33 Reports
Inspection Report — May 28, 2026
Date: May 28, 2026
Visit Reason
The inspection was a partial, unannounced visit conducted due to an incident at the facility.
Findings
No regulatory citations or deficiencies were identified during this inspection.
Report Facts
Residents Served: 42
Current Hospice Residents: 2
Inspection Report — May 19, 2026
Renewal
Date: May 19, 2026
Visit Reason
The inspection was an unannounced full renewal inspection conducted to review compliance with licensing requirements and verify the implementation of the submitted plan of correction.
Findings
The facility was found to have multiple deficiencies including failure to post the license inspection summary, incomplete staff training, uncovered trash cans, improper food storage, delayed emergency procedure submission, and incomplete resident assessments. All deficiencies had corrective actions planned or implemented.
Citations (7)
Regulation 2800.3.d: The residence's License Inspection Summary dated 9/17/25 was not posted in a conspicuous and public place.
Regulation 2800.65.i (2) & (6): Direct care staff person A did not receive required 2025 annual training on resident needs and safe management techniques.
Regulation 2800.65.j (1) & (2): Staff person A did not receive annual training in fire safety and emergency preparedness during 2025.
Regulation 2800.85.d: An uncovered trash can was present in the kitchen at 2:30 p.m.
Regulation 2800.103.g: The freezer section of the resident area refrigerator contained uncovered and unlabeled ice cream.
Regulation 2800.107.d: Emergency procedures were submitted for annual review on 2/5/26, exceeding the annual timeframe since the previous submission was 1/15/26.
Regulation 2800.225.a.2: An additional written assessment was not completed for Resident #1 after a significant change in condition including refusal of care and noncompliance with self-care.
Report Facts
Residents Served: 40
Current Hospice Residents: 3
Inspection Report — Mar 13, 2026
Date: Mar 13, 2026
Visit Reason
The inspection was conducted as a partial, unannounced visit due to an incident at the facility.
Findings
No regulatory citations or deficiencies were identified during the inspection.
Report Facts
Residents Served: 39
Current Hospice Residents: 5
Inspection Report — Sep 17, 2025
Follow-Up
Date: Sep 17, 2025
Visit Reason
The inspection was a partial, unannounced follow-up visit triggered by an incident to verify the implementation of a submitted plan of correction.
Findings
The facility was found to have fully implemented the plan of correction related to an incident of resident abuse/neglect involving inappropriate behavior between residents. Systemic changes including increased supervision, staff training, and safety measures were completed to prevent recurrence.
Citations (1)
Regulation 2800.42b prohibits neglect, intimidation, abuse, mistreatment, corporal punishment, or discipline of residents. An incident occurred where a resident with dementia and total assistance needs was inappropriately touched by another resident. The facility was unable to prevent the incident initially.
Report Facts
Residents Served: 35
Current Hospice Residents: 2
Residents Age 60 or Older: 25
Residents Diagnosed with Mental Illness: 1
Residents with Mobility Need: 18
Inspection Report — Jul 29, 2025
Follow-Up
Date: Jul 29, 2025
Visit Reason
The inspection visit was conducted as a follow-up to verify the implementation of a previously submitted plan of correction related to a complaint and incident.
Complaint Details
The inspection was complaint-related and incident-related, with the plan of correction fully implemented as of the follow-up date.
Findings
The submitted plan of correction was determined to be fully implemented, and the facility is currently in compliance. The report includes documentation of a completed annual fire safety inspection and fire drill conducted by a certified fire safety expert.
Citations (1)
The last annual fire safety inspection and fire drill observed by a fire safety expert were not documented on the required dates prior to correction.
Report Facts
Residents Served: 38
Current Hospice Residents: 1
Residents 60 Years or Older: 38
Residents with Mental Illness: 1
Residents with Mobility Need: 18
Total Daily Staff: 56
Waking Staff: 42
Inspection Report — Jul 1, 2025
Follow-Up
Date: Jul 1, 2025
Visit Reason
The inspection was conducted as a partial, unannounced follow-up visit triggered by an incident to review the submitted plan of correction for the facility.
Findings
The submitted plan of correction was found to be fully implemented, addressing the deficiency related to a resident's nighttime roaming behavior not documented in the support plan. The facility updated the support plan, implemented hourly safety checks, and established systemic measures including audits and staff training to ensure compliance.
Citations (1)
Resident's support plan did not document nighttime roaming behavior or interventions to address it.
Report Facts
Residents Served: 35
Current Residents in Hospice: 0
Residents 60 Years or Older: 35
Residents Diagnosed with Mental Illness: 1
Residents with Mobility Need: 16
Total Daily Staff: 51
Waking Staff: 38
Inspection Report — Jun 25, 2025
Renewal
Date: Jun 25, 2025
Visit Reason
The inspection was conducted as a renewal inspection of the assisted living facility to verify compliance with licensing requirements.
Findings
The facility was found to have multiple deficiencies including failure to post the current license, unlabeled leftover food, lint accumulation in the dryer lint trap, incomplete medical evaluation documentation, missing posted menus, and unsigned resident support plans. All deficiencies had plans of correction accepted and were implemented by July 14, 2025.
Citations (6)
The home did not have their current license posted in a public and conspicuous place.
There was an unlabeled, undated Saran wrapped covered salad in the kitchen’s refrigerator.
Approximately 1-inch accumulation of lint in the lint trap of the laundry room’s top right dryer.
Medical evaluation form for resident #1 did not include a list of the resident’s medications.
The home did not have the menu for the current week or the following week posted.
The support plan for resident #2 was not signed by the resident and lacked documentation of refusal or inability to sign.
Report Facts
Residents Served: 33
Current Residents in Hospice: 1
Residents 60 Years or Older: 33
Residents Diagnosed with Mental Illness: 1
Residents with Mobility Need: 15
Inspection Report — Mar 26, 2025
Date: Mar 26, 2025
Visit Reason
The inspection was a partial, unannounced licensing inspection conducted due to an incident.
Findings
No regulatory citations or deficiencies were identified during the inspection.
Report Facts
Total Daily Staff: 62
Waking Staff: 47
Resident Support Staff: 0
Residents Served: 36
Current Hospice Residents: 1
Residents Age 60 or Older: 36
Residents with Mobility Need: 26
Residents Receiving Supplemental Security Income: 0
Residents Diagnosed with Mental Illness: 0
Residents Diagnosed with Intellectual Disability: 0
Residents with Physical Disability: 0
Inspection Report — Sep 24, 2024
Date: Sep 24, 2024
Visit Reason
The inspection was conducted as a partial, unannounced visit due to an incident.
Findings
No regulatory citations or deficiencies were identified during the inspection.
Report Facts
Residents Served: 36
Current Residents in Hospice: 2
Residents Age 60 or Older: 36
Residents with Mobility Need: 26
Residents with Physical Disability: 1
Total Daily Staff: 62
Waking Staff: 47
Inspection Report — Jul 23, 2024
Follow-Up
Date: Jul 23, 2024
Visit Reason
The inspection was a partial, unannounced follow-up review conducted due to an incident involving allegations of resident abuse.
Complaint Details
The visit was triggered by a complaint/incident involving Resident #1 accusing Staff A and Staff B of rape. The Administrator reported the accusation to the local Area Agency on Aging and the Department, though with delays exceeding reporting requirements.
Findings
The facility was found to have fully implemented the submitted plan of correction related to the immediate reporting, supervision, and incident reporting requirements following allegations of resident abuse. The report details corrective actions including staff training, policy revisions, and monitoring systems to ensure compliance.
Citations (4)
Failure to immediately report suspected abuse of a resident as required by law.
Failure to immediately develop and implement a plan of supervision or suspend staff involved in alleged abuse.
Failure to submit a plan of supervision or notice of suspension to the Department within required timeframe.
Failure to report the incident to the Department within 24 hours as required.
Report Facts
Residents Served: 37
Current Hospice Residents: 4
Residents with Mobility Need: 24
Residents Age 60 or Older: 37
Total Daily Staff: 61
Waking Staff: 46
Inspection Report — Jun 11, 2024
Renewal
Date: Jun 11, 2024
Visit Reason
The inspection was conducted as a renewal visit to assess compliance with licensing requirements for Columbia Cottage Wyomissing, LLC.
Findings
The inspection identified several deficiencies including insufficient certified first aid/CPR staff during the 3rd shift, unlabeled leftover food in the kitchen, inadequate scheduling of fire drills during sleeping hours, and incomplete documentation in a resident's support plan regarding a bed mobility device. Plans of correction were accepted and fully implemented by the facility.
Citations (4)
On 6/8/24 during the 3rd shift hours of 11pm to 6am the home had only 1 staff person with certified First aid and CPR training on site.
An unlabeled package of lunchmeat was found in the home’s refrigerator located against the back wall of the kitchen.
The home has only conducted the required sleeping hour fire drills during times when additional staff were present and has not conducted a sleeping hour drill with 3rd shift staff only.
Resident #1's support plan dated 9/8/23 did not specify the type of halo type enabler bar being utilized or whether the bar requires a cover to meet FDA guidelines.
Report Facts
Residents Served: 36
Staffing Hours: 64
Waking Staff: 48
Current Hospice Residents: 3
Residents with Mobility Need: 28
Residents with Physical Disability: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Resident Wellness Director | LPN | Named in plan of correction for First Aid/CPR deficiency |
| Resident Services Director | Named in multiple plans of correction including First Aid/CPR staffing and fire drill scheduling | |
| Food Service Director | Named in plan of correction for unlabeled leftover food | |
| Managing Director | Named in plans of correction for fire drill scheduling and support plan compliance | |
| Regional Staff Development Manager | Named in plan of correction for updating resident support plan regarding bed mobility device |
Inspection Report — Jul 11, 2023
Renewal
Date: Jul 11, 2023
Visit Reason
The inspection was conducted as a renewal visit to review the facility's compliance and licensing status.
Findings
The submitted plan of correction was found to be fully implemented, with continued compliance required. One deficiency was noted regarding food protection where an opened block of cheese was not dated, which was corrected during the inspection.
Citations (1)
Opened block of cheese stored in the residence's refrigerator was not dated to indicate when it was opened.
Report Facts
Residents Served: 36
Staffing Hours - Total Daily Staff: 63
Staffing Hours - Waking Staff: 47
Current Residents in Hospice: 3
Residents Age 60 or Older: 36
Residents with Mobility Need: 27
Residents with Physical Disability: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Food Service Director | Named in relation to ensuring food deliveries are dated and food labeling procedures | |
| Managing Director | Named in relation to spot checking food labeling procedures for six months |
Inspection Report — Jan 26, 2023
Follow-Up
Date: Jan 26, 2023
Visit Reason
The inspection visit on 01/26/2023 was a partial, unannounced follow-up inspection triggered by an incident to verify the implementation of a submitted plan of correction.
Complaint Details
The visit was complaint-related due to an incident involving abuse/neglect. The allegations were investigated, found to be founded, and appropriate corrective actions were taken including termination of Staff A and reporting to the Area Agency on Aging and BHSL.
Findings
The facility was found to have fully implemented the submitted plan of correction related to abuse/neglect allegations involving Staff A. The allegations were substantiated, Staff A was terminated, and staff training and monitoring plans were put in place to ensure compliance and resident safety.
Citations (1)
Staff A verbally and physically abused residents by throwing a napkin in a resident's face, threatening to slap the resident, and forcibly removing another resident from the dining room.
Report Facts
Residents Served: 38
Current Hospice Residents: 4
Resident with Mobility Need: 23
Resident Age 60 or Older: 38
Resident with Physical Disability: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Named in abuse/neglect violation involving verbal and physical abuse of residents | |
| Managing Director | Involved in investigation, reporting, staff training, and monitoring compliance following abuse/neglect incident | |
| Resident Services Director | Participated in staff meetings and statements collection related to abuse/neglect incident |
Inspection Report — Sep 15, 2022
Plan of Correction
Date: Sep 15, 2022
Visit Reason
The document confirms that the submitted plan of correction for the facility was reviewed following an inspection on 09/15/2022.
Findings
The plan of correction submitted by the facility was determined to be fully implemented, and continued compliance must be maintained.
Inspection Report — Apr 12, 2022
Renewal
Date: Apr 12, 2022
Visit Reason
The inspection was an unannounced full renewal inspection conducted on 04/12/2022 and 04/13/2022 to review compliance with licensing requirements.
Findings
The facility was found to have multiple deficiencies including breaches in resident record confidentiality, storage of outdated food, incomplete emergency evacuation diagrams, missing first aid kit in the transport van, and medication record discrepancies. Plans of correction were submitted and determined to be fully implemented by the time of the follow-up review.
Citations (6)
Privacy coding sheet with resident names was posted along with license inspection summaries.
A dented can of cream of mushroom soup was found in the pantry stored with other canned foods.
Emergency evacuation diagrams did not include lines of travel to exit doors, location of fire extinguishers, or pull signals.
The home's van used to transport residents did not have a first aid kit.
Resident #1 was missing one glucometer reading for 4/9/22.
Resident #2's medication administration record did not match the pharmacy label for Warfarin frequency.
Report Facts
Residents Served: 39
Current Hospice Residents: 4
Residents with Mobility Need: 28
Residents with Physical Disability: 1
Inspection Report — Nov 4, 2021
Follow-Up
Date: Nov 4, 2021
Visit Reason
The visit was a follow-up inspection to review the submitted plan of correction related to an incident and resident rights violations reported at the facility.
Findings
The plan of correction was determined to be fully implemented, with corrective actions taken including staff administrative leave, investigations, notifications, and staff training on APS/OPSA. Continued compliance must be maintained.
Citations (2)
Failure to report a resident rights violation incident to the Department within 24 hours.
Direct care staff member was disrespectful to a resident by telling them they were rude while performing care.
Report Facts
Residents Served: 39
Current Residents in Hospice: 3
Residents Age 60 or Older: 39
Residents with Mobility Need: 15
Residents with Physical Disability: 1
Total Daily Staff: 54
Waking Staff: 41
Inspection Report — May 11, 2021
Renewal
Date: May 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.
Inspection Report — Apr 7, 2021
Renewal
Date: Apr 7, 2021
Visit Reason
A license renewal inspection was conducted on 04/07/2021 and 04/08/2021 to assess compliance with staffing levels and resident support plans.
Findings
The inspection found that the facility had insufficient staffing on overnight shifts to safely evacuate residents with mobility needs during emergencies. A minimum of four staff members is required overnight, but only three were routinely scheduled. The facility submitted a plan of correction which was initially not accepted but later approved after adjustments to staffing and fire drill procedures.
Citations (1)
Insufficient staffing levels on overnight shifts to safely evacuate residents with mobility needs during emergencies.
Report Facts
Residents served: 32
Residents with mobility needs: 18
Staff scheduled overnight: 3
Minimum required staff overnight: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Harold Hicks | Fire Expert | Consulted for training on evacuation plan and fire safe zones |
Notice — Mar 22, 2021
Date: Mar 22, 2021
Visit Reason
The document serves as a certificate of compliance and a license renewal notice for Columbia Cottage Wyomissing LLC, an Assisted Living facility. It also informs that an annual inspection will be conducted within the next twelve months as required by regulation.
Findings
No inspection findings are reported in this document. It confirms issuance of a regular license following the renewal application and advises that future inspections will be conducted to ensure compliance.
Report Facts
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary, Office of Long-term Living | Signed the renewal notice letter |
Inspection Report — Jan 20, 2021
Follow-Up
Date: Jan 20, 2021
Visit Reason
The inspection was conducted as a follow-up to verify the implementation of a previously submitted plan of correction related to an incident involving staff disrespect towards a resident.
Findings
The submitted plan of correction was determined to be fully implemented, including staff training on resident rights and abuse reporting. The incident involved one staff member who was terminated, and additional staff training was completed to prevent future occurrences.
Citations (1)
Staff member spoke to a resident in a disrespectful manner regarding a PRN medication request.
Report Facts
Residents Served: 32
Current Hospice Residents: 1
Total Daily Staff: 53
Waking Staff: 40
Residents with Mobility Need: 21
Residents 60 Years or Older: 32
Residents with Physical Disability: 1
Inspection Report — Nov 4, 2020
Renewal
Date: Nov 4, 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 — Mar 10, 2020
Renewal
Date: Mar 10, 2020
Visit Reason
The inspection was a renewal visit conducted by the Pennsylvania Department of Human Services, Bureau of Human Services Licensing, to review compliance and verify the submitted plan of correction.
Findings
The facility was found to have fully implemented the submitted plan of correction. Several violations were identified related to staff training, emergency telephone numbers, medication labeling, and medication administration records, all of which had corrective actions planned or completed.
Citations (4)
2800 65e. Staff person A did not receive training in safe management techniques within 40 scheduled working hours as required during orientation.
2800 91. The phone in resident room #20 did not have emergency telephone numbers posted on or near the phone.
2800 184a. The Lantus and Humalog insulin pens for resident #1 were stored without pharmacy labels in the medication cart.
2800 187a. Resident #2's medication for Levothyroxine was not initialed as administered on 3/3/20 as required in the medication record.
Report Facts
Residents Served: 44
Current Hospice Residents: 5
Residents Age 60 or Older: 44
Residents with Mobility Need: 28
Total Daily Staff: 72
Waking Staff: 54
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Noreen L. Krymski | Managing Director | Named in plan of correction and signature on multiple findings |
Inspection Report — Feb 7, 2020
Renewal
Date: Feb 7, 2020
Visit Reason
The document is related to the renewal of the license for Columbia Cottage Wyomissing LLC, an assisted living facility, following receipt of a renewal application and pursuant to Title 55, PA Code, Chapter 2800. The Department advises that an onsite inspection will be conducted within the next twelve months as part of the annual inspection requirement.
Findings
This document includes the issuance of a regular license in response to the renewal application and states that the Department will conduct an onsite inspection within the next twelve months to check for compliance with applicable laws and regulations.
Report Facts
Notice — Mar 29, 2019
Date: Mar 29, 2019
Visit Reason
The document is a response to a request to admit a resident with an excludable condition (RAREC) to Columbia Cottage Wyomissing LLC, reviewing the resident's needs and approving the admission.
Findings
The Department reviewed the submitted documentation and determined that the resident can be safely served in the licensed setting with 24-hour nursing staff assistance for tracheotomy care.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jacqueline L. Rowe | Director | Signed the approval letter for the RAREC admission. |
Inspection Report — Mar 14, 2019
Renewal
Date: Mar 14, 2019
Visit Reason
The inspection was a full renewal inspection of Columbia Cottage Wyomissing, LLC, conducted by the Department’s Bureau of Human Services Licensing.
Findings
The inspection found violations related to an uncovered enabler bar on a resident's bed that posed a potential hazard. The facility submitted a plan of correction and was partially implementing it with adequate progress as of May 29, 2019.
Citations (1)
2800.81(b) - An enabler bar on the right side of the resident’s bed in room #40 was uncovered and posed a possible hazard to the resident’s head, neck, or limbs.
Report Facts
Number of Residents Served: 43
Number of Current Hospice Residents: 5
Number of Residents 60 Years or Older: 43
Number of Residents with Mobility Need: 15
Number of Residents with Physical Disability: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Merri Ney | Managing Director | Named in relation to the plan of correction and signature on the violation report. |
Notice — Feb 1, 2019
Date: Feb 1, 2019
Visit Reason
The document serves as a renewal notification and issuance of a regular license for Columbia Cottage Wyomissing LLC to operate an assisted living home. It also informs the facility of the requirement for an annual onsite inspection within the next twelve months.
Findings
No inspection findings are reported in this document. It is a licensing and renewal notice without compliance or deficiency information.
Report Facts
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jacqueline L. Rowe | Director | Signed the renewal notification letter. |
| Robert E. Robinson | Issuing Officer | Signed the certificate of compliance. |
| Carolyn K. Ellison | Deputy Secretary | Signed the certificate of compliance. |
Inspection Report — Mar 14, 2018
Renewal
Date: Mar 14, 2018
Visit Reason
The inspection was a renewal inspection conducted by the Department of Human Services for Columbia Cottage Wyomissing, LLC on March 14, 2018.
Findings
Violations of 55 Pa.Code Ch. 2800 related to medication management were found, specifically involving expired narcotic medication for a resident. A plan of correction was submitted addressing staff training and medication audits.
Citations (1)
55 Pa.Code § 2800: A narcotic medication card for a resident contained expired Oxycodone pills found in the narcotic drawer on the day of inspection.
Report Facts
Number of Residents Served: 44
Number of Current Hospice Residents: 7
Number of Hospice Residents in past year: 17
Residents Age 60 or Older: 44
Residents with Mobility Need: 28
Inspection Report — Feb 1, 2018
Renewal
Date: Feb 1, 2018
Visit Reason
The document is a renewal application and license issuance for Columbia Cottage Wyomissing LLC to operate an Assisted Living facility. The Department advises that an annual onsite inspection will be conducted within the next twelve months as required by regulation.
Findings
No inspection findings are reported in this document. It confirms issuance of a regular license following the renewal application.
Report Facts
Inspection Report — Oct 4, 2017
Complaint Investigation
Date: Oct 4, 2017
Visit Reason
The inspection was conducted as a complaint investigation due to an incident involving alleged resident abuse at Columbia Cottage Wyomissing.
Complaint Details
The investigation was triggered by a complaint alleging resident abuse occurring on 9/26/2017. The allegations were substantiated by observations and internal investigation. The facility took corrective actions including staff suspension and supplemental training.
Findings
The facility failed to immediately report suspected abuse to the local Area Agency on Aging and the Department of Human Services as required. Staff were observed using disrespectful tone and physically restraining a resident, violating residents' rights and dignity. The facility conducted internal investigations, suspended involved staff, and provided supplemental training.
Citations (4)
2800.15(a) - The home did not notify the local Area Agency on Aging of an allegation of resident abuse that occurred from 9/26/2017 to 9/29/2017.
2800.16(c) - The home did not notify the Department of an allegation of resident abuse that occurred from 9/26/2017 to 9/29/2017 within 24 hours as required.
2800.42(c) - Staff member A was observed speaking to resident #1 in a loud disrespectful tone of voice on 9/26/2017 at approximately 7pm.
2800.202 (2,3,6) - On 9/26/2017 at approximately 7pm, direct care staff members A and B were observed holding down resident #1's arms and staff person A was observed screaming in resident #1's face, violating prohibitions on restraints and abuse.
Report Facts
Number of Residents Served: 43
Number of Current Hospice Residents: 8
Number of Hospice Residents in past year: 24
Inspection Report — Feb 22, 2017
Annual Inspection
Date: Feb 22, 2017
Visit Reason
The inspection was an annual licensing inspection conducted by the Department of Human Services 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 — Feb 10, 2017
Date: Feb 10, 2017
Visit Reason
The document serves as a renewal notice and license issuance for Columbia Cottage Wyomissing LLC to operate an assisted living facility. It also informs the facility of the requirement for an annual onsite inspection within the next twelve months.
Findings
No inspection findings are reported in this document. It is a license renewal approval and notification letter.
Inspection Report — Feb 26, 2016
Renewal
Date: Feb 26, 2016
Visit Reason
The document is a renewal of the license for Columbia Cottage Wyomissing LLC to operate an Assisted Living facility. The Department notifies that an annual 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 notification and outlines the requirement for future annual inspections.
Report Facts
Inspection Report — Jan 27, 2016
Renewal
Date: Jan 27, 2016
Visit Reason
The inspection was conducted as part of the Department of Human Services' annual licensing renewal inspections for Columbia Cottage Wyomissing, LLC on January 27 and 28, 2016.
Findings
One violation was found related to the fire drill frequency during sleeping hours, which was not conducted within the required six-month interval. A plan of correction was submitted to ensure compliance with the fire drill regulation.
Citations (1)
Regulation 2800.132e-A requires a fire drill during sleeping hours every six months. A fire drill was conducted on 10/20/15, but the previous drill was on 3/29/15, more than six months prior.
Report Facts
Number of Residents Served: 43
Number of Current Hospice Residents: 7
Number of Hospice Residents in Past Year: 15
Number of Residents Age 60 or Older: 43
Number of Residents with Mobility Needs: 20
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