served: 20
Hospice Current Residents: 5
Residents Diagnosed with Mental Illness: 10
Residents with Mobility Need: 29
Residents Age 60 or Older: 64
Residents Receiving Supplemental Security Income: 0
Residents Diagnosed with Intellectual Disability: 0
Residents with Physical Disability: 0
Total Daily Staff: 93
Waking Staff: 70
Inspection Report — Jul 11, 2025
Follow-Up
Date: Jul 11, 2025
Visit Reason
The inspection was conducted as a follow-up to verify the implementation of a previously submitted plan of correction related to complaints and incidents at the facility.
Complaint Details
The inspection was complaint-related, triggered by incidents and complaints involving resident interactions and medication management. The submitted plan of correction was accepted and fully implemented.
Findings
The facility was found to have fully implemented the submitted plan of correction addressing issues including resident dignity and respect, medication storage and administration, and support plan elements. Continued compliance must be maintained.
Citations (4)
Resident altercation involving shaking a resident's chair, physical contact, and emotional distress.
Failure to follow medication storage procedures, including incomplete or missing controlled substances count sheets and unaccounted medication tablets.
Failure to follow prescriber’s orders with multiple instances of residents not receiving prescribed medications at scheduled times.
Support plan did not address how a resident’s behavioral needs would be met after an altercation and hospital evaluation.
Report Facts
Residents Served: 58
Staffing Hours: 87
Waking Staff: 65
Current Residents in Hospice: 5
Special Care Unit Residents Served: 22
Residents Age 60 or Older: 58
Residents with Mobility Need: 29
Residents Diagnosed with Mental Illness: 2
Residents with Physical Disability: 1
Inspection Report — Apr 29, 2025
Complaint Investigation
Date: Apr 29, 2025
Visit Reason
The inspection was conducted as a complaint and incident investigation following allegations of staff abuse and neglect at the facility.
Complaint Details
The visit was complaint-related due to allegations of staff member abuse and neglect towards residents. The complaint was substantiated with findings of delayed reporting, failure to suspend involved staff, and resident injury due to improper handling.
Findings
The inspection found multiple violations related to resident abuse reporting delays, failure to suspend a staff member involved in alleged abuse, improper handling causing resident injury, failure to implement positive interventions for aggressive behavior, and inadequate reassessment of resident transfer needs. The facility submitted plans of correction which were accepted and implemented.
Citations (6)
Failure to immediately report suspected abuse of a resident to the local Area Agency on Aging.
Staff member involved in alleged abuse continued to provide services without an approved supervision plan or suspension.
Failure to notify the Department’s assisted living residence office or complaint hotline within 24 hours of an incident.
Resident was injured during a one-person transfer attempt by staff, resulting in an acute impacted fracture of the left shoulder.
Failure to implement positive interventions to modify or eliminate a resident's physically aggressive behavior.
Failure to complete additional written assessments after significant change in resident's transfer needs requiring two-person assist.
Report Facts
Residents Served: 54
Special Care Unit Residents Served: 27
Hospice Current Residents: 7
Residents with Mobility Need: 25
Residents Age 60 or Older: 54
Pain Level: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Resident Wellness Director | Named as responsible party for abuse reporting, staff training, incident reporting, and reassessment plans. | |
| Executive Operations Officer | Responsible party for immediate suspension of staff member involved in abuse allegation. |
Inspection Report — Apr 2, 2025
Complaint Investigation
Date: Apr 2, 2025
Visit Reason
The inspection was conducted as a complaint and incident investigation during an unannounced partial inspection visit.
Complaint Details
The inspection was triggered by a complaint and incident, but no deficiencies or citations were found.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Residents Served: 57
Special Care Unit Residents Served: 21
Current Hospice Residents: 4
Residents Age 60 or Older: 57
Residents Diagnosed with Mental Illness: 2
Residents with Mobility Need: 31
Residents with Physical Disability: 1
Inspection Report — Jan 9, 2025
Renewal
Date: Jan 9, 2025
Visit Reason
The inspection was conducted as a renewal inspection of the facility license.
Findings
The inspection identified multiple deficiencies related to staff training, resident equipment safety, fire safety evacuation procedures, medical evaluations, medication management, support plan documentation, and staff training compliance. Plans of correction were submitted and accepted with follow-up dates.
Citations (12)
Direct care staff person A did not receive training in medication self-administration during the training year 1/1/24 to 12/31/24.
Resident #1's bed cane was not secured to the bed, allowing the bed cane to move/tip side to side approximately 10 inches causing a potential fall risk.
There was an approximate 1/8-inch accumulation of lint in the lint trap of the first commercial dryer in the main laundry room.
The residence has a safe evacuation time of 15 minutes, 0 seconds established by a fire safety expert on 6/27/23; however, on 4/25/24, residents evacuated in 15 minutes and .0024 seconds, exceeding the safe time.
During the fire drill on 6/25/24, 58 residents were present but only 56 evacuated.
The medical evaluation for resident #2 did not include immunization history; this area of the form was blank.
Discontinued medications were found in the medication cart for residents #3 and #4.
Resident #1's Lantus Solostar medication did not include a pharmacy label; repeat violation.
Resident #1's Albuterol and resident #4's Ondansetron medications were not available in the residence on 1/9/25.
Resident #1's support plan was not updated to address use and safety needs of a bed cane; resident #4's support plan was not updated to address hospice services; repeat violation.
Resident #2 and resident #3 did not sign their support plans and no notation of refusal or inability to sign was documented.
Direct care staff person A had only 6 hours of dementia care training during the 1/1/24 to 12/31/24 training year, less than the required 8 hours.
Report Facts
Residents Served: 54
Special Care Unit Residents Served: 17
Hospice Residents: 5
Residents Present During Fire Drill: 58
Residents Evacuated During Fire Drill: 56
Staff Training Hours: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Direct care staff person A | Named in findings related to medication self-administration training deficiency and dementia care training deficiency. | |
| Resident Wellness Director | Responsible party for multiple plans of correction including medication management, support plan updates, and staff training. | |
| Administrative Services Director | Responsible party for staff training plans related to medication self-administration and dementia care. | |
| Safety and Maintenance Engineer | Responsible party for plans of correction related to equipment safety and fire safety training. | |
| Executive Operations Officer | Responsible party for training and support plan documentation oversight. |
Inspection Report — Jan 25, 2024
Renewal
Date: Jan 25, 2024
Visit Reason
The inspection was conducted as a renewal review of the facility's compliance with licensing requirements.
Findings
The facility was found to have multiple deficiencies related to fire safety evacuation times, medication storage and labeling, medication administration, and resident support plans. All deficiencies had plans of correction accepted and were implemented by April 26, 2024.
Citations (5)
The residence exceeded the maximum safe evacuation time during a fire drill, taking 15 minutes 20 seconds instead of the required 15 minutes.
Resident #6's insulin was stored in the refrigerator contrary to manufacturer instructions which require room temperature storage after opening.
Resident #6's prescription medication container lacked proper directions, with the label stating 'Please see attached for detailed directions' but no directions were attached.
Resident #6 was not administered a prescribed medication because it was not available in the residence.
Resident #6's support plan did not specify risks associated with the use of a mobile couch cane or the resident's ability to use the device safely.
Report Facts
Residents Served: 64
Special Care Unit Residents Served: 19
Current Hospice Residents: 3
Residents Age 60 or Older: 64
Residents Diagnosed with Mental Illness: 1
Residents with Mobility Need: 26
Total Daily Staff: 90
Waking Staff: 68
Inspection Report — Sep 29, 2023
Complaint Investigation
Date: Sep 29, 2023
Visit Reason
The inspection was conducted as a complaint investigation during an unannounced partial licensing inspection.
Complaint Details
The inspection was complaint-related, but no deficiencies were found and no follow-up was required.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Residents Served: 64
Special Care Unit Residents Served: 18
Hospice Residents: 3
Resident Support Staff Hours: 0
Total Daily Staff: 95
Waking Staff: 71
Residents Age 60 or Older: 64
Residents with Mobility Need: 31
Inspection Report — Jul 13, 2023
Complaint Investigation
Date: Jul 13, 2023
Visit Reason
The inspection was conducted as a complaint and incident investigation related to multiple physical altercations between residents at the facility.
Complaint Details
The complaint investigation was substantiated with findings that residents #1 and #2 had multiple physical altercations, including pushing and kicking incidents, some resulting in injury or hospital transport. The facility did not report one incident as required and lacked adequate safety measures. Behavioral health interventions, increased monitoring, and family involvement were part of the corrective actions.
Findings
The facility failed to report incidents of resident altercations to the Department within the required timeframe and did not implement adequate safety precautions to prevent repeated physical altercations between residents. Plans of correction including staff education, increased monitoring, and support plan updates were implemented and accepted.
Citations (4)
Failure to report an incident of resident altercation to the Department within 24 hours as required.
Inadequate safety precautions to prevent multiple physical altercations between residents.
Resident assessments did not fully reflect aggressive behaviors and risks.
Support plan did not address supervision needs due to aggressive behaviors.
Report Facts
Residents served: 63
Total daily staff: 95
Waking staff: 71
Special care unit residents served: 22
Hospice current residents: 5
Residents age 60 or older: 63
Residents with mobility need: 32
Residents with physical disability: 2
Inspection Report — Jun 23, 2023
Complaint Investigation
Date: Jun 23, 2023
Visit Reason
The inspection was conducted as a complaint and incident investigation during an unannounced partial licensing inspection.
Complaint Details
The inspection was triggered by a complaint and incident, 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
Total Daily Staff: 102
Waking Staff: 77
Residents Served: 65
Special Care Unit Residents Served: 22
Current Hospice Residents: 7
Residents Diagnosed with Mental Illness: 4
Residents with Mobility Need: 37
Residents Age 60 or Older: 65
Inspection Report — Jun 7, 2023
Complaint Investigation
Date: Jun 7, 2023
Visit Reason
The inspection was conducted as a complaint and incident investigation to review compliance and assess the facility's plan of correction.
Complaint Details
The visit was complaint-related with substantiation implied by the findings of medication mismanagement and inadequate support plans.
Findings
The inspection found deficiencies related to resident self-administration of medications without proper assessment and incomplete support plans addressing residents' physical and behavioral needs. The facility implemented corrective actions including medication removal, support plan updates, and staff training.
Citations (2)
Resident #1 was found with medications on the floor and had not been assessed by a qualified professional regarding ability to self-administer medications.
Support plans for Resident #1 and Resident #2 did not adequately address the resident's needs for Foley catheter care and management of aggressive behaviors, respectively.
Report Facts
Residents Served: 66
Special Care Unit Residents Served: 22
Current Hospice Residents: 6
Residents with Mobility Need: 33
Residents Age 60 or Older: 66
Inspection Report — Jan 18, 2023
Renewal
Date: Jan 18, 2023
Visit Reason
The inspection was conducted as a renewal, complaint, and incident review of the facility.
Findings
The inspection identified multiple deficiencies including missing posters in the special care unit, inadequate staffing during certain shifts, exterior hazards, inoperable bedside lamps, evacuation time exceeding limits during a fire drill, unsafe smoking area location, medication errors including discontinued medications still in carts, inaccurate pharmacy labels, and medication record discrepancies. Plans of correction were accepted and implemented by May 2, 2023.
Citations (11)
Influenza Awareness poster was not posted in the residence's special care unit.
Department's poster of resident's rights was not posted in the residence's special care unit.
Staffing schedule occasionally had only 3 staff on 11:15pm-6:45am shift, inadequate for emergency evacuation needs.
Exterior embankment with standing water posed a potential fall hazard.
Resident #3 did not have access to an operable lamp at bedside.
Fire drill evacuation time exceeded the maximum safe evacuation time of 15 minutes.
Designated smoking area was located alongside a common walkway, posing a safety risk.
Discontinued medications for resident #3 were found in the medication cart.
Pharmacy labels for resident #5's medications did not include prescribed dosages.
Medication administration record (MAR) discrepancies for residents #3 and #4.
Weekly activity calendar was not posted in a public and conspicuous place in the special care unit.
Report Facts
Residents Served: 58
Staff Total Daily: 81
Staff Waking: 61
Special Care Unit Residents Served: 19
Current Hospice Residents: 1
Residents Diagnosed with Mental Illness: 4
Residents with Mobility Need: 23
Residents Age 60 or Older: 58
Residents with Physical Disability: 2
Discontinued Medication Units: 300
Fire Drill Evacuation Time: 947
Inspection Report — Sep 13, 2022
Complaint Investigation
Date: Sep 13, 2022
Visit Reason
The inspection was conducted as a complaint investigation during an unannounced partial inspection on 09/13/2022.
Complaint Details
The inspection was triggered by a complaint as indicated under Inspection Information with Reason: Complaint.
Findings
The inspection identified deficiencies related to resident equipment and facility cleanliness, including torn wheelchair armrests posing skin tear hazards and dirty carpets with chewing gum and debris. Plans of correction were submitted and accepted with retraining and monitoring measures implemented.
Citations (3)
The right armrest of resident #1’s wheelchair had a 6 inch tear exposing padding, creating a potential skin tear hazard.
The right armrest of resident #2’s wheelchair was torn exposing a 3 inch diameter area of padding, and the left armrest was wrapped in medical tape.
The carpet in a resident's bedroom had multiple dried pieces of chewing gum stuck in the fibers, was dirty and discolored, with paper wrappers and food crumbs on the floor.
Report Facts
Residents Served: 60
Special Care Unit Residents Served: 22
Hospice Current Residents: 1
Residents 60 Years or Older: 60
Residents Diagnosed with Mental Illness: 3
Residents with Mobility Need: 34
Inspection Report — Feb 15, 2022
Renewal
Date: Feb 15, 2022
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 — Dec 15, 2021
Renewal
Date: Dec 15, 2021
Visit Reason
The inspection was conducted as a renewal inspection of the facility license for Colonial Courtyard at Clearfield.
Findings
The inspection found multiple deficiencies including a direct care staff member lacking required qualifications, lint accumulation in laundry areas posing fire hazards, missing exit signs and directional signage in memory care and residence courtyards, and incomplete medication records for a resident self-administering medication. Plans of correction were accepted and documented as implemented.
Citations (5)
Direct care staff person hired in 2021 did not have a high school diploma, GED, or active registry status on the Pennsylvania nurse aide registry.
Approximate 1/8 inch accumulation of lint on the back of the washing machine and on the floor behind the dryer in the Memory Care laundry room.
No exit signs over the doors exiting from the memory care courtyard to the memory care dining area and from the residence courtyard to the residence’s main dining area.
No direct visual line to the nearest exits at the memory care dining area and residence’s main dining area from the gates separating the courtyards.
Resident #1 self-administers medication but the medication list did not include a bottle of Mucinex 600mg found in the resident's drawer.
Report Facts
Residents Served: 57
Memory Care Residents Served: 19
Hospice Residents: 4
Residents with Mobility Need: 32
Residents 60 Years or Older: 57
Residents Diagnosed with Mental Illness: 2
Inspection Report — Sep 9, 2021
Complaint Investigation
Date: Sep 9, 2021
Visit Reason
The inspection was conducted as a complaint investigation with unannounced partial visits on 09/09/2021, 09/10/2021, and 09/14/2021 to review compliance and follow-up on a plan of correction submission.
Complaint Details
The visit was complaint-related with a follow-up type of Plan of Correction (POC) submission. The submitted plan of correction was determined to be fully implemented.
Findings
The inspection found deficiencies related to failure to follow prescriber’s orders for feeding assistance and incomplete resident assessment content, specifically regarding aspiration risk, assistance needs, and hospice services. Plans of correction were accepted and fully implemented with staff education and updated assessments.
Citations (2)
Resident #1 was prescribed assistance with feeding due to aspiration risk but was not assisted by staff on 9/9/21 for breakfast and lunch.
Resident #1's assessment did not address the need for assistance with feeding, ambulation, repositioning, or hospice services.
Report Facts
Residents Served: 59
Special Care Unit Residents Served: 17
Hospice Residents: 2
Total Daily Staff: 89
Waking Staff: 67
Inspection Report — Jul 2, 2021
Renewal
Date: Jul 2, 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 — Nov 10, 2020
Renewal
Date: Nov 10, 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 — Sep 11, 2020
Complaint Investigation
Date: Sep 11, 2020
Visit Reason
Complaint investigation conducted due to allegations related to resident care and treatment.
Complaint Details
Complaint investigation was substantiated with findings of neglect, failure to secure medical care, inadequate documentation of refusals, incomplete assessments, and admission of a resident with an excludable condition without proper exception request.
Findings
The investigation found multiple violations related to neglect, failure to secure medical care, refusal documentation, incomplete assessments, and admission of a resident with an excludable condition without proper exception request. The resident had a stage three non-healing pressure ulcer with osteomyelitis that was not properly managed or documented.
Citations (5)
42b Abuse/Neglect: Resident #1 had a left heel ulcer with maggot infestation that was not properly treated or reported, and staff were instructed not to send the resident to the ER to avoid state reporting.
142b Secure care-choice of phys: The residence failed to assist resident #1 in securing medical care and did not update the resident’s assessment and support plan accordingly.
142c Refusal-medical treatment: Resident #1 refused treatment for a left heel ulcer multiple times, but the residence did not document continued attempts to educate and inform the resident about the need for care.
225b Assessment content: Resident #1’s assessment and support plan did not address the left heel ulcer or resistance to care despite documented medical issues and refusals.
229a Excludable conditions: Resident #1 was admitted/retained with a stage 3 non-healing pressure ulcer with osteomyelitis, an excludable condition, without submission of an exception request.
Report Facts
Residents Served: 70
Refusals of treatment: 17
Inspection Report — Feb 27, 2020
Routine
Date: Feb 27, 2020
Visit Reason
Routine partial inspection conducted to assess compliance with regulations at Colonial Courtyard at Clearfield, including review of physical space use and resident safety.
Findings
The inspection identified violations related to hot water temperature exceeding 120°F and restricted access to exercise and activity spaces due to keypad locking devices. Plans of correction were submitted and approved, with immediate and ongoing corrective actions implemented.
Citations (3)
2800.89b Hot water temperature in areas accessible to the resident exceeded 120°F, with readings of 122.5°F and 122.3°F in kitchenette sinks of rooms E26 and E24.
2800.232a The residence failed to provide exercise space accessible to all residents due to a keypad locking device separating new and old wings of the special care unit.
2800.232c The residence failed to provide dining and activity space accessible to all residents due to a keypad locking device separating new and old wings of the special care unit.
Report Facts
Residents Served: 67
Special Care Unit Residents Served: 16
Hospice Current Residents: 5
Residents Diagnosed with Mental Illness: 2
Residents with Mobility Need: 26
Residents 60 Years or Older: 67
Residents with Physical Disability: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Miranda Coulter | Executive Director | Named in relation to approval of plans of correction and signature on violation reports |
Notice — Jan 24, 2020
Date: Jan 24, 2020
Visit Reason
This document serves as a renewal notification and certificate of compliance for Colonial Courtyard at Clearfield, confirming the facility's licensed capacity and informing about the requirement for an annual onsite inspection within the next twelve months.
Findings
The document does not report inspection findings but confirms the issuance of a regular license and states that the Department will conduct an annual inspection within twelve months to ensure compliance.
Report Facts
Special Care Unit Licensed Beds: 55
Inspection Report — Jan 10, 2020
Follow-Up
Date: Jan 10, 2020
Visit Reason
The visit was conducted as a follow-up to verify that the previously submitted plan of correction was fully implemented following a complaint investigation.
Complaint Details
The inspection was triggered by a complaint and was unannounced. The plan of correction was reviewed and approved, and implementation was verified as of March 30, 2020.
Findings
The submitted plan of correction was determined to be fully implemented. The facility demonstrated compliance with regulations related to resident assistance, assessment content, and support plans.
Citations (3)
2800.23a The resident's assessment and support plan did not reflect the required two-person assistance for ambulation and extensive supervision despite multiple falls and staff interviews indicating otherwise.
2800.225.b Resident #1's assessment did not include multiple care needs such as dental, dietary, hearing, and medical diagnoses, and staff interviews indicated physical aggression toward staff and residents.
2800.234.b1 Resident #1's support plan did not address how hospice care needs including eating, drinking, toileting, bowel management, bathing, and personal hygiene would be met, with these areas left blank.
Report Facts
Residents Served: 67
Memory Care Residents Served: 17
Current Hospice Residents: 1
Resident Falls: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Miranda Coulter | Executive Operations Officer | Signed plan of correction documents related to deficiencies |
| Debora McConnell | Department representative conducting the inspection on 1/10/2020 and 1/13/2020 |
Inspection Report — Dec 3, 2019
Renewal
Date: Dec 3, 2019
Visit Reason
The inspection was conducted as a renewal and complaint investigation visit to assess compliance with licensing regulations at Colonial Courtyard at Clearfield.
Findings
The inspection identified multiple violations including confidentiality breaches, administrator staffing hours, lack of dietitian, locked bedroom doors restricting resident access, missing emergency notification systems, fire safety issues, medication errors, and incomplete resident support plan signatures. Plans of correction were submitted and approved with implementation dates.
Citations (13)
2800.17 Confidentiality of Records was violated when the emergency preparedness plan was unlocked and accessible, exposing confidential resident information including names, mobility status, and medical details.
2800.56a The administrator was not present in the residence an average of 36 hours weekly as required by regulation.
2800.60e The residence lacked a current dietitian on staff or under contract to meet residents' special dietary needs.
2800.101i Bedroom doors in the special care unit were kept locked, preventing residents from freely accessing their rooms.
2800.102n The bathroom on the second floor did not have an emergency notification system to alert staff in case of emergency.
2800.130h The fire alarm system was malfunctioning; the fire panel showed a trouble message and the unit had a yellow trouble light on.
2800.132d The facility exceeded the maximum safe evacuation time during fire drills, with times up to 21 minutes recorded.
2800.183d Medication errors occurred including expired medication in the cart and discontinued medication still present.
2800.184a Prescription medication containers were not properly labeled according to pharmacy requirements.
2800.187a Medication records lacked required information such as resident name, drug allergies, dosage, and administration times.
2800.227g Resident #9's annual support plan was not signed by the assessor as required.
2800.233c Key-locking devices were not properly managed; the special care unit gate was unlocked by pushing a panic bar and the electronic lock remained unlocked until manually reset.
2800.252 Resident records did not include a recent photograph for resident #9, with the latest photo dated 2017.
Report Facts
Residents Served: 64
Special Care Unit Residents Served: 15
Hospice Current Residents: 3
Residents Age 60 or Older: 64
Residents Diagnosed with Mental Illness: 1
Residents with Mobility Need: 35
Residents with Physical Disability: 1
Medication Vials Expired: 16
Fire Drill Evacuation Time: 21
Inspection Report — Sep 11, 2019
Routine
Date: Sep 11, 2019
Visit Reason
The Department’s Bureau of Human Services Licensing conducted an inspection of the facility to assess compliance with 55 Pa. Code Ch. 2600 relating to Personal Care Homes.
Findings
No regulatory citations were identified as a result of this inspection.
Inspection Report — Mar 19, 2019
Annual Inspection
Date: Mar 19, 2019
Visit Reason
The inspection was an annual licensing inspection conducted on March 19 and 20, 2019, to assess compliance with 55 Pa. Code Ch. 2800 relating to Assisted Living Residence.
Findings
The inspection identified multiple violations related to posting of license inspection summary, fire extinguisher inspection, fire drill records, evacuation procedures, annual medical evaluations, medication management, refusal to take medication, prescriber’s orders, and assessment content. Plans of correction were submitted addressing each violation with partial implementation status as of May 30, 2019.
Citations (9)
2800.3d The assisted living residence failed to post the current license inspection summary in a conspicuous and public place in the residence.
2800.131f No tag was present on the fire extinguisher in hallway E of the special care unit, preventing determination of annual inspection and approval by a fire safety expert.
2800.132c Fire drill records from 1/22/18 through 2/21/19 did not include complete data on residents evacuated, evacuation times, staff participation, or fire alarm/smoke detector operation.
2800.132d The facility was unable to complete fire drills as required from 1/22/18 through 2/21/19.
2800.141b.1 Residents #1 and #3 did not have annual medical evaluations completed timely, with last tuberculin skin tests conducted in 2016.
2800.183d Resident #5 was prescribed Humalog insulin pen that expired 28 days after opening but was not replaced timely.
2800.187c Medication refusals for residents #3, #5, and #6 were not reported to the prescribing physician as required.
2800.187d The facility failed to follow prescriber’s orders for residents #1 and #4, including missed medication administration and unavailable prescribed nutritional supplement.
2800.225b Resident #2’s most recent assessment did not include the resident’s diagnosis of dementia.
Report Facts
Residents Served: 63
Special Care Unit Residents Served: 17
Current Hospice Residents: 4
Residents Age 60 or Older: 63
Residents Diagnosed with Mental Illness: 2
Residents with Mobility Need: 25
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tressia Day | LPN/ED | Signed multiple plans of correction related to violations |
| Rebecca Dale | Administrator | Named as facility administrator in facility information |
Inspection Report — Jan 11, 2019
Renewal
Date: Jan 11, 2019
Visit Reason
The document is a renewal notification and license issuance for Colonial Courtyard at Clearfield, confirming the facility's renewal application and informing about the requirement for an annual onsite inspection within the next twelve months.
Findings
No inspection findings are reported in this document. It serves as a license renewal confirmation and notification of upcoming annual inspection requirements.
Report Facts
Inspection Report — Nov 20, 2018
Complaint Investigation
Date: Nov 20, 2018
Visit Reason
The inspection was conducted as a partial investigation triggered by an incident involving alleged abuse at the facility.
Complaint Details
The complaint involved an allegation that staff person A grabbed resident #1's wrists and restrained the resident. The home failed to report the allegation timely. Staff person B was counseled and no longer employed. Staff person A remained on duty until 11 p.m. on the incident date. The complaint was substantiated by the investigation.
Findings
Two violations were found: failure to report suspected abuse of a resident by staff and lack of protective guards on a gas fireplace posing a burn risk to residents. Plans of correction were submitted and partially implemented.
Citations (2)
§ 2800.15 Abuse reporting covered by law. The facility failed to immediately report suspected abuse of resident #1 by staff, delaying notification to the local area agency on aging until the day after the incident.
§ 2800.84 Heat sources. The metal frame around the gas fireplace measured 166.1°F and lacked protective guards or insulation to prevent residents from coming into contact with the heat source.
Report Facts
Number of Residents Served: 58
Number of Residents Served in Secured Dementia Care Unit: 17
Number of Current Hospice Residents: 3
Number of Hospice Residents in Past Year: 10
Temperature of Gas Fireplace Frame: 166.1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rebecca Dale | Administrator | Signed plan of correction documents |
Inspection Report — Oct 16, 2018
Complaint Investigation
Date: Oct 16, 2018
Visit Reason
The inspection was conducted due to complaints and an incident at the Colonial Courtyard at Clearfield assisted living residence on October 16 and 17, 2018.
Complaint Details
The inspection was triggered by complaints and an incident involving resident safety hazards related to bed enablers and bed rails. Specific violations were documented and substantiated in the report.
Findings
Multiple violations related to resident safety and care were found, including unsecured bed enablers posing entrapment hazards, improper use of half-length bed rails without proper assessment, and failure to document assistive devices in residents' support plans.
Citations (3)
2800.81(b): Resident #2 had an unsecured bed enabler that moved approximately 2 inches side to side and had an open area posing an entrapment hazard.
2800.203(b): A half-length bedrail was used on resident #3's bed without proper assessment or documentation, and 15-minute checks were not completed as required.
2800.227(d): Residents #1 and #2 used bed enablers that were not indicated on their support plans as required.
Report Facts
Number of Residents Served: 61
Number of Residents Served in Secured Dementia Care Unit: 17
Number of Current Hospice Residents: 3
Number of Hospice Residents in Past Year: 10
Number of Residents 60 Years or Older: 61
Number of Residents with Mental Illness: 1
Number of Residents with Mobility Need: 24
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rebecca Dale | Executive Director | Signed plan of correction and legal entity representative |
Inspection Report — Mar 15, 2018
Renewal
Date: Mar 15, 2018
Visit Reason
The inspection was a full renewal inspection conducted on March 15 and March 21, 2018, for Colonial Courtyard at Clearfield, an assisted living residence, to assess compliance with 55 Pa. Code Chapter 2800.
Findings
The inspection identified violations including failure to post the current license inspection summary in a public place, incomplete staff training in medication self-administration and fire safety, and combustible materials present in the employee smoking area. Plans of correction were submitted and partially implemented as of September 21, 2018.
Citations (4)
2800.3(d) The assisted living residence did not post the current license inspection summary and related documents in a conspicuous public place; they were locked in a cabinet on the bulletin board.
2800.65(i) Staff person A did not receive required training in medication self-administration and instruction on meeting resident needs during the 2017 training year.
2800.65(i) Staff person A did not receive required training in fire safety and emergency preparedness during the 2017 training year.
2800.144(c) On 3/15/18, broken down cardboard boxes were found on two plastic chairs in the designated smoking area outside the back door, creating a fire hazard.
Report Facts
Number of Residents Served: 57
Secured Dementia Care Unit in Home: 17
Number of Residents Served in Secured Dementia Care Unit: 13
Number of Current Hospice Residents: 0
Number of Hospice Residents in Past Year: 5
Number of Residents 60 Years or Older: 57
Number of Residents with Mobility Need: 25
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rebecca Dale | Executive Director | Signed plans of correction and legal entity representative |
| Staff person A | Named in deficiencies for lack of required training in medication self-administration and fire safety |
Notice — Jan 2, 2018
Date: Jan 2, 2018
Visit Reason
The document serves as a renewal approval for the facility's license to operate an Assisted Living-Special Care home and notifies that an annual onsite 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.
Report Facts
Inspection Report — Oct 17, 2017
Complaint Investigation
Date: Oct 17, 2017
Visit Reason
The inspection was conducted as a partial investigation triggered by incident investigations related to suspected abuse at the assisted living residence.
Complaint Details
The visit was complaint-related due to incident investigations of suspected abuse. The violations were substantiated based on observations and interviews during the inspection.
Findings
The inspection found violations of 55 Pa.Code Ch. 2800 related to abuse and dignity of residents, specifically involving direct care staff physically restraining and verbally abusing a resident. The facility failed to immediately report the suspected abuse to the local Area Agency on Aging.
Citations (2)
2800.15(a) - The residence failed to immediately report suspected abuse of a resident as required by the Older Adults Protective Services Act and related regulations.
2800.42(c) - A resident was not treated with dignity and respect when direct care staff physically restrained and verbally abused the resident during care.
Report Facts
Number of Residents Served: 49
Number of Residents Served in Secured Dementia Care Unit: 15
Number of Current Hospice Residents: 2
Number of Hospice Residents in Past Year: 12
Residents 60 Years or Older: 49
Residents with Mental Illness: 1
Residents with Mobility Need: 21
Inspection Report — Aug 2, 2017
Routine
Date: Aug 2, 2017
Visit Reason
The Department of Human Services licensing representatives conducted an inspection of the facility on August 2, 2017.
Findings
No regulatory violations were identified as a result of this inspection.
Inspection Report — Jul 12, 2017
Routine
Date: Jul 12, 2017
Visit Reason
The Department of Human Services licensing representatives conducted an inspection of the facility on July 12, 2017.
Findings
No regulatory violations were identified as a result of this inspection.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Larry Mazza | Acting Regional Licensing Director | Signed the inspection report letter. |
Inspection Report — Apr 10, 2017
Complaint Investigation
Date: Apr 10, 2017
Visit Reason
The inspection was conducted due to an incident complaint at the assisted living residence.
Complaint Details
The visit was complaint-related due to an incident involving Resident #1 displaying aggressive and inappropriate behaviors. The violation was substantiated as the residence failed to update the resident's assessment and care plan accordingly.
Findings
Resident #1's assessment dated 8/8/2016 indicated no problem with irritability, judgment, agitation, or aggression, but caregiver notes from November 2016 to April 2017 showed problematic behaviors including raising a fist to threaten residents and staff, pushing staff, and inappropriate touching of other residents.
Citations (1)
Regulation 2800.225(a): The residence failed to amend the assessment service plan (ASP) for Resident #1 to reflect psychological changes and problematic behaviors documented between November 2016 and April 2017.
Report Facts
Number of Residents Served: 45
Number of Residents Served in Secured Dementia Care Unit: 12
Number of Current Hospice Residents: 1
Number of Hospice Residents in Past Year: 10
Residents Age 60 or Older: 45
Residents with Mental Illness: 2
Residents with Intellectual Disability: 0
Residents with Mobility Need: 26
Residents with Physical Disability: 0
Notice — Mar 17, 2017
Date: Mar 17, 2017
Visit Reason
This document serves as a renewal notification and license issuance for Colonial Courtyard at Clearfield following receipt of a renewal application dated January 9, 2017. It also informs the facility of the Department's requirement to conduct an annual onsite inspection within the next twelve months.
Findings
No inspection findings are reported in this document. It is a licensing and renewal notification letter confirming the issuance of a regular license.
Report Facts
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jacqueline L. Rowe | Director | Signed the renewal notification letter |
Inspection Report — Jul 19, 2016
Complaint Investigation
Date: Jul 19, 2016
Visit Reason
The inspection was conducted as a complaint investigation at Colonial Courtyard at Clearfield on July 19 and 20, 2016.
Complaint Details
The visit was complaint-related. Specific complaints involved medication errors and improper medication administration practices. Substantiation status is not explicitly stated.
Findings
Multiple violations related to medication administration and equipment calibration were found, including uncalibrated glucometers, incorrect medication administration, and missing medications. Plans of correction were submitted addressing these issues with partial implementation noted.
Citations (3)
55 Pa.Code Ch. 2800 185a - The residence did not have procedures for the safe use, access, and security of glucometers by trained staff. Six glucometers audited were not calibrated for date and time and did not match blood sugar readings from July 1 to July 19, 2016.
55 Pa.Code Ch. 2800 186b - On July 14, 2016, a staff member administered a nitroglycerin patch prescribed for Resident #7 to Resident #8.
55 Pa.Code Ch. 2800 187d - Medications were not administered as prescribed on July 8 and July 16, 2016, and Resident #3 reported receiving medications without requesting them.
Report Facts
Number of Residents Served: 34
Number of glucometers audited: 6
Dates of inspection: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Candy Shomo | Executive Director | Signed plan of correction documents related to violations |
Inspection Report — Jun 10, 2016
Renewal
Date: Jun 10, 2016
Visit Reason
The inspection was a 90 day interim licensing inspection conducted to assess compliance with 55 Pa.Code Chapter 2800 relating to Assisted Living Residences.
Findings
The inspection identified three violations: lint accumulation in the dryer lint trap, absence of posted menus in the special care unit, and expired insulin medication. Plans of correction were submitted addressing each violation with assigned responsible staff and corrective actions.
Citations (3)
Regulation 105g requires lint to be removed from the lint trap and drum of clothes dryers after each use. The lint trap of the empty dryer in the resident laundry room contained lint.
Regulation 162c requires menus stating specific food served at each meal to be prepared and posted one week in advance. There were no menus posted in the special care unit of the residence.
Regulation 183d allows only current prescription, OTC medications, sample and CAM to be kept in the residence. A vial of Novolog insulin prescribed for Resident #1 was opened on 5/1/16 and not discarded after 28 days as required.
Report Facts
Number of Residents Served: 33
Number of Residents Served in Secured Dementia Care Unit: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Candy Shomo | Executive Director | Named as legal entity representative and responsible party for plans of correction |
Inspection Report — Mar 22, 2016
Original Licensing
Date: Mar 22, 2016
Visit Reason
The inspection was conducted as a licensing inspection for the newly licensed assisted living-special care facility.
Findings
The facility was found to be in substantial compliance with applicable regulations, but the licensing inspector was unable to complete a full inspection because the home is new and not yet serving four or more residents.
Inspection Report — April 2, 2021
Renewal
Date: April 2, 2021
Visit Reason
The document is a renewal application and license issuance for Colonial Courtyard at Clearfield, an Assisted Living-Special Care facility, with a reminder that an annual inspection will be conducted within the next twelve months as required by regulation.
Findings
The Department has issued a regular license in response to the renewal application and advises that an onsite inspection will be conducted within the next twelve months. If noncompliance is found during the inspection, enforcement action will be taken.
Report Facts
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