Inspection Reports for
Colonial Courtyard at Tyrone
5546 East Pleasant Valley Blvd, Tyrone, PA 16686, Tyrone, PA, 16686
Back to Facility Profile27 Reports
Inspection Report — Apr 23, 2026
Renewal
Date: Apr 23, 2026
Visit Reason
The inspection was conducted as a renewal visit to assess compliance with licensing requirements for the facility.
Findings
Two deficiencies were identified: lack of certified staff in CPR and First Aid during certain shifts, and missing documentation of 'No Objection Statement' for a resident admitted to the secured dementia care unit. Both deficiencies have corrective actions completed or ongoing to ensure compliance.
Citations (2)
63a - First Aid/CPR Training: On 4/8/26 and 4/14/26, no staff certified in both CPR and First Aid were present during 3:00 PM to 9:00 PM shifts. The facility adjusted schedules and completed training to ensure compliance.
231e - No Objection Statement: Resident #1 admitted to the secured dementia care unit lacked documentation that the resident and designated person did not object to admission. Missing documentation was obtained and systemic changes implemented.
Report Facts
Residents Served: 33
Residents Served in Secured Dementia Care Unit: 9
Current Hospice Residents: 7
Inspection Report — Jan 13, 2026
Complaint Investigation
Date: Jan 13, 2026
Visit Reason
The inspection was conducted as a complaint investigation to review allegations related to resident abuse and aggressive behaviors on the Secure Dementia Care Unit (SDCU).
Complaint Details
The complaint investigation substantiated that a resident exhibited aggressive behaviors causing harm to other residents on the Secure Dementia Care Unit. The facility responded with a behavioral assessment, intervention plans, staff training, and ongoing monitoring.
Findings
The investigation found that a resident demonstrated physically aggressive behaviors towards other residents on the SDCU, resulting in injuries requiring medical attention. The facility implemented a comprehensive behavioral assessment, staff training, and ongoing management plans to address and mitigate these behaviors.
Citations (1)
42b Abuse: A resident demonstrated physically aggressive behaviors towards other residents on the Secure Dementia Care Unit, causing injuries including a fall with head injury and a red mark from a slap. The resident has a history of physical and verbal aggression towards multiple residents.
Report Facts
Residents Served: 35
SDCU Residents Served: 10
Current Hospice Residents: 5
Residents Age 60 or Older: 34
Residents with Mobility Need: 13
Residents Receiving Supplemental Security Income: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Amy Whitesel | CRNP | Named in behavioral assessment meeting for resident aggressive behavior |
Inspection Report — Nov 6, 2025
Date: Nov 6, 2025
Visit Reason
The inspection was an interim licensing inspection conducted by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing on 11/06/2025.
Findings
No regulatory citations or deficiencies were identified during this inspection.
Report Facts
Residents Served: 37
Secured Dementia Care Unit Residents Served: 11
Hospice Current Residents: 8
Resident Support Staff: 0
Total Daily Staff: 51
Waking Staff: 38
Residents Receiving Supplemental Security Income: 1
Residents Age 60 or Older: 37
Residents Diagnosed with Mental Illness: 0
Residents Diagnosed with Intellectual Disability: 0
Residents with Mobility Need: 14
Residents with Physical Disability: 0
Notice — Nov 6, 2025
Date: Nov 6, 2025
Visit Reason
The document serves as a notice of approval for a revised license increasing the Secured Dementia Care Unit capacity from 11 to 15 and includes a licensing inspection summary reporting no regulatory citations.
Findings
The licensing inspection conducted on 2025-11-06 found no regulatory citations or deficiencies at the facility.
Report Facts
Residents Served: 37
Residents Served in Dementia Unit: 11
Current Hospice Residents: 8
Inspection Report — Jul 2, 2025
Complaint Investigation
Date: Jul 2, 2025
Visit Reason
The inspection was conducted as a complaint investigation with an unannounced partial inspection on 07/02/2025.
Complaint Details
The inspection was complaint-driven and included a follow-up on the submitted plan of correction.
Findings
The inspection found multiple deficiencies related to medication administration errors, use of chemical restraints, incomplete significant change assessments, and lack of documentation regarding resident support plan signatures. The facility submitted a plan of correction which was determined to be fully implemented.
Citations (4)
Resident #1 was administered ABH topical gel twice within less than 2 hours, not following prescriber's directions.
Resident #1 was prescribed Quetiapine for agitation which may qualify as a chemical restraint without proper review.
The home did not complete a significant change assessment when Resident #1 was moved to the secure dementia care unit.
Resident #1 could not sign the support plan and the home did not document the resident's inability to sign.
Report Facts
Residents Served: 39
Residents Served in Dementia Unit: 10
Hospice Residents: 5
Residents Age 60 or Older: 39
Residents with Mobility Need: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Executive Operations Officer | Responsible party for corrective actions and education related to medication administration and other deficiencies. | |
| Resident Wellness Coordinator | Responsible party for auditing support plans to ensure compliance with documentation requirements. |
Inspection Report — Apr 17, 2025
Complaint Investigation
Date: Apr 17, 2025
Visit Reason
The inspection was conducted as a complaint investigation at the facility on 04/17/2025.
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 as a result of this inspection.
Report Facts
Residents Served: 36
Secured Dementia Care Unit Residents Served: 10
Current Hospice Residents: 4
Residents Receiving Supplemental Security Income: 1
Residents Age 60 or Older: 36
Residents with Mobility Need: 12
Resident Support Staff: 0
Total Daily Staff: 48
Waking Staff: 36
Inspection Report — Nov 14, 2024
Renewal
Date: Nov 14, 2024
Visit Reason
The inspection was conducted as a renewal visit to assess compliance with licensing requirements at Colonial Courtyard at Tyrone.
Findings
The inspection identified deficiencies related to contract signatures, signed statements acknowledging receipt of resident rights, and resident personal equipment safety hazards. The facility submitted and fully implemented a plan of correction to address these issues.
Citations (3)
The resident-home contract was not signed by the resident as required.
Resident record did not contain a statement signed by the resident acknowledging receipt of a copy of the resident rights and complaint procedures.
An enabler bar attached to a bed had an uncovered opening measuring 7 ½ inches by 11 ¾ inches, creating a potential entrapment hazard.
Report Facts
Residents Served: 37
Memory Care Residents Served: 11
Current Hospice Residents: 4
Residents Age 60 or Older: 37
Residents with Mobility Need: 13
Uncovered Opening Dimensions: 7.5
Uncovered Opening Dimensions: 11.75
Inspection Report — Jun 13, 2024
Complaint Investigation
Date: Jun 13, 2024
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.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Residents Served: 42
Secured Dementia Care Unit Residents Served: 8
Hospice Current Residents: 5
Residents Age 60 or Older: 42
Residents with Supplemental Security Income: 1
Residents with Mobility Need: 12
Inspection Report — Jan 24, 2024
Renewal
Date: Jan 24, 2024
Visit Reason
The inspection was an unannounced full renewal inspection conducted to review compliance with licensing requirements and verify the submitted plan of correction.
Findings
The inspection identified multiple deficiencies including unsigned resident contracts, incomplete criminal background checks, lack of current first aid/CPR training for staff, improper medication administration, unsecured medications and syringes, and incomplete preadmission screening forms. All deficiencies had plans of correction accepted and were implemented or scheduled for completion.
Citations (6)
Resident-home contracts for two residents were not signed by the residents.
Staff member lacked a Pennsylvania State Police clearance within 1 year prior to hire and within 30 days after hire as required.
The home lacked a staff member with current training in first aid and CPR during the inspection period.
Staff member observed placing medications beside a resident and walking away without administering them properly.
Medications and creams were found unlocked, unattended, and accessible in resident rooms and bathrooms.
Resident's preadmission screening form did not include a determination that the resident's needs could be met by the home.
Report Facts
Residents served: 41
Residents in secured dementia care unit: 10
Current hospice residents: 6
Residents with mobility need: 12
Inspection Report — Nov 2, 2023
Follow-Up
Date: Nov 2, 2023
Visit Reason
The inspection visit on 11/02/2023 was a partial, unannounced follow-up inspection triggered by an incident to verify the implementation of a previously submitted plan of correction.
Findings
The submitted plan of correction related to additional resident assessments for significant changes was determined to be fully implemented as of the follow-up review. The facility demonstrated compliance with updating Resident Assessment and Support Plans (RASPs) for residents with significant changes.
Citations (2)
Resident #1's RASP did not update personal care need for supervision and mental health need of wandering after transfer from secured dementia care to senior care.
Resident #2's RASP was not updated to reflect initiation of hospice services despite documentation by the home's CRNP.
Report Facts
Residents Served: 42
Secured Dementia Care Unit Residents Served: 9
Hospice Residents: 9
Total Daily Staff: 53
Waking Staff: 40
Inspection Report — May 16, 2023
Follow-Up
Date: May 16, 2023
Visit Reason
The visit was a follow-up review conducted on 05/16/2023 to determine if the submitted plan of correction for previous deficiencies was fully implemented.
Findings
The submitted plan of correction was found to be fully implemented, with updated documentation and corrective actions taken for medical evaluations, medication labeling, and preadmission screening forms. Continued compliance must be maintained.
Citations (3)
Resident 1's Documentation of Medical Evaluation (DME) was incomplete, missing health status and mobility needs sections.
Resident 1 had discrepancies between medication orders and pharmacy labels regarding dosage instructions.
Resident 2's preadmission screening form was missing date of birth and medical, psychological, and behavioral diagnoses.
Report Facts
Residents Served: 44
Secured Dementia Care Unit Residents Served: 10
Resident Supplemental Security Income: 1
Residents Age 60 or Older: 44
Residents with Mobility Need: 19
Inspection Report — Mar 9, 2023
Renewal
Date: Mar 9, 2023
Visit Reason
The inspection was conducted as a renewal and complaint investigation to review compliance with licensing requirements and address specific complaints.
Complaint Details
The complaint investigation included allegations of improper restraint use and failure to report incidents. The internal investigation and Blair County Adult Protective Services found the restraint allegation unsubstantiated.
Findings
The inspection identified multiple deficiencies including failure to report a medication error incident, improper use of restraints, inadequate staff training on fire safety and abuse reporting, incomplete medical evaluations, medication record inaccuracies, failure to follow prescriber's orders, incomplete preadmission screening, and inconsistent documentation regarding residents' ability to self-administer medications. Plans of correction were accepted and implemented by May 19, 2023.
Citations (12)
Failure to report a medication error incident to the Department within 24 hours.
Use of restraints by denying assistance to Resident 1 to get out of bed.
Staff Member B did not receive required fire safety and emergency preparedness training on the first day.
Staff Members A, B, C, and D did not receive required training on mandatory reporting of abuse and neglect.
Annual staff training plan for 2023 was not developed.
Resident 2’s pet canine had an expired rabies vaccination.
Resident 3’s medical evaluation did not include blood pressure, height, weight, pulse rate, and temperature.
Medication records for Residents 4 and 5 lacked specific diagnoses for prescribed medications.
Failure to follow prescriber's orders for Resident 5’s blood glucose levels and insulin administration.
Resident 3's preadmission screening lacked required cognitive screening for secured dementia care unit admission.
Resident 3's and Resident 4's preadmission screening forms lacked determinations that residents' needs can be met by the home.
Inconsistent documentation regarding Resident 2’s ability to self-administer medications.
Report Facts
Residents Served: 36
Secured Dementia Care Unit Residents Served: 7
Current Hospice Residents: 5
Residents Age 60 or Older: 36
Residents with Mobility Need: 10
Residents Receiving Supplemental Security Income: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Resident Wellness Director | Named in multiple findings related to reeducation and auditing of staff and compliance. | |
| Staff Member A | Involved in medication error incident not reported. | |
| Staff Member B | Did not receive required fire safety training and abuse reporting training. | |
| Staff Member C | Did not receive required abuse reporting training. | |
| Staff Member D | Did not receive required abuse reporting training. | |
| Staff Member E | Confirmed management instructed staff not to assist Resident 1 with getting out of bed. | |
| Administrator | Involved in reeducation and corrective actions for multiple deficiencies. |
Inspection Report — Jan 26, 2022
Follow-Up
Date: Jan 26, 2022
Visit Reason
The inspection was an unannounced partial review conducted due to an incident at the facility.
Findings
The submitted plan of correction was determined to be fully implemented. The report details incidents of abuse and aggression involving Resident #1 and outlines corrective actions including staff education and ongoing monitoring.
Citations (3)
Failure to report incidents of suspected abuse involving Resident #1 on 11/28/21 and 12/4/21.
Resident #1 physically abused Resident #2 by pushing and forcing hands down the front of Resident #2's pants on 12/19/21.
Support plans did not address behaviors of Resident #1 including agitation and aggression, nor were revisions made to address these behaviors.
Report Facts
Residents Served: 43
Secured Dementia Care Unit Residents Served: 11
Current Hospice Residents: 4
Residents Age 60 or Older: 43
Residents with Supplemental Security Income: 1
Residents with Mobility Need: 13
Notice — Sep 16, 2021
Date: Sep 16, 2021
Visit Reason
This document serves as a renewal notification and license issuance for the Personal Care Home 'Colonial Courtyard at Tyrone' following receipt of the renewal application dated September 14, 2021.
Findings
The Department advises that an onsite annual inspection will be conducted within the next twelve months to ensure compliance with Title 55, PA Code, Chapter 2600. No findings or deficiencies are reported in this document.
Report Facts
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary | Signed the renewal notification letter |
Inspection Report — Aug 11, 2021
Renewal
Date: Aug 11, 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 — Jul 29, 2020
Date: Jul 29, 2020
Visit Reason
The document serves as a renewal notification and issuance of a regular license for the Personal Care Home 'Colonial Courtyard at Tyrone' following receipt of the renewal application dated July 24, 2020.
Findings
No inspection findings are reported in this document. It advises that an onsite inspection will be conducted within the next twelve months as required by regulation.
Report Facts
Inspection Report — Jun 18, 2020
Renewal
Date: Jun 18, 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 or deficiencies were identified as a result of this licensing inspection.
Inspection Report — May 15, 2019
Renewal
Date: May 15, 2019
Visit Reason
The inspection was a full, unannounced annual licensing renewal inspection of Colonial Courtyard at Tyrone conducted on May 15, 2019.
Findings
Violations of 55 Pa.Code Ch. 2600 related to Personal Care Homes were found, including deficiencies in staff first aid/CPR training and incomplete directions for electronic locking devices in the secured dementia care unit. Plans of correction were submitted and partially or fully implemented.
Citations (2)
2600.63a requires at least one staff person trained in first aid and CPR present at all times. Between 4/29/19 and 5/5/19, during overnight hours, there were between one and fifty residents present but no staff with current first aid training was present.
2600.233c requires directions for operating key-locking devices to be conspicuously posted. The directions posted at the exit of the secured dementia care unit did not contain the complete code required to operate the system.
Report Facts
Residents Served: 34
Secured Dementia Care Unit Residents Served: 9
Hospice Current Residents: 5
Residents Age 60 or Older: 32
Residents with Mobility Need: 9
Residents Diagnosed with Mental Illness: 2
Residents Receiving Supplemental Security Income: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Miranda Coulter | Administrator | Signed plan of correction documents related to deficiencies |
Notice — May 7, 2019
Date: May 7, 2019
Visit Reason
The document serves as a license renewal approval for Colonial Courtyard at Tyrone, a Personal Care Home, following receipt of a renewal application dated May 6, 2019.
Findings
No inspection findings are reported in this document. It confirms the issuance of a regular license and states that an annual onsite inspection will be conducted within the next twelve months.
Report Facts
Inspection Report — Jun 26, 2018
Renewal
Date: Jun 26, 2018
Visit Reason
The inspection was a licensing inspection conducted on June 26 and 27, 2018, for renewal and provisional purposes of the Colonial Courtyard at Tyrone personal care home.
Findings
Several violations of 55 Pa.Code Chapter 2600 were found, including lack of certified staff for first aid and CPR, inoperable lighting in a resident's room, lint accumulation in the dryer lint trap, improper medication storage, incomplete resident support plans, and missing posted directions for key-locking devices. Plans of correction were submitted and partially implemented by the time of report.
Citations (6)
Regulation 55 Pa.Code §2600.63(a): At least one staff person trained in first aid and certified in obstructed airway techniques and CPR was not present during specified times on 6/24/18.
Regulation 55 Pa.Code §2600.101(j)(7): The lamp in resident bedroom #107 was inoperable and could not be turned on or off from bedside.
Regulation 55 Pa.Code §2600.105(g)(1): Lint accumulated in the lint trap of the dryer in the laundry room outside the secured dementia care unit on 6/26/18.
Regulation 55 Pa.Code §2600.183(e): Loose prescription and over-the-counter pills were found in the second drawer of medication cart #2 on 6/27/18.
Regulation 55 Pa.Code §2600.227(g): Resident #1 and #2 support plans did not indicate their ability to participate in development and/or sign the plans.
Regulation 55 Pa.Code §2600.233(c): Directions for operating the home's locking mechanism were not conspicuously posted near the secured dementia care unit courtyard door.
Report Facts
Number of Residents Present: 39
Number of Residents Served: 39
Number of Current Hospice Residents: 6
Number of Hospice Residents in Past Year: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Miranda Coulter | ED | Signed plans of correction and involved in corrective actions. |
| Denise Gillespie | Department representative on-site during inspection. | |
| Jason McCloskey | Department representative on-site during inspection. |
Inspection Report — Apr 24, 2018
Renewal
Date: Apr 24, 2018
Visit Reason
Licensing inspections were conducted on April 24 and April 25, 2018, for Colonial Courtyard at Tyrone to identify violations related to 55 Pa.Code Chapter 2600 for Personal Care Homes.
Findings
Multiple violations were found including failure to report medication errors timely, improper smoking practices, expired medications on site, failure to follow prescriber directions, and incomplete resident support plans. Plans of correction were submitted and partially implemented with adequate progress noted.
Citations (5)
55 Pa.Code 2600.16(c) - The home did not report prescribed medication errors for two residents to the Department until several days after occurrence.
55 Pa.Code 2600.144(c)(1) - Staff was observed smoking a cigarette outside the first floor side exit several yards away from the designated smoking area.
55 Pa.Code 2600.183(d) - Expired medications were found for three residents, including Acetaminophen and Lopermide tablets.
55 Pa.Code 2600.187(d) - The home failed to follow prescriber directions when prescribed medications were not administered to two residents on specified dates.
55 Pa.Code 2600.227(c) - The most recent support plan for a resident did not reflect specific care needs regarding mood disorder, denture care, and eating assistance.
Report Facts
Number of Residents Served: 32
Number of Deficiencies: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Miranda Coulter | Executive Director (ED) | Named as legal entity representative signing plans of correction and involved in corrective actions. |
Inspection Report — Feb 15, 2018
Plan of Correction
Date: Feb 15, 2018
Visit Reason
This document is an appeal letter responding to a Notice of First Provisional License issued to Colonial Courtyard at Tyrone, addressing prior violation reports and plans of correction.
Findings
The letter summarizes multiple violation reports from 2017, details corrective actions taken including staff retraining and monitoring, and disputes the issuance of the provisional license based on the facility's compliance efforts and improvements.
Citations (7)
Regulation 2600.42(c): An employee spoke loudly at a resident and was suspended, then rehired and reoriented with understanding that future disrespect will result in termination.
Regulation 2600.190(a): Plan of Correction approved and fully implemented with added requirements including monitoring and training for medication administration staff.
Regulation 2600.16(c): Alleged neglect was not reported timely and no onsite visit was conducted; investigation found no abuse or neglect but cited a disgruntled worker's actions.
Regulation 2600.42(b): Neglect allegation was not reported to leadership and no onsite observation occurred; records showed proper care was provided to the resident involved.
Regulation 2600.60(a): Staffing adjustments made including discharging high acuity residents and retraining staff to meet regulatory requirements and resident needs.
Regulation 2600.185(a): False readings recorded by an employee who was terminated; all corrective actions and retraining completed and audited for compliance.
Regulation 2600.202: All corrective actions and staff retraining completed and residents audited for compliance.
Report Facts
Date of Plan of Correction approval: 2017
Date of surveyor onsite visit: 2018
Resident counts: 22
Resident counts: 9
Resident counts: 18
Resident counts: 7
Residents discharged: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Loriann Putzier | President & Chief Operating Officer | Author of the appeal letter responding to the provisional license decision |
| Jacqueline L. Rowe | Director | Recipient of the appeal letter and sender of the acknowledgment letter |
Inspection Report — Sep 19, 2017
Complaint Investigation
Date: Sep 19, 2017
Visit Reason
The inspection was conducted as a complaint investigation and incident review at Colonial Courtyard at Tyrone on multiple dates including September 19, 2017, September 20, 2017, October 27, 2017, November 22, 2017, and January 18, 2018.
Complaint Details
The visit was complaint-related with substantiated violations including abuse, neglect, medication errors, and failure to report incidents timely. The complaint investigation included multiple on-site inspections and follow-up visits.
Findings
Multiple violations related to resident dignity, medication administration, abuse reporting, staffing, and resident care were identified. Plans of correction were submitted addressing these issues with partial implementation progress noted as of January 2018.
Citations (7)
55 Pa.Code 2600.42(c) - A resident was physically struck by staff during assistance in the bathroom, violating dignity and respect requirements.
55 Pa.Code 2600.190(a) - Staff person failed to complete required medication administration training and administered medications without proper training.
55 Pa.Code 2600.42(b) - Resident #2 was found lying in bed with dried vomit; staff failed to provide timely care and supervision.
55 Pa.Code 2600.185(a) - The home failed to implement safe procedures for medication and medical equipment use, including improper blood sugar testing documentation.
55 Pa.Code 2600.16(d) - The home failed to report an alleged abuse incident to the Department within required timeframes.
55 Pa.Code 2600.60(a) - The memory care unit lacked adequate staffing to meet residents' needs, with some residents no longer present and staffing exceeding minimum requirements.
55 Pa.Code 2600.202 - Use of chemical and mechanical restraints and involuntary confinement of a resident were prohibited but occurred.
Report Facts
Number of Residents Surveyed: 35
Staffing Hours: 54
Walking Staff: 41
Number of Current Hospice Residents: 1
Number of Hospice Residents in Past Year: 25
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lisa Cowan | Executive Director | Named in relation to multiple findings and plans of correction signatures. |
| Staff Person A | Involved in physical abuse incident and medication administration violation. |
Inspection Report — Aug 23, 2017
Renewal
Date: Aug 23, 2017
Visit Reason
The inspection was conducted as part of the Department of Human Services' annual licensing renewal inspections for the Colonial Courtyard at Tyrone personal care home.
Findings
Multiple violations of 55 Pa.Code Chapter 2600 were found related to contract signatures, medication administration documentation, support plan signatures, medical evaluations, and support plan development. Plans of correction were submitted addressing these issues with partial implementation progress noted.
Citations (6)
Regulation 2600.25(b): Contracts for Residents #1, #2, and #3 admitted to the secured dementia care unit were not signed by the resident or designated person as required.
Regulation 2600.185(a): Glucometer readings for Residents #4, #5, and #6 were erased after 2 days and did not match medication administration records.
Regulation 2600.227(h): Resident #7's support plans dated 4/26/17 and 8/6/17 were not signed and lacked notations of refusal or inability to sign.
Regulation 2600.231(b): Resident #2's medical evaluation dated 7/6/17 did not document the need for secured dementia care unit placement.
Regulation 2600.234(a): Resident #2 was admitted to the secured dementia care unit on an unspecified date, but the support plan was dated more than 72 hours prior to admission.
Regulation 2600.234(e): The support plan for Resident #2 dated 6/29/17 did not indicate participation by the resident or designated person in its development.
Report Facts
Number of Residents Served: 36
Total Daily Staff: 59
Waking Staff: 44
Number of Current Hospice Residents: 11
Number of Hospice Residents in Past Year: 25
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lisa Cohen | Executive Director | Named as legal entity representative signing plans of correction on multiple pages. |
| Doug Hoover | Named as surveyor providing education and training during the annual survey. |
Notice — Jul 7, 2017
Date: Jul 7, 2017
Visit Reason
The document serves as a license renewal approval and notification that the Department will conduct an onsite inspection within the next twelve months as required by state regulations.
Findings
No inspection findings are reported in this document. It confirms the issuance of a regular license following the renewal application.
Report Facts
Inspection Report — Aug 24, 2016
Renewal
Date: Aug 24, 2016
Visit Reason
The inspection was conducted as part of the Department of Human Services' annual licensing inspections on August 24 and 25, 2016, including renewal and incident reasons.
Findings
Multiple violations of 55 Pa.Code Chapter 2600 were found related to personal care services, staff certification, fire safety, emergency procedures, and fire drills. Plans of correction were submitted addressing each violation with partial or full implementation status.
Citations (6)
2600.57(d) - At least 75% of the personal care service hours specified must be available during waking hours. On August 21, 2016, only 39.75 hours were provided instead of the required 40.5 hours.
2600.63(a) - At least one staff person trained in first aid and certified in CPR must be present at all times. On August 17, 18, and 20, 2016, no certified staff were present during specified overnight hours.
2600.105(g)(1) - Lint must be removed from the lint trap and dryer drum after each use. On August 24, 2016, lint accumulation was found in the dryer lint trap by the secured dementia care unit.
2600.107(d) - Written emergency procedures must be reviewed, updated, and submitted annually to the local emergency management agency. The home's procedures had not been submitted since May 2015.
2600.123(b) - Emergency procedures must be posted conspicuously in the home and a copy kept. The home's emergency procedures were not posted in a conspicuous and public place.
2600.132(e) - A fire drill must be held during sleeping hours once every 6 months. The last drill was held on March 24, 2016, more than six months after the previous drill on August 26, 2015.
Report Facts
Direct care hours required: 40.5
Direct care hours provided: 39.75
Staff present certified in CPR and First Aid: 0
Number of Residents Served: 36
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lisa Cowan | Executive Director | Named as legal entity representative signing plans of correction and responsible for corrective actions. |
Inspection Report — Jun 14, 2016
Renewal
Date: Jun 14, 2016
Visit Reason
The document is a renewal application and license issuance for the Personal Care Home Colonial Courtyard at Tyrone. The Department notifies that an 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 confirmation and notification of future inspection requirements.
Report Facts
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