Inspection Reports for
Divine Living Home
3828 COMLUMBIA AVENUE,, MOUNTVILLE, PA, 17554
Back to Facility Profile15 Reports
Inspection Report — Aug 10, 2026
Date: Aug 10, 2026
Visit Reason
The inspection was a licensing inspection conducted by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing, on 08/10/2026, with the reason noted as 'Fine'.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Residents Served: 29
Resident Support Staff: 0
Total Daily Staff: 29
Waking Staff: 22
Inspection Report — Jun 4, 2026
Complaint Investigation
Date: Jun 4, 2026
Visit Reason
The inspection was a partial, unannounced visit conducted due to a complaint and incident at the facility.
Complaint Details
The visit was complaint-related and involved allegations of resident abuse and behavioral issues. Protective services investigated and closed the case. The facility was required to update assessments and improve supervision.
Findings
The inspection found violations related to resident abuse and failure to update resident assessments to reflect behavioral changes. The facility submitted a plan of correction which was accepted and fully implemented.
Citations (2)
42b - Abuse: A resident punched another resident in the eye causing a bruised eye. Police were contacted and assault charges were requested. Protective services conducted an investigation which was later closed.
225c - Additional Assessment: Resident assessments did not reflect behavioral or cognitive needs despite staff reports of aggressive and impulsive behavior. Medication refusals and verbal insults toward other residents were documented but not addressed in assessments.
Report Facts
Residents Served: 31
Medication Refusals: 22
Notice — Apr 22, 2026
Date: Apr 22, 2026
Visit Reason
This document serves as a notice regarding an overdue fine payment assessed on April 22, 2026, for a Personal Care Home due to enforcement actions.
Findings
The notice informs the facility that a fine of $14,080 is more than 30 days past due and requests payment to the Commonwealth of Pennsylvania to avoid further license action or referral to the Attorney General.
Report Facts
Fine amount: 14080
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Theresa Hartman | Director | Signed the notice letter |
Notice — Jan 28, 2026
Date: Jan 28, 2026
Visit Reason
This document serves as a notice rescinding a previous letter and removing fines for certain violations, while also assessing fines for uncorrected regulatory violations at Divine Living Home.
Findings
The Department assessed fines for uncorrected violations under 55 Pa. Code Chapter 2600, specifically Section 181c, with a total fine amount of $3,040 for the period from January 10 to January 28, 2026. The fines will continue to accumulate until all violations are fully corrected and verified.
Report Facts
Fine amount: 3040
Fine per resident per day: 5
Fine per day: 160
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Theresa Hartman | Director | Signed the notice letter |
Inspection Report — Jan 28, 2026
Enforcement
Date: Jan 28, 2026
Visit Reason
The inspection was conducted as a provisional licensing inspection with a focus on compliance with 55 Pa. Code Chapter 2600 relating to Personal Care Homes, including follow-up on previous violations and enforcement actions.
Findings
The facility was found to have multiple violations including medication administration errors, sanitary condition issues, infestation, fire safety deficiencies, and staff qualification concerns. Several plans of correction were directed or accepted with specified completion dates. Enforcement actions including fines and provisional licensing were issued.
Citations (23)
2600.23a Activities of Daily Living Assistance: Resident medication self-administration support was inconsistent with assessments and support plans, with some residents not receiving indicated assistance.
2600.85a Sanitary Conditions: Inoperable toilet with fecal matter and black mold found in bathrooms near resident rooms.
2600.85b Infestation: Dead bedbug carcasses and live bedbugs observed in resident rooms and bathrooms.
2600.88a Surfaces: Ceiling paint bulging due to water damage in hallway bathroom near medication room.
2600.89a Hot Water Temperature: Hot water temperatures in multiple bathrooms exceeded 120°F, reaching up to 134°F.
2600.95 Furniture and Equipment: Broken chair grip on toilet in bathroom creating a hazard.
2600.101o Walls, Floors, Ceilings: Significant dust, debris, and food particles observed in resident bedrooms.
2600.132a Monthly Fire Drill: Fire drills had not been conducted for several months and alarm system was not activated during drills.
2600.132e Fire Drill Sleeping Hours: Last two sleeping hour fire drills were not conducted within required 6-month interval.
2600.161d Dietary Needs: Resident with special diabetic diet was not provided the prescribed diet.
2600.181c Self-administration Assessment: Resident assessed as unable to self-administer medications was observed self-administering improperly.
2600.181e Capable to Self Administer: Resident unable to correctly self-administer insulin and medication doses.
2600.182c Medication Administration: Staff failed to observe resident ingesting medication and proper documentation was incomplete.
2600.183b Medications and Syringes Locked: Multiple instances of unlocked, unattended medications accessible to residents.
2600.183e Storing Medications: Medications not labeled with date opened and expired medications stored in resident bedroom.
2600.187b Date/Time of Medication Administration: Medication administered to resident when resident was not present in the home.
2600.187d Follow Prescriber's Orders: Medication administration did not follow prescriber's tapering orders.
2600.227e Self Administer Medication: Resident support plan did not include plan to meet medication needs despite assessment indicating need.
2600.42q Compensation: Resident performing tasks on behalf of home without compensation in violation of labor laws.
2600.51 Criminal Background Check: Staff member began work before Pennsylvania State Police Criminal Background check was requested.
2600.54a Direct Care Staff: Staff member lacked required high school diploma, GED, or active nurse aide registry status.
2600.65f Training Topics: Staff member did not receive required training in personal care service needs for residents with mental illness or intellectual disability.
2600.65g Annual Training Content: Staff member did not receive required training in fire safety, emergency preparedness, falls and accident prevention.
Report Facts
Fine Per Resident Per Day: 3
Fine Per Resident Per Day: 5
Notice — Jan 9, 2026
Date: Jan 9, 2026
Visit Reason
The Department of Human Services issued a notice of intent to assess fines for uncorrected regulatory violations at Divine Living Home.
Findings
The facility was found to have uncorrected violations of 55 Pa. Code Chapter 2600, resulting in assessed fines based on a census of 32 residents.
Report Facts
Fine amount: 4864
Inspection Report — Nov 18, 2025
Complaint Investigation
Date: Nov 18, 2025
Visit Reason
The inspection was a partial, unannounced complaint investigation conducted due to complaints received, with an interim exit conference on 2025-11-19.
Complaint Details
The inspection was complaint-driven, triggered by allegations of abuse and medication errors. The complaint was substantiated with multiple violations found.
Findings
Multiple deficiencies were found including failure to immediately report suspected abuse, medication administration errors, inadequate staffing, sanitary and infestation issues, incomplete medical evaluations, and failure to follow prescriber's orders. Many corrective actions were directed but not implemented as of the follow-up date.
Citations (23)
2600.15a The home failed to immediately report suspected abuse of a resident following a verbal altercation on 10/12/25, with delayed submission of the mandatory abuse report until 10/15/25.
2600.16c The home did not report an incident involving a resident being pulled to the ground to the Department within 24 hours, reporting it late on 10/14/25.
2600.42b Resident #1 and #3 did not receive prescribed pain and diabetic medications timely, and Resident #1 suffered a fracture with delayed medication administration.
2600.57b Direct care staff hours were insufficient on multiple days in November 2025, providing fewer hours than required per resident census.
2600.57d Less than 75% of personal care service hours were provided during waking hours on 11/9/25 and 11/14/25.
2600.60a On 11/16/25 overnight shift lacked staff trained in Medication Administration, preventing medication services during that time.
2600.65f Two staff members hired in 2022 did not receive required training on infection control, safe management, and care for residents with mental illness during 2024.
2600.85a Sanitary conditions were not maintained with feces found on bathroom surfaces and mold in the basement freezer on 11/18 and 11/19/25.
2600.85b Evidence of bed bug infestation was found in residents' beds and bedding on 11/18 and 11/19/25.
2600.87 Exterior porch lights were inoperable on 11/18/25, compromising safe egress and lighting.
2600.88a Two electrical outlets in Resident #2’s bedroom lacked covers and a bathroom ceiling had a large hole, posing safety hazards.
2600.101j3 Resident #6’s bed lacked a pillowcase on one pillow on 11/19/25.
2600.101j7 Residents #2 and #7 did not have operable lamps or bedside lighting on 11/18/25.
2600.141a Resident #4’s initial medical evaluation did not include the medication regimen.
2600.141b1 Resident #8’s most recent medical evaluation was outdated, completed in 2024.
2600.181c Resident #3 was assessed as unable to self-administer medications despite self-administering insulin.
2600.185a Medications for Residents #1 and #3 were not available in the home as prescribed, including Hydrocodone and Ondansetron.
2600.187a Resident #4’s November 2025 Medication Administration Record lacked diagnosis or purpose for prescribed medications.
2600.187b Resident #4’s October 2025 and Resident #9’s November 2025 MARs lacked staff initials documenting medication administration.
2600.187c Refusals of medications by Residents #4 and #10 were not documented or reported to prescribers as required.
2600.187d Resident #3, #4, and #9 did not receive prescribed medications due to unavailability or missing orders from 9/1/25 through 11/18/25.
2600.190b Staff person without required diabetes education verbally directed Resident #11 to administer insulin with an incorrect dose.
2600.227e Resident #12’s support plan incorrectly stated the resident could not self-administer medications, but resident self-administers all medications.
Report Facts
Residents Served: 32
Direct Care Hours Provided: 30
Direct Care Hours Provided: 22
Direct Care Hours Provided: 21
Direct Care Hours Required: 31
Bed Bugs Found: 3
Inspection Report — Sep 3, 2025
Renewal
Date: Sep 3, 2025
Visit Reason
The inspection was a renewal licensing inspection conducted on September 3-4, 2025, to assess compliance with 55 Pa. Code Chapter 2600 for Personal Care Homes.
Findings
The facility was found to have multiple violations including failure to report incidents timely, inadequate financial record keeping, abuse incidents, insufficient direct care staffing hours, incomplete staff training, sanitary and infestation issues, safety hazards, medication administration errors, and incomplete resident assessments. A provisional license was issued with required plans of correction and fines pending if violations are not corrected.
Citations (35)
2600.16c The home failed to report an incident of a staff member threatening a resident to the Department within 24 hours.
2600.20b1 The home did not keep records of financial transactions for resident #3 including dates, deposits, withdrawals, and balances.
2600.20b8 Resident #3 did not receive quarterly itemized accounts of financial transactions made on their behalf.
2600.42b Resident #6 physically abused resident #7 by striking them in the face; police issued a citation for harassment.
2600.57b The facility failed to provide at least 1 hour per day of personal care services to each mobile resident on multiple days.
2600.57d Only 53% of required direct care service hours were provided during waking hours on multiple days.
2600.64c An administrator completed only 23.5 hours of required annual training in 2024, below the 24-hour requirement.
2600.65f Staff member B did not receive required training on medication self-administration and infection control in 2024.
2600.65g Staff member B did not receive required annual training on emergency preparedness, resident rights, and protective services in 2024.
2600.85a Sanitary conditions were not maintained; feces found on bathroom floor, toilet, resident bed, and laundry basket.
2600.85b Evidence of bedbug infestation found in residents #3 and #5 beds with live bedbugs and feces present.
2600.87 The interior overhead light by the 2nd floor west exit was not operable, impairing safe evacuation.
2600.88a Missing light switch covers exposing rusted metal and wires in common bathroom and hallway.
2600.89b Hot water temperature exceeded 120°F at bathroom sinks in the 2nd floor new wing hallway.
2600.92 The medication room door was propped open without a screen, allowing flies in medication room and kitchen.
2600.93a The left side descending handrail for the front porch stairs was missing.
2600.100a The exterior right ascending handrail to medication room entrance was missing the cover exposing nails.
2600.101j2 Bedroom 2 occupied by two residents had only one folding chair.
2600.101j3 Several residents' beds lacked pillowcases on pillows.
2600.101j7 Resident #12 lacked access to an operable lamp or lighting source at bedside due to obstruction.
2600.101o Large dark stains approximately 18” x 24” on carpet next to resident #8's bed.
2600.103f Refrigerator temperatures exceeded 40°F in dining room refrigerator on multiple occasions.
2600.123b Emergency procedures for local municipality were not posted in a conspicuous and public place.
2600.141b1 Resident medical evaluations were incomplete or missing required information including medication regimens and certifications.
2600.181c Residents #6 and #13 were assessed as unable to self-administer medications but were self-administering.
2600.183b Prescription and OTC medications and syringes were unlocked and accessible in resident #14's bedroom.
2600.183e Medications were not stored in an organized manner; loose pills found and insulin pen unlabeled with opening date.
2600.184b OTC medications and CAM belonging to resident #14 were not labeled with resident's name.
2600.187b Medication Administration Records for residents #3 and #13 lacked staff initials for multiple medication administrations.
2600.187c Resident #3 refused multiple prescribed medications which were not reported to the prescriber within 24 hours.
2600.187d Resident #13 was given Ibuprofen without physician orders to hold medication on multiple dates.
2600.190c Staff member C's training record lacked documentation of successful completion of medication administration training.
2600.221c The home did not have a current weekly activity calendar posted in a conspicuous and public place.
2600.224a Resident #14's preadmission screening form lacked a date of completion.
2600.225c Resident assessments were incomplete or outdated, missing diagnoses and not reflecting significant changes.
Report Facts
Fine Per Resident Per Day: 5
Fine Per Resident Per Day: 3
Fine Per Resident Per Day: 5
Inspection Report — Aug 27, 2024
Renewal
Date: Aug 27, 2024
Visit Reason
The inspection was conducted as a renewal, provisional inspection of Divine Living Home to assess compliance with applicable laws and regulations.
Findings
The inspection identified multiple deficiencies including expired licenses posted, boiler inspection overdue, abuse incident, staff training deficiencies, sanitary and safety issues, medication management problems, and documentation errors. Plans of correction were accepted and implemented with follow-up scheduled.
Citations (32)
The home did not have a current license and license inspection summary posted in a conspicuous and public place.
Gas boiler inspection was last done on 03/03/23 and certificate expired 01/30/24.
Resident #2 hit Resident #1 with a lamp causing injury and fear.
Staff Member C worked alone without First Aid and CPR certification during multiple shifts.
Administrator had only 8 hours of required annual training in 2023.
Staff Member B and Staff Member F did not receive required fire safety and emergency preparedness orientation.
Staff Member B and Staff Member F did not receive required 40 hours orientation on resident rights, emergency medical plan, abuse reporting, and incident reporting.
Direct Care Staff Member E received only 10 hours of required 12 hours annual training in 2023.
Staff Member E did not receive training on medication self-administration, dementia care, infection control, personal care needs, safe management, and mental illness care.
Floors, walls, ceilings, windows, doors and other surfaces were not clean or in good repair; bedbug feces and open drain hazard observed.
First aid kits lacked eye coverings.
Insufficient chairs in resident bedrooms.
Pillows had blood stains or missing pillowcases.
Residents #6 and #7 lacked operable lamps at bedside.
Bedroom ceiling showed water damage, brown staining, and exposed wires.
No emergency water supply for 30 residents; water agreement outdated and incomplete.
Written emergency procedures last updated and submitted in 2022.
Two unlocked plastic kerosene jugs stored near garage and smoking area.
Last fire safety inspection and drill by expert conducted 03/31/23.
Fire drills exceeded maximum evacuation time; no current maximum safe evacuation time established.
Fire drill during sleeping hours not held every 6 months as required.
Fire drills during sleeping hours routinely held with only one staff present, contrary to requirements.
Resident #8's medical evaluation not current; previous evaluation from 5/17/23.
Residents #1, #3, #8, and #9 self-administer medications without documented assessment by qualified medical professional.
Unlocked medication boxes found in resident rooms #7 and #9 with medications accessible.
Expired OTC medications found in resident room refrigerator.
Improper medication disposal methods used by staff.
Discrepancies between medication counts on medication cart and electronic narcotic sheets for multiple residents.
Medications not administered as prescribed to Resident #8; missed doses documented.
Resident #9's preadmission screening form incomplete regarding ability to meet resident needs.
Correction fluid used on Resident #1's medical evaluation form in critical sections.
Resident #3 and #8 records missing information on religion, hair color, and eye color.
Report Facts
Residents served: 30
Staffing hours: 30
Waking staff: 23
Residents served: 33
Staffing hours: 33
Waking staff: 25
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Juliet Marsala | Deputy Secretary | Signed correspondence regarding plan of correction implementation |
Inspection Report — Jun 27, 2024
Date: Jun 27, 2024
Visit Reason
The inspection was an unannounced partial licensing inspection conducted as an interim visit on 06/27/2024.
Findings
No regulatory citations or deficiencies were identified during this inspection.
Report Facts
Total Daily Staff: 30
Waking Staff: 23
Residents Receiving Supplemental Security Income: 19
Residents 60 Years of Age or Older: 22
Residents Diagnosed with Mental Illness: 16
Residents Diagnosed with Intellectual Disability: 4
Residents with Mobility Need: 0
Residents with Physical Disability: 0
Inspection Report — May 3, 2024
Complaint Investigation
Date: May 3, 2024
Visit Reason
The inspection was conducted as a complaint investigation with unannounced partial on-site and off-site reviews on 05/03/2024, 05/06/2024, and 05/08/2024 to assess compliance with state regulations and the submitted plan of correction.
Complaint Details
The inspection was complaint-driven, with the reason explicitly stated as 'Complaint' and a follow-up type of POC (Plan of Correction) Submission scheduled.
Findings
The inspection found multiple deficiencies including failure to provide adequate supervision for a resident, unauthorized audio/video monitoring, bedbug infestation with blood-stained bedding, incomplete resident medical evaluations, and overdue resident assessments. The facility submitted plans of correction which were determined to be fully implemented as of the last review.
Citations (6)
Failure to provide assistance with Instrumental Activities of Daily Living (IADLs) as indicated in the resident’s assessment, resulting in a resident frequently leaving the property unsupervised.
Unauthorized audio/video monitoring with cameras recording audio in the office, kitchen, and dining room areas, violating resident privacy rights.
Sanitary conditions compromised by a bedbug infestation causing blood-stained bedding and rusted electric baseboards with stained box springs in resident bedrooms.
Evidence of live bedbugs and infestation throughout the home including bathrooms and bedrooms, noted as a repeated violation.
Resident medical evaluations lacking required documentation of body positioning and movement stimulation, noted as a repeated violation.
Resident assessments not completed annually as required, with previous assessments overdue.
Report Facts
Residents Served: 32
Staffing Hours: 32
Waking Staff: 24
Residents Receiving Supplemental Security Income: 21
Residents Age 60 or Older: 21
Residents Diagnosed with Mental Illness: 18
Residents Diagnosed with Intellectual Disability: 4
Inspection Report — Oct 17, 2023
Enforcement
Date: Oct 17, 2023
Visit Reason
The inspection was conducted due to a renewal and complaint investigation of Divine Living Home on October 17-18, 2023 and February 8, 2024.
Complaint Details
The inspection included a complaint investigation component, with violations substantiated as detailed in the Licensing Inspection Summary.
Findings
Multiple violations were found including staffing shortages, infestation of bedbugs, improper medication administration and documentation, refrigeration temperature issues, combustible material accessibility, and incomplete resident assessments. The facility was issued a provisional license due to these violations and has submitted plans of correction.
Citations (12)
Staff Persons A and B had criminal background checks without completion dates, making it unclear if checks were timely.
Direct care staff hours were insufficient to meet the minimum required hours for residents on multiple dates.
Evidence of bedbug infestation found in multiple resident rooms including live bedbugs and feces.
Refrigerator and freezer temperatures exceeded required limits, with food stored above safe temperatures.
Combustible materials such as oxygen canisters were accessible to residents in unlocked rooms.
Resident medical evaluations were not completed within required timeframes or lacked required information.
Medications were not administered as prescribed, including missing documentation and unavailable medications.
Medication refusals were not properly documented or reported to prescribers within required timeframes.
Staff member lacked required medication administration training and worked shifts alone without medication administration capability.
Resident preadmission screening form was completed more than 30 days prior to admission.
Medication records documented administration of medications not available in the home.
Weekly menus were not posted in a conspicuous and public place as required.
Report Facts
Residents Served: 33
Residents Served: 32
Direct Care Staffing Hours Provided: 20
Direct Care Staffing Hours Provided: 18
Direct Care Staffing Hours Provided: 20
Direct Care Staffing Hours Provided: 24
Direct Care Staffing Hours Provided During Waking Hours: 11.5
Direct Care Staffing Hours Provided During Waking Hours: 19.5
Residents Served: 32
Inspection Report — Sep 15, 2022
Original Licensing
Date: Sep 15, 2022
Visit Reason
The inspection visits on July 19, 2022, and September 15, 2022, were conducted as part of the licensing process for Divine Living Home to ensure compliance with 55 Pa. Code Chapter 2600 for Personal Care Homes.
Findings
The facility was found to be in substantial compliance with applicable regulations during the licensing inspections. A re-inspection will be conducted within three months of the license effective date to verify continued compliance.
Inspection Report — Sep 15, 2022
Plan of Correction
Date: Sep 15, 2022
Visit Reason
The document reports on the Pennsylvania Department of Human Services, Bureau of Human Service Licensing review conducted on 09/15/2022 regarding the submitted plan of correction for Divine Living Home.
Findings
The submitted plan of correction was determined to be fully implemented and the facility is required to maintain continued compliance.
Document — August 5, 2026
Date: August 5, 2026
Visit Reason
This document is an invoice for assessment fees related to the licensing or regulation of Divine Living Home LLC.
Findings
The document contains billing information including invoice date, due date, license number, and total balance due. No inspection findings or regulatory compliance information is included.
Report Facts
Invoice Date: 8/5/2026
Due Date: 9/1/2026
Balance From Last Invoice: 13520
Payments Since Last Invoice: 560
Total Balance Due: 12960
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