Inspection Reports for
Columbia Cottage Hanover, LLC
2288 GRANDVIEW ROAD, HANOVER, PA, 17331
Back to Facility Profile19 Reports
Inspection Report — May 7, 2025
Follow-Up
Date: May 7, 2025
Visit Reason
The inspection was a partial, unannounced follow-up visit conducted due to an incident involving a resident fall and potential neglect.
Findings
The facility was found to have failed to properly assess a resident for suspected fractures following a fall, resulting in a delayed diagnosis of a right hip fracture requiring surgery. The facility updated its post-fall protocols, educated staff, and implemented ongoing audits to ensure compliance.
Citations (1)
Failure to assess resident for suspected fractures as required per the home's post-fall policy after an unwitnessed fall.
Report Facts
Residents Served: 37
Total Daily Staff: 58
Waking Staff: 44
Notice — Apr 22, 2025
Date: Apr 22, 2025
Visit Reason
The document serves as an approval of a Request to Admit a Resident with an Excludable Condition (RAREC) submitted on behalf of a specific resident to Columbia Cottage Hanover, LLC.
Findings
The Department approved the RAREC request based on submitted treatment plans and established conditions for wound care documentation and notification of any change in the resident's condition.
Report Facts
Licensed nurses on staff: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Theresa Hartman | Director, Bureau of Human Services Licensing | Signed the approval letter for the RAREC request. |
Inspection Report — Sep 24, 2024
Renewal
Date: Sep 24, 2024
Visit Reason
The inspection was conducted as a renewal review of the facility's license on 09/24/2024 and 09/25/2024 to determine compliance with regulatory requirements.
Findings
The submitted plan of correction was found to be fully implemented. A violation was identified where a non-licensed staff member administered injectable medication, but immediate corrective actions were taken and policies updated to prevent recurrence.
Citations (1)
Staff Person A, who is not a licensed medical professional, administered prescribed injectable medication to Resident #1, violating medication administration requirements.
Report Facts
Residents Served: 42
Total Daily Staff: 60
Waking Staff: 45
Current Residents in Hospice: 1
Residents Age 60 or Older: 42
Residents with Mobility Need: 18
Residents with Physical Disability: 1
Inspection Report — Oct 11, 2023
Annual Inspection
Date: Oct 11, 2023
Visit Reason
The inspection was conducted as part of the Pennsylvania Department of Human Services Bureau of Human Services Licensing annual licensing inspections on October 11, 2023, October 12, 2023, November 1, 2023, and December 28, 2023.
Findings
The facility was found to be in compliance with 55 Pa. Code Ch. 2600 relating to Personal Care Homes. Several deficiencies were identified related to resident care, equipment safety, medication management, and training, all with plans of correction submitted and accepted.
Citations (12)
42b. A resident receiving hospice services was not awake for two days and was not administered PRN morphine as prescribed. Staff person A, the medication technician, refused to administer the medication.
81b. The bed enabler for resident #3 had a top and bottom opening without a cover on the bedside mobility device.
102d. The shower for residents in rooms #15 and #17 did not have a nonslip surface.
121a. The exit door near Room #37 required excessive force to open.
183d. Discontinued medications were found in the medication cart for resident #2 despite orders to discontinue them.
184a. Resident #2 had multiple medications with pharmacy labels missing or incorrect directions, including escitalopram and aspirin.
225a. Resident #5's initial assessment was not updated to include diet changes and bedside mobility device use. Resident #6's assessment had conflicting mobility information.
225c. Resident #1's annual assessment was not updated to include admission to hospice services.
65f. Direct care staff person A did not receive instruction on meeting residents' needs as described in the preadmission screening and support plan.
65g. Direct care staff person A did not receive required fire safety training during the 2022 staff training year.
95. The toilet in the bathroom shared by rooms #52 and #53 was inoperable due to missing parts that were on back order.
183d. A blister pack of Senna and hydrocortisone cream for residents #1 and #2 were found in the medication cart despite orders to discontinue them.
Report Facts
Inspection dates: 4
Residents served: 33
Current hospice residents: 2
Inspection Report — Jun 14, 2023
Renewal
Date: Jun 14, 2023
Visit Reason
The inspection was conducted as a renewal licensing inspection of the facility.
Findings
No regulatory citations or deficiencies were identified during this licensing inspection.
Report Facts
Residents Served: 44
Current Residents in Hospice: 4
Residents Age 60 or Older: 43
Residents Diagnosed with Intellectual Disability: 3
Residents with Mobility Need: 10
Residents with Physical Disability: 1
Inspection Report — May 24, 2022
Renewal
Date: May 24, 2022
Visit Reason
The inspection was conducted as a renewal visit with an incident review on 05/24/2022 at Columbia Cottage Hanover, LLC.
Findings
The inspection identified several deficiencies including combustible materials stored near heat sources, unlocked medications accessible to residents not assessed for self-administration, inaccurate glucometer readings not matching the Medication Administration Record (MAR), and failure to follow prescriber’s orders for insulin administration. Plans of correction were accepted and implemented with follow-up audits and staff re-education.
Citations (4)
Combustible materials were stored near the furnace and hot water heater in the mechanical room.
A prescribed OTC medication was found unlocked and accessible in a resident's medicine cabinet despite the resident not being assessed to self-administer medications.
Two glucometer readings for Resident #2 did not match the readings reported on the Medication Administration Record (MAR).
Resident #2 did not receive insulin as prescribed according to the sliding scale instructions based on glucometer readings.
Report Facts
Residents Served: 36
Staffing: 56
Waking Staff: 42
Glucometer Reading: 207
Glucometer Reading: 191
Glucometer Reading: 317
Glucometer Reading: 371
Insulin Units Given: 8
Insulin Units Recommended: 6
Notice — Mar 28, 2022
Date: Mar 28, 2022
Visit Reason
The document serves as an approval from the Department of Human Services for Columbia Cottage Hanover, LLC's Request to Admit a Resident with an Excludable Condition, based on submitted treatment plans and conditions.
Findings
The Department approved the RAREC request contingent on documentation of all care provided, notification of any worsening condition within one business day, and monthly status updates from the care doctor until the resident is healed.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jeanne Parisi | Bureau Director, Human Services Licensing | Signed the approval letter for the RAREC request. |
Inspection Report — Jan 5, 2021
Routine
Date: Jan 5, 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 — Jan 23, 2020
Date: Jan 23, 2020
Visit Reason
The document serves as a renewal notification and license issuance for Columbia Cottage Hanover LLC to operate as an Assisted Living Home under Pennsylvania regulations.
Findings
No inspection findings are reported in this document. It confirms the issuance of a regular license following the renewal application and advises that an onsite inspection will occur within the next twelve months.
Inspection Report — Jan 8, 2020
Annual Inspection
Date: Jan 8, 2020
Visit Reason
The visit was an annual licensing inspection conducted by the Pennsylvania Department of Human Services, Bureau of Human Services Licensing.
Findings
The facility was found to be in compliance with 55 Pa. Code Chapter 2800 relating to Assisted Living Residence.
Inspection Report — Nov 26, 2019
Follow-Up
Date: Nov 26, 2019
Visit Reason
The visit was a follow-up review conducted by the Pennsylvania Department of Human Services on November 26, 2019, to verify that the submitted plan of correction for prior deficiencies was implemented.
Findings
The plan of correction submitted by Columbia Cottage Hanover, LLC was determined to be implemented. The facility conducted staff trainings and took corrective actions related to resident abuse reporting and dignity/respect violations.
Citations (3)
2800.15a: The residence failed to immediately report suspected resident abuse to the local Area Agency on Aging, with a delay from 11/2/19 to 11/7/19.
2800.16c: The residence failed to report the incident or condition to the Department’s assisted living residence office within 24 hours, with the same delay noted from 11/2/19 to 11/7/19.
2800.42c: Staff used profanity while providing care to residents, violating the requirement that residents be treated with dignity and respect.
Report Facts
Residents Served: 38
Residents 60 Years or Older: 37
Residents with Mobility Need: 16
Residents with Physical Disability: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Deena Brant | Managing Director | Named in plan of correction and signature on violation reports |
Notice — Feb 1, 2019
Date: Feb 1, 2019
Visit Reason
This document serves as a renewal notification and issuance of a regular license for Columbia Cottage Hanover LLC to operate an assisted living home, pursuant to Title 55, PA Code, Chapter 2800.
Findings
No inspection findings are reported in this document. It confirms the receipt of the renewal application and the issuance of the license with a reminder that an onsite inspection will be conducted within the next twelve months.
Notice — Feb 1, 2018
Date: Feb 1, 2018
Visit Reason
This document serves as a renewal notification and license issuance for Columbia Cottage Hanover LLC to operate an assisted living facility. It informs the facility that an onsite annual inspection will be conducted within the next twelve months as required by state regulations.
Findings
No inspection findings are reported in this document. It is a licensing and renewal notice confirming the facility's compliance and upcoming inspection requirements.
Inspection Report — Jan 31, 2018
Annual Inspection
Date: Jan 31, 2018
Visit Reason
The Department of Human Services conducted an annual licensing inspection of Columbia Cottage – Hanover, LLC to assess compliance with 55 Pa.Code Ch. 2800 relating to Assisted Living Residences.
Findings
The facility was found to be in compliance with the applicable regulations during the annual licensing inspection.
Notice — Jan 31, 2017
Date: Jan 31, 2017
Visit Reason
The document serves as a renewal notification and license issuance for Columbia Cottage Hanover, LLC to operate an assisted living facility. It also informs the facility that an annual onsite inspection will be conducted within the next twelve months as required by state regulations.
Findings
No inspection findings are reported in this document. It is a licensing and renewal notification letter with an attached certificate of compliance.
Report Facts
Inspection Report — Jan 18, 2017
Renewal
Date: Jan 18, 2017
Visit Reason
The inspection was conducted as an annual licensing renewal inspection of Columbia Cottage Hanover, LLC, to assess compliance with 55 Pa.Code Ch. 2800 relating to Assisted Living Residences.
Findings
Violations were found related to admission documentation and staff training requirements. Plans of correction were submitted to address medical evaluations and mandatory staff training deficiencies.
Citations (2)
Admission documents were incomplete as Resident #1's date of admission and initial medical evaluation dates were missing or not properly documented.
Staff Member A did not receive required training in fire safety, emergency preparedness, and residents' rights during the 2016 training year.
Report Facts
Number of Residents Served: 38
Number of Current Hospice Residents: 1
Number of Hospice Residents in past year: 4
Number of Residents Age 60 or Older: 37
Number of Residents with Mobility Need: 3
Number of Residents with Physical Disability: 1
Notice — Feb 19, 2016
Date: Feb 19, 2016
Visit Reason
The document serves as a renewal notification and license issuance for Columbia Cottage Hanover LLC to operate an assisted living facility, with a reminder of the requirement for annual onsite inspections.
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 — Jan 19, 2016
Annual Inspection
Date: Jan 19, 2016
Visit Reason
The inspection was conducted as part of the Department of Human Services' annual licensing inspections for Columbia Cottage – Hanover, LLC.
Findings
The facility was found to be in compliance with 55 Pa.Code Ch. 2800 relating to Assisted Living Residences during the inspections on January 19 and January 20, 2016.
Notice — January 29, 2021
Date: January 29, 2021
Visit Reason
This document serves as a renewal notice and certificate of compliance for Columbia Cottage Hanover LLC to operate an assisted living facility. It informs the facility of the license renewal, the requirement for annual inspections, and the fee payment needed to maintain the certificate.
Findings
No inspection findings are reported. The document confirms issuance of a regular license and outlines the requirement for an onsite inspection within the next twelve months to ensure compliance with applicable regulations.
Report Facts
License fee per bed: 35
Total license fee: 1680
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Deena Brant | Managing Director | Named as legal entity representative and recipient of correspondence |
| Jamie L. Buchenauer | Deputy Secretary, Office of Long-term Living | Signed renewal letter dated January 29, 2021 |
| Linnette Bidelspach | Acting Director Licensing Administration | Signed letter regarding license fee payment dated January 18, 2021 |
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