Inspection Reports for
Concordia at Weatherwood
896 WEATHERWOOD LANE,, GREENSBURG, PA, 15601
Back to Facility Profile37 Reports
Inspection Report — Apr 8, 2026
Complaint Investigation
Date: Apr 8, 2026
Visit Reason
The inspection was conducted as a complaint and incident investigation at Concordia at Weatherwood.
Complaint Details
The visit was complaint-related and incident-based, with no explicit substantiation status stated.
Findings
The inspection found deficiencies related to failure to provide timely assistance with activities of daily living, improper medication administration documentation, and failure to follow prescriber's orders regarding ace wraps application. A plan of correction was submitted and fully implemented.
Citations (3)
23a - Activities of Daily Living Assistance: Resident assessment indicated need for ace wraps application, but resident experienced delays of up to 3 hours waiting for staff assistance to change wraps.
185a - Implement Storage Procedures: Resident's Medication Administration Record did not document application of ace wraps on multiple dates and times, indicating incomplete medication administration records.
187d - Follow Prescriber's Orders: Staff failed to follow prescriber's orders for ace wraps application, causing resident to wait extended periods for assistance despite clear instructions.
Report Facts
Residents Served: 76
Current Hospice Residents: 16
Staff Counts: 91
Waking Staff: 68
Inspection Report — Nov 25, 2025
Follow-Up
Date: Nov 25, 2025
Visit Reason
The inspection was a follow-up visit to verify the correction of previously identified deficiencies based on a plan of correction submission.
Findings
The facility demonstrated full implementation of the submitted plan of correction with resolved issues related to contract signatures, payment responsibility, food storage, medication security, storage procedures, and following prescriber's orders.
Citations (6)
2600.25.b The resident-home contract was not signed by the resident or responsible party.
2600.25.c4 The resident-home contract did not specify the party responsible for payment.
2600.103.g Food was stored in an opened and unsealed zip lock bag in the main kitchen refrigerator.
2600.183.b Prescription medications and syringes were unlocked, unattended, and accessible in a resident's bedroom bathroom.
2600.185.a The home failed to properly document medication administration per sliding scale and did not follow safe storage procedures.
2600.187.d The home did not follow prescriber's orders for medication administration and documentation.
Report Facts
Residents Served: 76
Current Hospice Residents: 12
Residents Diagnosed with Mental Illness: 57
Residents Diagnosed with Intellectual Disability: 1
Residents with Mobility Need: 13
Residents with Physical Disability: 1
Residents Age 60 or Older: 76
Inspection Report — Sep 3, 2025
Renewal
Date: Sep 3, 2025
Visit Reason
The inspection was conducted as a renewal review of the facility license with unannounced full inspections on 09/03/2025, 09/04/2025, and an off-site review on 09/11/2025.
Findings
Multiple deficiencies were identified related to contract payment responsibility, sanitary conditions, lighting, food storage, lint removal, egress, fire extinguisher inspection, first aid kit contents, medication storage and administration, and preadmission screening. All deficiencies had plans of correction accepted and were implemented by 12/15/2025.
Citations (14)
25c4 Payment Responsibility: The resident-home contract did not specify the party responsible for payment.
85a Sanitary Conditions: A resident's glucometer was used to measure another resident's level, risking contamination.
101j7 Lighting/Operable Lamp: A resident did not have access to a bedside lamp that could be turned on/off; the lamp was unplugged and away from the bed.
103g Storing Food: Uncovered trays of breaded fish and pork roasts were found in the main kitchen's walk-in freezer.
105g Lint Removal and Duct Cleaning: A baseball-sized ball of lint was found behind the lint trap in the main laundry room industrial dryer.
121a Unobstructed Egress: Emergency exit doors to Alpha and Bravo staircases required significant force to open.
131f Fire Extinguisher Inspection: The fire extinguisher in the resident transport vehicle had not been inspected by a fire safety expert since January 2024.
171b First Aid Kit: The vehicle first aid kit used for resident transport lacked a breathing shield.
181d Storing Medication: Resident medications were unlocked, unattended, and accessible on the bathroom sink in the resident's bedroom.
183b Meds and Syringes Locked: Prescription and OTC medications and syringes were unlocked, unattended, and accessible on the bathroom sink and bedside dresser in resident rooms.
185a Implement Storage Procedures: Blood glucose readings documented on medication records were not present on the resident's glucometer as required.
187b Date/Time of Medication Admin.: Medication administration records lacked staff initials for medications given at 8:00 a.m.
187d Follow Prescriber's Orders: Resident blood glucose readings were not taken at prescribed times, including 9:00 p.m.
224a Preadmission Screen Form: Resident's preadmission screening was not completed within 30 days prior to admission.
Report Facts
Residents Served: 78
Current Residents in Hospice: 12
Residents Diagnosed with Mental Illness: 20
Residents with Mobility Need: 30
Residents 60 Years or Older: 78
Residents Diagnosed with Intellectual Disability: 1
Residents with Physical Disability: 1
Total Daily Staff: 108
Waking Staff: 81
Inspection Report — May 29, 2025
Complaint Investigation
Date: May 29, 2025
Visit Reason
The inspection was conducted as a complaint and incident investigation during an unannounced partial inspection on 05/29/2025.
Complaint Details
The visit was complaint-related with substantiated findings of neglect and improper treatment of residents, including failure to assist a resident in a timely manner and inappropriate presence of minors in resident areas.
Findings
The inspection found violations related to abuse and treatment of residents, including neglect in assisting a resident from the toilet and allowing minors to enter resident rooms and disturb residents during overnight shifts. Corrective actions including staff training, counseling, and terminations were implemented.
Citations (2)
Resident was left on the toilet for an extended period without assistance, causing pain and discomfort.
Staff allowed minors to enter resident bedrooms during overnight shifts, disturbing residents and taking food and drinks.
Report Facts
Residents Served: 73
Current Residents in Hospice: 12
Diagnosed with Mental Illness: 19
Have Mobility Need: 10
Are 60 Years of Age or Older: 73
Diagnosed with Intellectual Disability: 1
Have Physical Disability: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff Person A | Counseled and terminated for neglecting to assist a resident on the toilet. | |
| Staff Person B | Observed leaving resident unattended on the toilet. | |
| Staff Person C | Terminated for allowing minors to enter resident rooms and disturbing residents. |
Notice — May 5, 2025
Date: May 5, 2025
Visit Reason
This document serves to notify the facility that a waiver request to 55 Pa.Code § 2600.54(a)(2) regarding direct care staff educational qualifications has been granted.
Findings
The waiver allows a specific employee to serve as direct care staff despite not having a U.S. high school diploma, based on submitted educational documentation. The Department will review this waiver annually during inspections to ensure compliance with conditions.
Inspection Report — Apr 23, 2025
Complaint Investigation
Date: Apr 23, 2025
Visit Reason
The inspection was conducted as a complaint investigation, unannounced, to review allegations of abuse and medication management issues at the facility.
Complaint Details
The visit was triggered by allegations of resident abuse involving two staff members who continued to provide services without approved supervision plans. The complaint was substantiated with findings related to abuse supervision and medication management.
Findings
The inspection found multiple deficiencies including failure to implement a supervisor plan for staff accused of abuse, medications and syringes not properly locked, presence of medications without physician orders, and inadequate documentation of residents' ability to self-administer medications. Plans of correction were accepted and implemented with ongoing audits and staff training.
Citations (4)
Failure to develop and implement a plan of supervision or suspend staff members involved in alleged resident abuse incidents.
Prescription medications, OTC medications, CAM and syringes were not kept in locked areas or containers as required.
Medications present in the facility without current physician orders.
Resident support plan did not document the ability to self-administer medications or need for reminders, despite medication orders.
Report Facts
Residents Served: 66
Total Daily Staff: 76
Waking Staff: 57
Hospice Residents: 5
Diagnosed with Mental Illness: 10
Residents 60 Years or Older: 66
Diagnosed with Intellectual Disability: 1
Residents with Mobility Need: 10
Residents with Physical Disability: 1
Inspection Report — Mar 12, 2025
Complaint Investigation
Date: Mar 12, 2025
Visit Reason
The inspection was conducted as a complaint investigation with an unannounced partial inspection on 03/12/2025 and 03/13/2025.
Complaint Details
The inspection was triggered by a complaint; the inspection type is listed as Partial and Unannounced. No deficiencies or citations were found.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Total Daily Staff: 82
Waking Staff: 62
Resident Support Staff: 0
Residents Served: 70
Current Residents in Hospice: 7
Residents Diagnosed with Mental Illness: 9
Residents Diagnosed with Intellectual Disability: 1
Residents with Mobility Need: 12
Residents with Physical Disability: 1
Residents 60 Years of Age or Older: 70
Residents Receiving Supplemental Security Income: 0
Inspection Report — Feb 26, 2025
Complaint Investigation
Date: Feb 26, 2025
Visit Reason
The inspection was conducted as a complaint and incident investigation following allegations of caregiver neglect and abuse at the facility.
Complaint Details
The complaint investigation was triggered by allegations of caregiver neglect including leaving a resident on the toilet for over 1.5 hours, administering extra medication dosages, misuse of a resident's oxygen concentrator on another resident, and failure to seek timely medical care after a fall resulting in a fracture. The facility failed to timely report these incidents to the Department and local agencies.
Findings
The investigation found multiple violations including delayed reporting of abuse allegations, failure to provide timely assistance to residents, improper medication administration, lack of proper documentation, and incomplete resident support plan signatures. The facility implemented staff training and corrective actions to address these deficiencies.
Citations (9)
Failure to immediately report suspected abuse of residents as required by law.
Failure to report incidents to the Department within 24 hours as required.
Delayed staff response to resident call bells for toileting assistance (42 and 44 minutes delays).
Medication prescribed for one resident was administered to another resident.
Medication administration records did not include initials of staff administering medication at specified times.
Medication was administered after it was discontinued according to the medication administration record.
Medication was administered at incorrect times and in incorrect dosages compared to prescriber's orders.
Resident assessments and medical evaluations were inconsistent regarding ability to self-administer medications.
Resident support plans were not signed by residents nor documented reasons for lack of signature.
Report Facts
Residents Served: 66
Staffing Hours: 76
Waking Staff: 57
Delayed call bell response times: 42
Delayed call bell response times: 44
Inspection Report — Dec 17, 2024
Renewal
Date: Dec 17, 2024
Visit Reason
The inspection was an unannounced full renewal inspection conducted on 12/17/2024 to review compliance with licensing requirements and verify the implementation of a previously submitted plan of correction.
Findings
The inspection identified several deficiencies including a direct care staff member lacking required qualifications and training, presence of discontinued medications in the medication cart, missing prescribed medications, and incomplete preadmission screening for a resident. Plans of correction were submitted and accepted, with full implementation verified by 02/14/2025.
Citations (5)
Direct care staff person A did not have a high school diploma, GED diploma, or active registry status on the Pennsylvania nurse aide registry and provided unsupervised ADL services.
Direct care staff person A did not receive required initial direct care training and did not complete and pass the Department-approved competency test.
Discontinued medications (Polyethylene Glycol and Delsym) were still present in the medication cart.
Prescribed stimulant laxative medication was not available in the home for Resident #1; medications for Resident #3 were not available as ordered.
Preadmission screening was not completed for Resident #4 prior to admission.
Report Facts
Total Daily Staff: 65
Waking Staff: 49
Residents Served: 55
Hospice Residents: 3
Residents with Mental Illness: 1
Residents with Mobility Need: 10
Inspection Report — Sep 18, 2024
Follow-Up
Date: Sep 18, 2024
Visit Reason
The inspection was a partial, unannounced incident investigation conducted on 09/18/2024 to review compliance following a plan of correction submission.
Findings
The facility was found to have delayed reporting an incident involving alleged theft, and failed to provide proper assistance during resident transfers, resulting in a resident fall and subsequent death. Plans of correction were accepted and fully implemented by 02/21/2025.
Citations (3)
Failure to report an incident to the Department within 24 hours as required by regulation 2600.16.c.
Failure to provide assistance with activities of daily living as indicated in the resident’s assessment and support plan, resulting in a resident fall and death.
Failure to prevent abuse, including neglect and improper handling during resident transfer, violating regulation 2600.42.b.
Report Facts
Residents Served: 58
Total Daily Staff: 71
Waking Staff: 53
Current Hospice Residents: 4
Residents Diagnosed with Mental Illness: 12
Residents with Mobility Need: 13
Residents Aged 60 or Older: 58
Residents with Physical Disability: 1
Notice — Aug 13, 2024
Date: Aug 13, 2024
Visit Reason
The document serves to notify Concordia at Weatherwood that their request to waive certain Pennsylvania Code requirements for preadmission screening and medical evaluation forms is granted.
Findings
The waiver allows the facility to use forms from Point, Click, Care instead of the Department's specified forms. The Department will review compliance with this waiver during its annual inspection.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Theresa Hartman | Bureau Director, Human Services Licensing | Signed the waiver approval letter. |
Inspection Report — Jul 30, 2024
Original Licensing
Date: Jul 30, 2024
Visit Reason
The inspection was conducted as a licensing inspection for a new legal entity operating the personal care home facility, Concordia at Weatherwood.
Findings
The facility was found to be in substantial compliance with applicable regulations, though the inspection was partial due to the new legal entity status. A re-inspection is scheduled within 3 months to ensure full compliance. One deficiency was noted regarding the walk-in freezer temperature, which was corrected promptly.
Citations (1)
2600.103.f requires refrigerated food to be stored at or below 40°F and frozen food at or below 0°F. The walk-in freezer was found at 19°F during inspection but was corrected with ongoing monitoring.
Report Facts
Residents Served: 55
Current Residents in Hospice: 4
Residents Age 60 or Older: 55
Residents Diagnosed with Mental Illness: 5
Residents with Mobility Need: 20
Total Daily Staff: 75
Waking Staff: 56
Inspection Report — May 21, 2024
Renewal
Date: May 21, 2024
Visit Reason
The inspection was conducted as a renewal inspection of the facility's license.
Findings
The inspection found multiple deficiencies including improper placement of carbon monoxide detectors, unlabeled and undated leftover food, unavailable prescribed medication for a hospice resident, medication record errors, and incomplete resident support plans. All deficiencies had plans of correction accepted and were implemented by mid-July 2024.
Citations (5)
Carbon monoxide detectors were not installed within required proximity to fossil-fuel burning devices.
Multiple bags of frozen spaghetti and frozen bananas were opened and undated in the walk-in freezer.
Prescribed medication Atropine Sulfate 1% was not available in the home for a hospice resident.
Medication administration record (MAR) for Resident #2 did not include the strength of Novolog; incorrect dosage recorded for Resident #3.
Resident #3's support plan did not address the specific need, intended use, risks, or identification of a bedside mobility device attached to the bed frame.
Report Facts
Residents Served: 58
Total Daily Staff: 79
Waking Staff: 59
Hospice Residents: 3
Residents with Mobility Need: 21
Residents Diagnosed with Mental Illness: 4
Inspection Report — Apr 18, 2023
Complaint Investigation
Date: Apr 18, 2023
Visit Reason
The inspection was conducted as a partial, unannounced visit due to an incident at the facility.
Complaint Details
The inspection was incident-related; no deficiencies or citations were found, indicating no substantiated complaints.
Findings
No regulatory citations or deficiencies were identified during the inspection.
Report Facts
Total Daily Staff: 73
Waking Staff: 55
Residents Served: 53
Current Hospice Residents: 8
Residents Diagnosed with Mental Illness: 6
Residents with Mobility Need: 20
Residents Aged 60 or Older: 53
Residents with Physical Disability: 1
Inspection Report — Apr 4, 2023
Renewal
Date: Apr 4, 2023
Visit Reason
The inspection was conducted as a full, unannounced renewal inspection with an incident review on 04/04/2023 and 04/05/2023.
Findings
The inspection found multiple deficiencies including unlocked resident records, unlabeled carbon monoxide detector batteries, locked egress door, outdated fire safety inspections, incomplete fire drill records, medication storage issues, inaccurate resident assessments, and improper use of correction fluid in records. Plans of correction were accepted and implemented with ongoing audits and education.
Citations (9)
Unlocked and unattended 1st floor nurse's station containing confidential resident face sheets.
Battery-operated carbon monoxide detectors not labeled with date of battery installation.
Exit door from laundry room to parking lot was locked, blocking egress.
Fire safety inspection and fire drill not conducted annually as required.
Fire drill record did not include number of staff persons who participated.
Resident #1's inhalers were unlocked and unattended in living unit contrary to support plan.
Resident #2's glucometer was not set to the current date and time.
Resident #3's medical diagnoses were not indicated on assessment as required.
Correction fluid was present under the 'assessor's printed name' section of resident #3’s support plan.
Report Facts
Residents Served: 53
Current Hospice Residents: 9
Residents with Mobility Need: 20
Residents with Physical Disability: 1
Total Daily Staff: 73
Waking Staff: 55
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Resident Care | Director of Resident Care | Named in relation to corrections of resident assessments, glucometer settings, and medication audits. |
Inspection Report — Jan 26, 2023
Complaint Investigation
Date: Jan 26, 2023
Visit Reason
The inspection was conducted as a complaint investigation with a partial, unannounced visit to the facility.
Complaint Details
The inspection was complaint-related, but no deficiencies or citations were found, indicating no substantiated issues.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Total Daily Staff: 76
Waking Staff: 57
Residents Served: 57
Current Hospice Residents: 8
Residents Diagnosed with Mental Illness: 4
Residents with Mobility Need: 19
Residents with Physical Disability: 1
Residents Age 60 or Older: 57
Inspection Report — Mar 14, 2022
Plan of Correction
Date: Mar 14, 2022
Visit Reason
The inspection was a follow-up review conducted on 03/14/2022 to verify that the submitted plan of correction was fully implemented following a prior incident.
Findings
The plan of correction was determined to be fully implemented, addressing a violation involving abuse/neglect where a resident was improperly handled by staff. Continued compliance and staff education on resident rights and abuse prevention were emphasized.
Citations (1)
A resident was verbally abused and intimidated by staff who forcibly removed covers and pillows, causing the resident to experience a panic attack.
Report Facts
Residents Served: 56
Current Hospice Residents: 5
Total Daily Staff: 90
Waking Staff: 68
Inspection Report — Feb 11, 2022
Renewal
Date: Feb 11, 2022
Visit Reason
The inspection was conducted as a renewal inspection with an incident review, including unannounced full inspections on 02/11/2022, 02/14/2022, and 02/15/2022.
Findings
The submitted plan of correction was determined to be fully implemented. Deficiencies included uncovered bedside enablers posing entrapment hazards, a bedside lamp not operable from bedside, and incomplete medical evaluation documentation. All cited deficiencies had corrective plans accepted and were addressed with staff education and procedural changes.
Citations (3)
Resident #1's and Resident #2's bedside enablers were not covered, posing entrapment hazards with openings measuring 9.5" x 11.5".
Resident #1's bedside lamp was approximately 3 feet from the bed and could not be turned on/off from bedside.
Resident #3's new medical evaluation did not include the date of the in-person evaluation or the date the form was completed; these sections were blank.
Report Facts
Residents Served: 56
Current Hospice Residents: 4
Total Daily Staff: 82
Waking Staff: 62
Inspection Report — Dec 3, 2021
Complaint Investigation
Date: Dec 3, 2021
Visit Reason
The inspection was conducted as a complaint investigation following allegations of resident abuse involving staff persons during COVID-19 testing.
Complaint Details
The complaint involved allegations of resident abuse by staff during COVID-19 testing. The investigation found that the facility delayed implementing a plan of supervision or suspending involved staff. The resident was forcibly tested with a nasopharyngeal swab despite resistance, resulting in distress and a nosebleed. The facility disputed some details but accepted the need for corrective education and procedural improvements.
Findings
The facility was found to have delayed implementing a plan of supervision or suspending staff involved in an abuse allegation until 12/2/2021, after being notified on 11/23/2021. The investigation detailed an incident where resident #1 was forcibly tested for COVID-19 using a nasopharyngeal swab, resulting in distress and a nosebleed. The facility disputed some aspects of the allegation but acknowledged the need for improved education and procedures regarding abuse investigations and COVID testing.
Citations (2)
Failure to immediately develop and implement a plan of supervision or suspend staff involved in an allegation of abuse until 12/2/2021 after notification on 11/23/2021.
Resident #1 was subjected to physical abuse during COVID-19 testing involving forced nasopharyngeal swabbing causing distress and a nosebleed.
Report Facts
Residents Served: 53
Current Hospice Residents: 4
Residents Diagnosed with Mental Illness: 5
Residents with Mobility Need: 15
Inspection Report — Jul 8, 2021
Renewal
Date: Jul 8, 2021
Visit Reason
The inspection was conducted as part of the Pennsylvania Department of Human Services, Bureau of Human Service Licensing licensing inspections on 07/08/2021 and 07/14/2021 for Weatherwood Manor.
Findings
No regulatory citations were identified as a result of this inspection.
Inspection Report — Jun 11, 2021
Routine
Date: Jun 11, 2021
Visit Reason
The inspection was conducted as a routine 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 inspection.
Inspection Report — Apr 22, 2021
Renewal
Date: Apr 22, 2021
Visit Reason
The inspection was conducted as a licensing inspection of the facility Weatherwood Manor 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 — Feb 5, 2021
Complaint Investigation
Date: Feb 5, 2021
Visit Reason
The inspection was conducted as a complaint and incident investigation with unannounced partial inspections on 02/05/2021, 02/20/2021, and 03/02/2021 to review compliance and follow up on submitted plans of correction.
Complaint Details
The inspection was triggered by complaints and incidents, with a focus on dignity/respect violations and failure to follow prescriber’s orders. The complaint was substantiated as deficiencies were found and plans of correction were required and implemented.
Findings
The facility was found to have deficiencies related to dignity and respect towards residents, failure to follow prescriber’s wound care orders, and incomplete significant change assessments. Plans of correction were accepted and fully implemented with ongoing audits and staff education.
Citations (3)
Direct care staff used a harsh tone causing a resident to feel shocked and hurt, violating dignity and respect requirements.
Incorrect wound care dressings were applied contrary to prescriber’s orders, constituting a repeat violation.
Resident’s annual assessment and support plan was not updated to include significant changes such as pressure ulcer and ordered Hoyer lift.
Report Facts
Residents Served: 57
Current Hospice Residents: 5
Residents Diagnosed with Mental Illness: 2
Residents with Mobility Need: 14
Residents Age 60 or Older: 57
Residents with Physical Disability: 2
Inspection Report — Nov 23, 2020
Follow-Up
Date: Nov 23, 2020
Visit Reason
The inspection was a partial, unannounced follow-up visit conducted on 11/23/2020 to review the implementation of a previously submitted plan of correction related to an incident.
Findings
The submitted plan of correction was determined to be fully implemented. The facility was found to have addressed the issue of a staff member calling a resident a derogatory name during medication administration, with staff education and ongoing monitoring planned.
Citations (1)
42c. A resident shall be treated with dignity and respect. A direct care staff person called resident #1 a brat during medication administration, causing the resident to feel insulted and humiliated.
Report Facts
Residents Served: 73
Current Hospice Residents: 4
Total Daily Staff: 89
Waking Staff: 67
Residents Age 60 or Older: 73
Residents with Mobility Need: 16
Residents with Physical Disability: 2
Inspection Report — Sep 2, 2020
Complaint Investigation
Date: Sep 2, 2020
Visit Reason
The inspection was a complaint investigation conducted as a partial, unannounced visit to review compliance with regulations and the submitted plan of correction.
Complaint Details
The visit was complaint-related and focused on verifying the submitted plan of correction. The plan was accepted and fully implemented.
Findings
The facility was found to have discrepancies in resident assessments and support plans, specifically for Resident #1, whose assessed needs did not match the support plan. The submitted plan of correction was fully implemented and compliance was maintained.
Citations (1)
Regulation 2800.225.b assessment content: Resident #1's most recent assessment indicated independence in ADLs, but the support plan showed need for assistance. The resident also required more supervision than assessed due to wandering and fear of being alone.
Report Facts
Residents Served: 70
Current Hospice Residents: 5
Residents Diagnosed with Mental Illness: 5
Residents with Mobility Need: 20
Residents with Physical Disability: 2
Inspection Report — Apr 28, 2020
Complaint Investigation
Date: Apr 28, 2020
Visit Reason
The inspection was conducted as a complaint investigation with an unannounced partial inspection on April 28, 29, and 30, 2020.
Complaint Details
The inspection was triggered by a complaint. The plan of correction was reviewed and approved, and the violations were addressed with corrective actions including updated policies and education of staff.
Findings
The submitted plan of correction was found to be fully implemented. Violations involved issues with involuntary discharge notices, individualized resident support plans, and provision of copies of assessments of service plans (ASP).
Citations (3)
On 4/21/20, the residence issued a 30-day written notice of involuntary discharge to resident #1's designated person but failed to include the specific reason, effective date, or discharge location.
Resident #2's medical evaluation dated 1/28/20 did not include medications ordered by the MD in the assessment and support plan to meet all resident needs.
Resident #1's designated person was not given a copy of resident #1's ASP dated 4/8/20 as required.
Report Facts
Residents Served: 79
Current Hospice Residents: 3
Residents Age 60 or Older: 79
Residents Diagnosed with Mental Illness: 4
Residents with Mobility Need: 25
Residents with Physical Disability: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Laurie Tamasy | Administrator | Named in plan of correction and signature on corrective action documents |
Inspection Report — Mar 26, 2020
Routine
Date: Mar 26, 2020
Visit Reason
The Department’s Bureau of Human Services Licensing conducted an inspection of Weatherwood Manor to assess compliance with 55 Pa. Code Ch. 2800 relating to Assisted Living Residence.
Findings
No regulatory citations were identified as a result of this inspection.
Inspection Report — Feb 3, 2020
Complaint Investigation
Date: Feb 3, 2020
Visit Reason
The inspection was conducted as a complaint investigation during an unannounced partial inspection of Weatherwood Manor.
Complaint Details
The inspection was triggered by a complaint. The report does not explicitly state substantiation status.
Findings
The facility had multiple medication administration and labeling violations involving several residents. Plans of correction were submitted and fully implemented by May and June 2020.
Citations (5)
Medication labeling violations included incorrect directions on medication labels for Residents #3, #4, and #5, and unlabeled medication vials found in the third-floor medication room.
Medications for Residents #1 and #2 were discontinued but not destroyed until after the inspection date.
A 26.5oz bottle of Polyethylene Glycol without a resident name was found in the third-floor medication room and destroyed after inspection.
Resident #6's prescribed medication Topamax was not included on the February 2020 Medication Administration Record (MAR).
Facility cameras recorded interior hallways including resident accessible areas without proper signage or notification, violating privacy regulations.
Report Facts
Residents served: 84
Current Hospice Residents: 4
Resident with mobility need: 21
Resident aged 60 or older: 84
Resident with mental illness: 4
Resident with physical disability: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Laurie Tamasy | Administrator | Signed multiple plans of correction related to medication and camera violations |
Inspection Report — Nov 21, 2019
Renewal
Date: Nov 21, 2019
Visit Reason
The inspection was conducted as a renewal visit to review compliance and licensing status of Weatherwood Manor.
Findings
The submitted plan of correction was found to be fully implemented. Several specific violations related to resident safety and medication administration were identified and addressed with corrective actions.
Citations (6)
The enabler bar for Resident #1 was not securely strapped to the bed, moving approximately 2 inches when grabbed.
The medical evaluation for Resident #2 did not document whether a tuberculin test was administered within the past two years.
A random Ranitidine tablet was found unlocked, unattended, and accessible in an unused medication cart next to bedroom #108.
Medication orders for Resident #3 did not match pharmacy label instructions regarding dosage frequency.
Resident #2's medication administration record showed a failure to sign the Controlled Drug Receipt Record/Disposition Form after administering medication.
Resident #4's assessment and support plan did not address medical symptoms necessitating the use of half-length bed rails.
Report Facts
Residents Served: 82
Current Hospice Residents: 2
Resident Diagnosed with Mental Illness: 4
Residents with Mobility Need: 20
Residents Aged 60 or Older: 82
Residents with Physical Disability: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Laurie Tamasy | Administrator | Signed plan of correction documents and named as facility administrator |
Notice — Nov 19, 2019
Date: Nov 19, 2019
Visit Reason
This document serves as a renewal notification and license issuance for Weatherwood Manor, an assisted living facility, following receipt of a renewal application dated November 6, 2019. It also advises 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 confirms the issuance of a regular license and outlines the requirement for future annual inspections to ensure compliance with applicable laws and regulations.
Report Facts
Notice — Nov 26, 2018
Date: Nov 26, 2018
Visit Reason
This document serves as a renewal notice and certificate of occupancy for Weatherwood Manor, an assisted living facility, confirming the renewal of its license to operate 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 only confirms the issuance of a regular license and the requirement for future inspections.
Report Facts
Inspection Report — Nov 1, 2018
Renewal
Date: Nov 1, 2018
Visit Reason
The inspection was conducted as a renewal inspection of Weatherwood Manor, an assisted living residence, to assess compliance with 55 Pa. Code Ch. 2800.
Findings
Several violations were found related to resident privacy, medication storage and administration, and support plan documentation. Plans of correction were submitted addressing these issues with partial implementation noted at the time of report.
Citations (6)
A privacy coding document with resident names was attached to the license inspection summary and posted publicly. Packing slips for resident prescriptions were unlocked and accessible on the nurses' desk.
Resident #13's Morphine Sulfate oral solution bottle contained 30 ml despite records indicating 58 doses administered. Medication storage and recording procedures were inadequate.
Resident #13's medication administration record showed a discrepancy in Lorazepam dosage compared to the prescribed order.
Resident #17's preliminary support plan lacked an accurate description of supervision and mobility needs despite indicating total supervision and total mobility needs.
Resident #14's quarterly assessment and support plan did not accurately describe supervision and mobility needs despite indicating moderate supervision and minimal mobility needs.
Resident #16's quarterly assessment and support plan did not accurately describe supervision and mobility needs despite indicating extensive supervision and total mobility needs.
Report Facts
Number of Residents Served: 82
Number of Current Hospice Residents: 8
Number of Hospice Residents in past year: 20
Residents Age 60 or Older: 82
Residents with Mental Illness: 1
Residents with Mobility Need: 22
Residents with Physical Disability: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nancy Woodward | Administrator | Named in plan of correction signatures and referenced in findings |
| Amy Duncan | Named as department representative on-site and involved in medication order information | |
| Cindy Mulick | Named as department representative on-site and responsible for removing privacy document |
Notice — Nov 28, 2017
Date: Nov 28, 2017
Visit Reason
This document serves as a renewal notification and license issuance for Weatherwood Manor Assisted Living Home following receipt of a renewal application.
Findings
No inspection findings are reported in this document. It informs the facility of the requirement for an annual onsite inspection within the next twelve months.
Report Facts
Inspection Report — Nov 1, 2017
Renewal
Date: Nov 1, 2017
Visit Reason
The inspection was conducted as a renewal of the facility license for Weatherwood Manor, an assisted living residence, on November 1 and 2, 2017.
Findings
Multiple violations of 55 Pa. Code Ch. 2800 were found related to staff training, fire safety, medication administration, and resident care documentation. Plans of correction were submitted and partially implemented as of May 7, 2018.
Citations (12)
Regulation 65(h): Staff person A completed only 12 hours of annual training instead of the required 16 hours during the 2016 training year.
Regulation 65(i): Several staff did not receive annual training on medication self-administration and care for residents with mental illness during the 2016 training year.
Regulation 65(j): Staff persons did not receive annual fire safety training by a fire safety expert or trained staff during the 2016 training year.
Regulation 106g: Approximately 1 inch of lint was found in lint traps of commercial dryers on November 1, 2017.
Regulation 132(c): Resident #8 remained in bedroom during fire drills and was not evacuated to designated safe area, which was not documented in fire drill records.
Regulation 132(e): The most recent fire drill during sleeping hours was conducted on March 29, 2017, not within the required six-month interval.
Regulation 132(h): Resident #8 was not evacuated to designated meeting place or safe area during fire drills.
Regulation 141(a): Medical evaluations for residents #3, #4, and #6 lacked dates, times, or initials of the person making the entries.
Regulation 183d: Resident #1 was prescribed medication that was still present in the residence after the prescribed period ended on November 2, 2017.
Regulation 183e: An open and undated bottle of eye drops belonging to resident #5 was present, with medication expired 28 days after opening.
Regulation 187(b): The residence's electronic medication administration records were offline multiple times in October 2017, preventing staff from signing medication administration.
Regulation 203(b)1: Resident #3 was prescribed half-length bed rails but the assessment and support plan did not address their use.
Report Facts
Number of Residents Served: 86
Number of Current Hospice Residents: 7
Number of Hospice Residents in past year: 20
Inspection Report — Nov 21, 2016
Renewal
Date: Nov 21, 2016
Visit Reason
The document is a renewal license issued to Weatherwood Manor for operating an Assisted Living facility. The Department of Human Services will conduct an onsite inspection within the next twelve months as part of the annual inspection requirement.
Findings
No inspection findings are reported in this document. It serves as a license renewal notification and states that enforcement action will be taken if noncompliance is found during the upcoming inspection.
Inspection Report — Oct 4, 2016
Annual Inspection
Date: Oct 4, 2016
Visit Reason
The inspection was conducted as part of the Department of Human Services' annual licensing inspections, including renewal and incident investigations, on October 4, 5, and 12, 2016.
Findings
Violations were found related to fire safety training and medical evaluation requirements. Plans of correction were submitted addressing these deficiencies with partial implementation progress noted.
Citations (2)
Regulation 65J requires direct care staff to be trained annually in fire safety by a qualified expert. A direct care staff member hired in 2014 did not have the required fire safety training for the 2015 training year.
Regulation 141b1 requires residents to have a medical evaluation at least annually. The last medical evaluation for Resident #1, admitted in 2015, was dated 9/14/15 and was overdue.
Report Facts
Number of Residents Served: 73
Number of Current Hospice Residents: 9
Number of Hospice Residents in past year: 15
Number of Residents 60 Years or Older: 73
Number of Residents with a Mobility Need: 19
Number of Residents with a Physical Disability: 1
Notice — December 1, 2020
Date: December 1, 2020
Visit Reason
The document serves as a license renewal notice and certificate of compliance for Weatherwood Manor Assisted Living Home. It informs the facility that the Department will conduct an onsite inspection 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.
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