29 Reports
Inspection Report — May 12, 2026
Complaint Investigation
Date: May 12, 2026
Visit Reason
The inspection was conducted as a complaint investigation to review compliance with licensing regulations at Evergreen Estates Retirement Community.
Complaint Details
The visit was complaint-related as indicated by the inspection information on page 2, with the reason explicitly stated as 'Complaint'.
Findings
The inspection identified multiple violations including improper storage and labeling of poisonous materials, unlocked hazardous chemicals accessible to residents, unsanitary conditions in resident rooms, and incomplete resident support plans. Plans of correction were directed and accepted with follow-up audits and education scheduled.
Citations (6)
82a Poisonous Materials: Nine spray bottles with unidentified substances were stored unlabeled in the housekeeping closet.
82c Locking Poisonous Materials: Several poisonous materials including Clorox toilet bowl cleaner and acid bowl cleaner were unlocked and accessible to residents.
85a Sanitary Conditions: Dark brown stains and strong urine odors were present in multiple resident rooms, with urine-filled urinals left hanging on a walker.
101o Walls, Floors, Ceilings: Large dark brown stains were observed on bedroom carpets of multiple residents.
227d Support Plan Medical/Dental: Resident's support plan was not updated to reflect the use of a Wonder Pole for transferring.
233c Key-Locking Devices: Directions for operating locking mechanisms were not conspicuously posted in the Secure Dementia Care Unit therapy area.
Report Facts
Residents Served: 96
Secured Dementia Care Unit Residents Served: 13
Hospice Current Residents: 6
Residents Age 60 or Older: 95
Residents with Mobility Need: 42
Inspection Report — Dec 9, 2025
Complaint Investigation
Date: Dec 9, 2025
Visit Reason
The inspection was conducted as a renewal, complaint, and incident investigation to assess compliance with 55 Pa. Code Chapter 2600 relating to Personal Care Homes.
Complaint Details
The inspection was complaint-related with substantiated violations found as detailed in the Licensing Inspection Summary.
Findings
Multiple violations were found including issues with resident confidentiality, compliance with laws, poisonous materials storage, sanitary conditions, hot water temperature, lighting, walls/floors/ceilings, medication administration, support plans, and fire safety training. Plans of correction were proposed with various completion dates.
Citations (28)
Resident confidentiality was violated by posting DNR status publicly and leaving resident records accessible without consent.
Carbon monoxide alarms were operable but batteries were not dated or missing in several locations.
Poisonous materials were stored in unlabeled containers and accessible to residents without proper locking.
Sanitary conditions were not maintained; blood sugar readings were not properly documented and trash dumpsters were left open.
Floors and ceilings had water damage and tripping hazards; hot water temperature exceeded 120°F in resident bathrooms.
Resident did not have access to operable bedside lighting.
Walls and ceilings in resident rooms were stained and damaged with light-colored swirls and cracked plaster.
Food was stored on the floor in the walk-in freezer and leftovers were unlabeled and undated in the refrigerator.
No thermometer was present in the mini refrigerator containing milk.
Lint accumulated in dryer vents and ducts were not cleaned regularly.
Furnaces were inspected but annual cleaning and servicing were not scheduled timely.
An unannounced fire drill was not held as required during the month of September 2025.
Fire drill records were incomplete and did not include all required details or times.
Resident medical evaluations were incomplete or missing required documentation.
Home failed to maintain current vehicle safety inspection certification for a transport van.
Medication and syringes were not locked; nursing office door was left open allowing access to medications.
Blood sugar readings were not stored properly and medications were not administered as prescribed.
Resident support plans and assessments were incomplete or not completed within required timeframes.
Resident records contained white-out corrections and were not legible or properly signed.
Medication storage procedures were not followed; blood sugar readings were inaccurately documented.
Prescriber’s orders were not followed; medications were not administered as prescribed at specified times.
Resident support plans were not signed by residents or assessors as required.
Criminal background checks were not obtained timely for new staff members.
Staff did not receive required training in medication self-administration, fire safety, and resident rights.
Sanitary conditions were compromised by mold on ceilings and holes in acoustic ceiling tiles.
Walls, floors, and ceilings in resident rooms were damaged by water leaks and not properly repaired.
Medication labels did not include prescribed dosage and administration instructions.
Medication administration records lacked initials of staff administering medications at required times.
Report Facts
Residents Served: 82
Residents Served in Dementia Unit: 13
Current Residents Hospice: 8
Fine Per Resident Per Day: 3
Calculated Fine Per Day: 267
Residents Served: 86
Residents Served: 89
Total Daily Staff: 122
Total Daily Staff: 123
Total Daily Staff: 126
Inspection Report — Mar 25, 2025
Follow-Up
Date: Mar 25, 2025
Visit Reason
The inspection visit was a follow-up to verify the implementation of a previously submitted plan of correction related to an incident involving a resident ingesting poisonous materials.
Findings
The facility was found to have fully implemented the submitted plan of correction, including removal of hazardous items from the resident's room, conducting room audits, and preparing a new medical evaluation for the resident after a change in medical condition.
Citations (2)
Poisonous materials were not kept locked and inaccessible to residents, as a full unopened bottle of Scope mouthwash and other hazardous items were found in a resident's room despite the resident no longer being capable of safely using poisons.
A new medical evaluation was not completed after the resident's medical condition changed following the ingestion incident.
Report Facts
Residents Served: 89
Residents Served in Dementia Care Unit: 11
Current Hospice Residents: 6
Residents Age 60 or Older: 84
Residents Diagnosed with Mental Illness: 1
Residents Diagnosed with Intellectual Disability: 1
Residents with Mobility Need: 45
Residents with Physical Disability: 6
Total Daily Staff: 134
Waking Staff: 101
Inspection Report — Jan 28, 2025
Complaint Investigation
Date: Jan 28, 2025
Visit Reason
The inspection was conducted as a complaint and interim review to assess compliance with regulatory requirements.
Complaint Details
The inspection was complaint-driven and interim in nature, with the submitted plan of correction fully implemented as of 01/28/2025.
Findings
Multiple deficiencies were identified related to medication storage and administration, documentation of medication refusals, following prescriber's orders, and resident assessments. The facility submitted plans of correction which were determined to be fully implemented by the follow-up date.
Citations (5)
Medications and syringes were found unlocked, unattended, and accessible in a resident's room contrary to regulations requiring locked storage.
Failure to properly document and report blood glucose readings and discrepancies between glucometer readings and Medication Administration Records.
Refusals of prescribed medications were not documented or reported to the prescriber as required.
Medications were not administered as prescribed due to unavailability in the home, including repeated violations.
Resident's initial assessment did not include necessary information regarding the use and safety of a bedside mobility device (enabler bar).
Report Facts
Residents Served: 95
Secured Dementia Care Unit Residents Served: 14
Hospice Current Residents: 4
Residents Age 60 or Older: 93
Residents with Mobility Need: 27
Residents Diagnosed with Mental Illness: 1
Residents Diagnosed with Intellectual Disability: 1
Residents with Physical Disability: 5
Inspection Report — May 21, 2024
Complaint Investigation
Date: May 21, 2024
Visit Reason
The inspection was conducted as a complaint investigation and incident review at Evergreen Estates Retirement Community on 05/21/2024.
Complaint Details
The visit was complaint-related as indicated by the reason for inspection and the investigation of a choking incident involving Resident 1.
Findings
The inspection identified multiple deficiencies including neglect related to a resident choking incident due to missing dentures and delayed diet order, incomplete medical evaluations missing dietary needs, failure to meet residents' special dietary needs with proper physician orders, improper self-administration of medications by a resident assessed as incapable, and failure to follow prescriber's medication orders for two residents.
Citations (5)
Resident 1's upper denture went missing and the home did not assist in securing health care, resulting in a choking incident; delayed obtaining a new diet order until the department's investigation.
Resident 2's medical evaluation did not include special health or dietary needs.
Resident 1 was placed on a pureed diet per family request without a physician's order until later.
Resident 2 self-administers medications but was assessed as incapable to do so by a qualified practitioner.
Resident 1 and Resident 2 were not administered prescribed medications on specified dates.
Report Facts
Residents Served: 91
Secured Dementia Care Unit Residents Served: 11
Hospice Current Residents: 10
Residents Diagnosed with Mental Illness: 3
Residents Diagnosed with Intellectual Disability: 1
Residents with Mobility Need: 34
Residents with Physical Disability: 3
Inspection Report — Feb 6, 2024
Complaint Investigation
Date: Feb 6, 2024
Visit Reason
The inspection was conducted as a complaint investigation with an unannounced partial inspection on 02/06/2024.
Complaint Details
The inspection was triggered by a complaint and conducted as a partial unannounced visit on 02/06/2024. The submitted plan of correction was fully implemented.
Findings
The inspection found multiple violations related to food storage and kitchen cleanliness, including stains and mold in the kitchen, food stored on the floor, unsealed food containers, and improper thawing of food. A plan of correction was submitted and fully implemented by 03/29/2024.
Citations (4)
Kitchen had multiple stains on the floor with dirt and grime, mold on the wall above the dishwashing station, and food items improperly stored under shelving units.
Box of frozen bakery rolls and frozen orange juice concentrate stored on the floor in the walk-in freezer.
Opened and unsealed 12 ounce can of beef paste and other open food items in refrigerators.
Frozen food was sometimes left out on the counter to air thaw for extended periods instead of approved thawing methods.
Report Facts
Residents Served: 89
Memory Care Residents Served: 11
Current Hospice Residents: 7
Residents 60 Years or Older: 84
Residents Diagnosed with Mental Illness: 1
Residents with Mobility Need: 35
Resident Support Staff: 124
Waking Staff: 93
Inspection Report — Nov 7, 2023
Follow-Up
Date: Nov 7, 2023
Visit Reason
The inspection was conducted as a follow-up to verify the implementation of a previously submitted plan of correction, as well as for renewal, complaint, and incident reasons.
Findings
The facility was found to have multiple deficiencies including failure to report suspected resident abuse properly, incomplete incident reports, inadequate quality management plan content, resident abuse incidents, insufficient CPR/first aid trained staff, incomplete staff training records, unsafe resident personal equipment, unsanitary conditions, obstructed egress routes, combustible materials accessible to residents, overdue furnace inspection and cleaning, incomplete fire drill records, smoking policy violations, incomplete menu postings, unsecured medications, expired medications, medication labeling and administration errors, and incomplete resident support plans. All deficiencies had plans of correction accepted and were implemented by December 2023.
Citations (24)
Failure to complete Act 13 form for suspected resident abuse.
Incident reports not submitted for missed prescribed blood sugar tests.
Quality management plan did not address required elements including incident reporting and complaint procedures.
Resident abuse incident resulting in injury and hospitalization.
Insufficient number of staff trained in CPR and first aid on multiple dates.
Incomplete staff training records for fire safety and emergency preparedness.
Resident enabler bars not securely attached, posing entrapment risk.
Overwhelming smell of incontinence and incontinence stains in secured dementia care unit.
Trash dumpster lids left open, allowing potential insect and rodent infestation.
Torn carpet in resident bedroom posing tripping hazard.
Exit doors and egress routes blocked by furniture and trash cans.
Combustible materials accessible to residents in resident bedroom.
Furnace inspection overdue since May 2022.
Furnace cleaning overdue.
Fire drill records incomplete, missing resident counts and other required details.
Smoking observed outside community room in prohibited area.
Menus not posted for current and following weeks in November.
Prescription medications and syringes found unlocked and unattended in resident rooms.
Expired PRN medication found in medication cart.
Medication label did not reflect changed dosage order.
Resident medication checks did not match documentation on Medication Administration Record (MAR).
Controlled substance balance incorrectly documented in controlled substance log.
Failure to follow prescriber's orders for medication administration.
Resident support plans did not document need for leg brace and enabler bar.
Report Facts
Residents Served: 89
Residents in Secured Dementia Care Unit: 13
Resident Support Staff: 0
Total Daily Staff: 118
Waking Staff: 89
Residents Age 60 or Older: 83
Residents with Mobility Need: 29
Inspection Report — Aug 17, 2023
Complaint Investigation
Date: Aug 17, 2023
Visit Reason
The inspection was conducted as a complaint investigation to review compliance with regulations and verify the submitted plan of correction.
Complaint Details
The inspection was complaint-related as indicated by the reason 'Complaint' and was conducted unannounced on 08/17/2023.
Findings
The inspection identified multiple deficiencies including lack of proper smoking area signage, sanitary condition issues such as urine odor in a resident's room, uncovered trash receptacles in the kitchen, use of plastic utensils in the memory care unit, inadequate smoking area maintenance, expired and improperly stored medications, unlabeled OTC medications, medication count discrepancies, failure to report significant resident condition changes, and missing posted directions for key-locking devices in the secure dementia care unit. All deficiencies had plans of correction accepted and were implemented by 09/25/2023.
Citations (12)
No sign at the main entrance stating 'Smoking is Permitted in Designated Smoking Areas Only' and no signs stating 'Smoking Permitted' at the designated smoking area on the patio.
Strong odor of urine in Resident 1's bedroom and adjacent hallway.
Two full and uncovered rectangular trash cans in the kitchen.
Large dark stain in the carpet of Resident 2's bedroom.
Plastic utensils and Styrofoam cups regularly used in the P Hall.
Single smoking tower present with ashes on patio and wall where no receptacle was available.
Expired prescription medication found in the P Hall medication cart.
Resident 4 had medication tablets removed from original blister and taped into another blister instead of being destroyed.
OTC medication bottles in P Hall and West Hall medication carts were not labeled with resident names.
Discrepancies in medication count sheets for Resident 5 who no longer resides in the home.
Resident 6 had feces on the floor indicating a significant change in condition not previously assessed.
Directions for operating the home's locking mechanism not conspicuously posted near exit door closest to room P 111 in the Secure Dementia Care Unit.
Report Facts
Residents Served: 87
Residents Served in Secured Dementia Care Unit: 12
Current Hospice Residents: 6
Residents Age 60 or Older: 82
Residents with Mobility Need: 41
Residents with Physical Disability: 3
Total Daily Staff: 128
Waking Staff: 96
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kim Jackson | LPN Director of Resident Care | Provided remedial training related to medication storage, resident change of status reporting, and medication procedures. |
Inspection Report — Dec 12, 2022
Complaint Investigation
Date: Dec 12, 2022
Visit Reason
The inspection was a partial, unannounced visit conducted due to a complaint and interim review on 12/12/2022.
Complaint Details
The inspection was complaint-related and interim in nature, triggered by concerns leading to a partial unannounced visit on 12/12/2022.
Findings
Multiple deficiencies were identified related to incomplete or missing medical evaluations, improper medication storage and administration, failure to report medication refusals timely, incomplete preadmission screening, and inadequate resident support plans including fall prevention. Plans of correction were accepted and implemented by late January 2023.
Citations (11)
Medical evaluation for Resident #5 did not indicate the date the resident was evaluated.
Medical evaluation for Resident #3 was incomplete, missing body positioning/movement, health status, cognitive functioning, and medical professional's name.
Resident #4, #8, and #9 had missing or incomplete annual medical evaluations.
Medication Administration Records (MAR) for Residents #3, #4, and #10 showed blood glucose readings without corresponding glucometer readings.
Resident #10 refused medication doses which were not reported to the prescriber within 24 hours.
Resident #10 was prescribed a medication that was not administered due to unavailability in the home.
Resident #2’s preadmission screening form did not include a determination that the resident's needs could be met by the home.
Resident #4’s most recent additional assessment was incomplete or missing.
Resident #5 had repeated falls with injuries but the support plan did not address fall prevention or additional needs.
Support plans for Residents #5, #6, #7, and #9 were not signed by the assessor or resident as required.
Resident #1’s written cognitive preadmission screening for the Secure Dementia Care Unit was completed after admission.
Report Facts
Residents Served: 78
Secured Dementia Care Unit Residents Served: 8
Hospice Current Residents: 5
Residents Age 60 or Older: 74
Residents with Mobility Need: 28
Residents with Physical Disability: 1
Documented Falls for Resident #5: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Resident Care | Involved in reviewing medical evaluations, medication error remediation, and reporting medication errors and refusals at Quality Assurance meetings. | |
| Resident Care Coordinator | Involved in reviewing medical evaluations, medication error remediation, and reporting medication refusals. | |
| Administrator | Responsible for reviewing DME's, preadmission screening forms, support plans, and placing reminder signs; also disciplined staff and oversaw corrective actions. | |
| Med Tech | Disciplined and remediated for errors in blood glucose readings and medication refusals. | |
| Y Ramos | Former LPN | Support plans submitted by this individual were noted; terminated for cause. |
Inspection Report — Jun 9, 2022
Date: Jun 9, 2022
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
Memory Lane Residents Served: 10
Current Hospice Residents: 7
Residents Age 60 or Older: 78
Residents with Mental Illness: 1
Residents with Intellectual Disability: 0
Residents with Mobility Need: 18
Residents with Physical Disability: 1
Total Daily Staff: 99
Waking Staff: 74
Inspection Report — May 19, 2022
Renewal
Date: May 19, 2022
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 — Sep 14, 2021
Renewal
Date: Sep 14, 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 — Aug 20, 2021
Follow-Up
Date: Aug 20, 2021
Visit Reason
The inspection visit on 08/20/2021 was a follow-up to verify the implementation of a previously submitted plan of correction for the Evergreen Estates Retirement Community.
Findings
The submitted plan of correction was determined to be fully implemented, with continued compliance required. The report details deficiencies related to annual medical evaluations and additional assessments for residents, which have been addressed by the Director of Nursing through a tickler file system to maintain compliance.
Citations (2)
The most recent medical evaluations for Resident 1 and Resident 2 were not completed annually as required.
The most recent additional assessments for Resident 1 and Resident 2 were not completed annually as required.
Report Facts
Residents Served: 62
Residents Served in Dementia Unit: 7
Hospice Residents: 1
Resident Mobility Need: 7
Total Daily Staff: 69
Waking Staff: 52
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Responsible for reviewing residents' annual medical evaluations and assessments, updating the tickler file, and ensuring ongoing compliance |
Notice — Feb 5, 2021
Date: Feb 5, 2021
Visit Reason
The document serves as a renewal notification and issuance of a regular license for Evergreen Estates Retirement Community to operate as a Personal Care Home, pursuant to a renewal application submitted on November 20, 2020.
Findings
The Department has approved the renewal application and issued a regular license. It advises that an onsite annual inspection will be conducted within the next twelve months to ensure compliance with applicable regulations.
Report Facts
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary, Office of Long-term Living | Signed the renewal notification letter. |
Inspection Report — Oct 13, 2020
Renewal
Date: Oct 13, 2020
Visit Reason
The inspection was conducted as a licensing inspection by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing for Evergreen Estates Retirement Community.
Findings
No regulatory citations were identified as a result of the inspection conducted on 10/13/2020 and 10/14/2020.
Inspection Report — Aug 17, 2020
Follow-Up
Date: Aug 17, 2020
Visit Reason
The visit was a partial inspection conducted as a follow-up to verify the implementation of a previously submitted plan of correction related to an incident.
Findings
The facility was found to have fully implemented the submitted plan of correction addressing assistance with activities of daily living for Resident #1, who had multiple falls due to lack of supervision. Continued compliance and safety precautions were emphasized.
Citations (1)
23a - Activities of Daily Living Assistance: Resident #1's assessment required supervision during ambulation, but assistance was not provided, resulting in more than 10 falls between 7/21/20 and 8/9/20 with injuries including bruises and head lumps.
Report Facts
Residents served: 71
Residents in Dementia Care Unit: 6
Hospice residents: 2
Residents aged 60 or older: 68
Residents with mobility need: 10
Residents with physical disability: 5
Residents diagnosed with mental illness: 5
Inspection Report — Mar 3, 2020
Renewal
Date: Mar 3, 2020
Visit Reason
The inspection was conducted as a licensing inspection for Evergreen Estates Retirement Community to determine compliance with 55 Pa. Code Chapter 2600 relating to Personal Care Homes and to approve a revised license for a Secured Dementia Care Unit addition.
Findings
The facility was found to be in compliance with applicable regulations. A revised license was approved to add a Secured Dementia Care Unit with a capacity of 13, while maintaining the overall facility capacity at 125.
Report Facts
Notice — Nov 27, 2019
Date: Nov 27, 2019
Visit Reason
This document serves as a renewal notification and license issuance for Evergreen Estates Retirement Community to operate as a Personal Care Home, with a reminder of the requirement for an annual onsite inspection within the next twelve months.
Findings
No inspection findings are reported in this document. It confirms the issuance of a regular license following the renewal application.
Report Facts
Inspection Report — Oct 28, 2019
Complaint Investigation
Date: Oct 28, 2019
Visit Reason
The inspection was conducted as a complaint and incident investigation following licensing inspections on October 28, 2019 and November 12, 2019 at Evergreen Estates Retirement Community.
Complaint Details
The inspection was complaint-related with allegations of abuse involving multiple residents. The Department found incidents of physical abuse, neglect, and failure to report incidents timely. The facility disputed the abuse allegations and submitted a plan of correction. The Department revoked the regular license and issued a provisional license based on the violations.
Findings
The Department found violations related to resident abuse, neglect, and failure to report incidents timely, resulting in revocation of the regular license and issuance of a first provisional license. The facility submitted a plan of correction which was initially accepted but later revised by the Department. The Department alleges incidents of abuse and noncompliance with reporting requirements.
Citations (7)
2600.15a - Staff witnessed excessive physical force used on Resident 1 and failed to report the incident timely to the local Area Agency on Aging as required.
2600.16c - Staff failed to report the incident involving Resident 1 to the Department within 24 hours as required by regulation.
2600.23a - Resident 2 threatened self-harm and staff failed to provide adequate supervision and timely emergency response.
2600.42b - Resident 4 was neglected and left unattended outside his room, leading to his death; staff failed to provide necessary supervision and timely intervention.
2600.42b - Staff used excessive physical force on Resident 3 and failed to prevent emotional distress following the incident.
2600.42b - Staff used excessive physical force on Resident 1 and failed to prevent emotional distress following the incident.
2600.183b - Medication cart was found unlocked and unattended in the first floor hallway, violating medication security regulations.
Report Facts
Residents Served: 81
Current Residents Hospice: 2
Residents Age 60 or Older: 80
Residents with Physical Disability: 3
Residents with Mobility Need: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Charity Cruz | Executive Director | Named as administrator and signer of plans of correction related to abuse and incident reports |
Inspection Report — Oct 28, 2019
Complaint Investigation
Date: Oct 28, 2019
Visit Reason
The inspection was conducted as a complaint investigation and incident review following allegations of resident abuse and failure to report incidents timely at Evergreen Estates Retirement Community.
Complaint Details
The inspection was triggered by complaints and incidents involving alleged resident abuse and failure to report. The allegations were substantiated based on witness statements and investigation findings.
Findings
The investigation found multiple incidents of resident abuse including staff using excessive physical force and failure to report incidents to the administration and Department within required timeframes. Additional violations included failure to lock medication carts and inadequate supervision of residents at risk of elopement.
Citations (5)
2600.15a - Staff Person A yelled at Resident 1 and used excessive physical force to move the resident's legs against her will. The incident was not reported timely to the administration or local agency as required.
2600.16c - The incident involving Staff Person A's abuse of Resident 1 was not reported to the Department within 24 hours as required by law.
2600.23a - Resident 2's assessment plan directed staff to call 911 immediately if self-harm was threatened, but staff delayed calling until the resident had already harmed herself.
2600.42b - Multiple abuse incidents were documented including Resident 4 eloping and Resident 3 being forcibly grabbed and yelled at by staff, causing emotional distress.
2600.183b - On 11/12/19, an unlocked and unattended medication cart was observed in the first floor hallway, violating medication security regulations.
Report Facts
Resident Support Staff: 81
Total Daily Staff: 163
Waking Staff: 122
Residents Served: 81
Current Hospice Residents: 2
Residents Age 60 or Older: 80
Residents with Physical Disability: 3
Residents with Mobility Need: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Charity Cruz | Executive Director | Signed multiple plans of correction and was involved in oversight of corrective actions |
Inspection Report — Sep 26, 2019
Complaint Investigation
Date: Sep 26, 2019
Visit Reason
The inspection was conducted as a partial, unannounced visit due to an incident at Evergreen Estates Retirement Community on September 26, 2019.
Complaint Details
The visit was triggered by an incident complaint involving medication errors for Resident 1. The medication error was substantiated as described in the findings.
Findings
Two violations related to medication administration were found involving Resident 1. One violation involved a medication not listed on the resident's medication record, and the other involved a medication error where the wrong eye drops were administered.
Citations (2)
2600.187.a: Resident 1 is prescribed Carbamide Perox 6.5% ear drops, but this medication is not listed on the resident's medication administration record.
2600.187.d: Resident 1 was prescribed eye drops to be given four times daily, but a medication error occurred when Carbamide Perox 6.5% ear drops were administered into the resident's eye instead of the prescribed eye drops.
Report Facts
Residents Served: 87
Total Daily Staff: 91
Waking Staff: 68
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Charity Cruz | Executive Director | Signed plan of correction related to medication violations |
| Jason McCloskey | Department representative on-site during inspection |
Inspection Report — Mar 19, 2019
Annual Inspection
Date: Mar 19, 2019
Visit Reason
The inspection was conducted as an annual licensing inspection with renewal and incident triggers on March 19 and 20, 2019.
Findings
A violation was found related to unlocked medications in residents' rooms. The facility was required to correct the medication storage issue and maintain compliance with 55 Pa.Code Chapter 2600.
Citations (1)
Regulation 55 Pa.Code §2600.183(b) requires prescription medications, OTC medications, CAM, and syringes to be kept locked. Medications were found unlocked in residents' bedrooms, including a bottle of Anbesol Maximum Strength and Orajel Maximum Strength.
Report Facts
Number of Residents Served: 90
Number of Current Hospice Residents: 3
Number of Hospice Residents in past year: 25
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Charity Cruz | Administrator | Named as administrator of the facility |
Notice — Jan 4, 2019
Date: Jan 4, 2019
Visit Reason
This document serves as a renewal notification and license issuance for Evergreen Estates Retirement Community to operate as a Personal Care Home under Pennsylvania regulations.
Findings
The Department of Human Services has approved the renewal application and issued a regular license valid from March 1, 2019, to March 1, 2020. The Department will conduct an onsite annual inspection within the next twelve months to ensure compliance.
Report Facts
Inspection Report — Mar 27, 2018
Annual Inspection
Date: Mar 27, 2018
Visit Reason
The inspection was an annual licensing inspection conducted on March 27, 2018, March 28, 2018, and May 2, 2018, at Evergreen Estates Retirement Community to assess compliance with 55 Pa.Code Chapter 2600 relating to Personal Care Homes.
Findings
Multiple violations related to medication administration, sanitary conditions, resident assessments, and proper use of glucometers were found. Plans of correction were submitted and partially implemented with adequate progress noted as of May 30, 2018.
Citations (5)
55 Pa.Code 2600.18(c) - The home failed to report a medication error involving Resident #4 not receiving a prescribed mid-day blood sugar test and failure to notify the Department.
55 Pa.Code 2600.85(a) - Sanitary conditions were not maintained when staff used Resident #1's glucometer to test Resident #2's blood sugar and vice versa.
55 Pa.Code 2600.185(a) - The home did not implement safe procedures for the use of glucometers, resulting in Resident #4 not performing a mid-day blood sugar check while out of the facility.
55 Pa.Code 2600.187(c) - The home failed to document and report Resident #1's refusal to take prescribed insulin doses to the prescriber within 24 hours.
55 Pa.Code 2600.225(c) - Resident #3 lacked completed assessments for agitation and psychiatric hospitalization, and the home failed to complete a reassessment addressing these behaviors.
Report Facts
Number of Residents Served: 93
Number of Current Hospice Residents: 5
Number of Hospice Residents in past year: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Charity Cruz | Executive Director | Signed plans of correction and legal entity representative |
Notice — Nov 14, 2017
Date: Nov 14, 2017
Visit Reason
The document serves as a renewal notification and license issuance for Evergreen Estates Retirement Community to operate as a Personal Care Home.
Findings
The Department confirms receipt of the renewal application and states that an onsite annual inspection will be conducted within the next twelve months. Enforcement actions will be taken if noncompliance is found during the inspection.
Report Facts
Inspection Report — Jun 20, 2017
Routine
Date: Jun 20, 2017
Visit Reason
The Department of Human Services conducted an unannounced licensing inspection on June 20, 2017, at Evergreen Estates Retirement Community to assess compliance with 55 Pa.Code Chapter 2600 related to Personal Care Homes.
Findings
Violations were found related to medication administration, resident assessments, and reporting requirements. The facility submitted a plan of correction with partial implementation status noted as of July 14, 2017.
Citations (3)
2600.16(c) - The home failed to report a medication incident to the Department within 24 hours as required. Resident did not receive prescribed Combigan eye drops on 6-14-17 and 6-15-17 due to medication not arriving from the pharmacy.
2600.187(d) - The home did not follow the directions of the prescriber when resident did not receive Combigan eye drops as ordered on 6-14-17 and 6-15-17 because medication was unavailable.
2600.225(c) - The resident did not have properly documented assessments for bladder and bowel management and personal hygiene. The current assessment did not properly document the resident's need for assistance.
Report Facts
Number of Current Hospice Residents: 3
Number of Hospice Residents in Past Year: 16
Residents Age 60 or Older: 93
Residents with Mobility Need: 3
Residents with Physical Disability: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Charity Cruz | Executive Director | Signed plan of correction and legal entity representative |
| Jason McCloskey | Department representative on-site during inspection | |
| Brett Swanger | Human Services Licensing Supervisor | Signed cover letter for inspection report |
Inspection Report — Apr 10, 2017
Annual Inspection
Date: Apr 10, 2017
Visit Reason
The inspection was conducted as part of the annual licensing inspections on April 10 and April 11, 2017, including renewal and complaint investigation.
Complaint Details
The inspection included a complaint investigation as indicated by the reason for inspection: Renewal, Complaint.
Findings
Violations were found related to staffing certification in first aid and CPR, and food refrigeration temperature control. Plans of correction were submitted and partially implemented as of the report date.
Citations (2)
Regulation 55 Pa.Code §2600 63(a) requires at least one staff person trained and certified in first aid and CPR for every 50 residents. On 3/31/2017, only one staff person was certified in first aid and CPR despite more than 50 residents being present.
Regulation 55 Pa.Code §2600 103(f) requires food requiring refrigeration to be stored at or below 40°F and frozen food at or below 0°F. On 4/11/17 at 3:00 pm, the walk-in freezer temperature was 25 degrees Fahrenheit.
Report Facts
Number of Residents Served: 96
Number of Current Hospice Residents: 4
Number of Hospice Residents in past year: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Charity Cruz | Administrator | Named as administrator and signed plan of correction. |
| Denise Gillespie | Department representative conducting inspection. | |
| Cybil Bomberger | Department representative conducting inspection. |
Notice — Nov 14, 2016
Date: Nov 14, 2016
Visit Reason
This document serves as a renewal notification and license issuance for Evergreen Estates Retirement Community to operate as a Personal Care Home. It informs the facility that an annual onsite inspection will be conducted within the next twelve months as required by state regulations.
Findings
No inspection findings are reported in this document. It is a license renewal notice confirming the issuance of a regular license and outlining the requirement for a future annual inspection.
Report Facts
Inspection Report — Apr 14, 2016
Annual Inspection
Date: Apr 14, 2016
Visit Reason
The document reports the results of the Department of Human Services' annual licensing inspections conducted on April 14, 15, and 19, 2016, for Evergreen Estates Retirement Community.
Findings
The facility was found to be in compliance with 55 Pa.Code Chapter 2600 relating to Personal Care Homes during the annual licensing inspections.
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