Inspection Reports for
Faith Friendship Villa of Mountville
128 WEST MAIN STREET,, MOUNTVILLE, PA, 17554
Back to Facility Profile27 Reports
Inspection Report — May 5, 2026
Renewal
Date: May 5, 2026
Visit Reason
The inspection was a renewal visit conducted by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing, to review compliance and verify the submitted plan of correction for the facility.
Findings
The inspection identified multiple deficiencies including lack of required annual staff training, inadequate emergency lighting, missing emergency telephone numbers in resident rooms, obstructed egress in a resident room, combustible materials accessible to residents, presence of a prohibited portable space heater, delayed annual fire safety inspection and drill, and medication record and storage issues. Plans of correction were accepted and implemented with ongoing monitoring and audits scheduled.
Citations (10)
65f - Training topics: Staff Member A and Staff Member B did not have infection control training for calendar year 2025.
65g - Annual training content: Staff Member A did not have training in falls and accident prevention for calendar year 2025.
87 - Lighting: The exterior emergency exit on the east side of the home lacked adequate illumination on 5/5/26.
91 - Telephone numbers: Emergency telephone numbers for the nearest hospital and fire department were missing on or by the telephone in resident room #112b.
121a - Unobstructed egress: Resident room #206 was obstructed by personal belongings, preventing the bedroom door from fully opening and allowing only a 14-inch pathway.
125b - Combustible restrictions: A partially full red five-gallon gasoline can was unlocked, unattended, and accessible to residents near the maintenance shed on 5/4/26.
127a - Portable space heaters: An electric portable space heater was located on the 3rd floor of the home on 5/5/26.
132b - Safety inspection/fire drill: The required annual fire safety inspection and supervised fire drill were not completed within the required timeframe.
181f - Record of medication: Resident #1's record did not include a current list of medications on 5/5/26.
183b - Meds and syringes locked: Resident #2’s Lisinopril medication was unlocked and accessible, and Resident #1’s medication lock box was unlocked and unattended on 5/5/26.
Report Facts
Residents served: 58
Staff total daily: 58
Staff waking: 44
Residents diagnosed with mental illness: 47
Residents receiving Supplemental Security Income: 42
Residents age 60 or older: 33
Residents diagnosed with intellectual disability: 12
Residents with physical disability: 2
Inspection Report — Feb 20, 2026
Date: Feb 20, 2026
Visit Reason
The inspection was an unannounced partial licensing inspection conducted as an interim review by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing.
Findings
No regulatory citations or deficiencies were identified during this inspection.
Notice — Aug 1, 2025
Date: Aug 1, 2025
Visit Reason
The document serves as a response to a facility's request for a waiver of Pennsylvania Code § 2600.190(b) to allow unlicensed direct care staff to administer subcutaneous injections of GLP-1 agonist medications.
Findings
The waiver outlines specific training and competency requirements for direct care staff administering GLP-1 agonist injections, including completion of approved courses, in-person training, annual training hours, and facility policies for monitoring and clinical contact availability.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Theresa Hartman | Bureau Director, Human Services Licensing | Signed the waiver approval letter. |
Inspection Report — May 20, 2025
Complaint Investigation
Date: May 20, 2025
Visit Reason
The inspection was conducted as a complaint investigation to review compliance and verify the submitted plan of correction for the facility.
Complaint Details
The visit was complaint-related. The complaint involved behavioral misconduct by a resident including bullying, foul language, and name calling. The resident had multiple verbal and written warnings, but the resident's assessment did not reflect these issues until updated during the plan of correction process. The complaint was substantiated by these findings.
Findings
The submitted plan of correction was found to be fully implemented, with the facility demonstrating compliance. A specific deficiency involved failure to update resident assessments to reflect behavioral issues, which was corrected by the administrator and staff.
Citations (1)
Failure to update resident assessment to reflect significant behavioral changes including bullying and aggression.
Report Facts
Residents Served: 60
Total Daily Staff: 62
Waking Staff: 47
Residents Receiving Supplemental Security Income: 43
Residents Diagnosed with Mental Illness: 42
Residents Aged 60 or Older: 39
Residents Diagnosed with Intellectual Disability: 12
Residents with Mobility Need: 2
Residents with Physical Disability: 2
Inspection Report — Mar 19, 2025
Follow-Up
Date: Mar 19, 2025
Visit Reason
The inspection was a partial, unannounced follow-up visit triggered by a complaint and incident to review the submitted plan of correction and verify compliance.
Complaint Details
The visit was complaint-related, involving substantiated incidents of resident-to-resident physical and verbal abuse, including threats and physical assault. The facility was directed to implement corrective actions and ongoing monitoring.
Findings
The facility was found to have fully implemented the submitted plan of correction related to resident abuse and aggression incidents. Staff were trained on incident and abuse reporting, and ongoing monitoring plans were established to ensure resident safety.
Citations (1)
Resident exhibited physical and verbal aggression resulting in fear among other residents, including cursing, starting fights, yelling threats, and physical assault leading to arrest.
Report Facts
Total Daily Staff: 62
Waking Staff: 47
Residents Served: 62
Residents Receiving Supplemental Security Income: 51
Residents Age 60 or Older: 40
Residents Diagnosed with Mental Illness: 49
Residents Diagnosed with Intellectual Disability: 16
Residents with Physical Disability: 2
Residents with Mobility Need: 0
Inspection Report — Nov 5, 2024
Complaint Investigation
Date: Nov 5, 2024
Visit Reason
The inspection was conducted as a partial, unannounced visit due to a complaint and incident at the facility.
Complaint Details
The inspection was complaint-related and incident-related; no deficiencies or citations were substantiated.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Total Daily Staff: 62
Waking Staff: 47
Residents Served: 62
Residents Receiving Supplemental Security Income: 45
Residents Aged 60 or Older: 15
Residents Diagnosed with Mental Illness: 50
Residents Diagnosed with Intellectual Disability: 15
Residents with Physical Disability: 2
Residents with Mobility Need: 0
Current Hospice Residents: 0
Inspection Report — Apr 16, 2024
Date: Apr 16, 2024
Visit Reason
The inspection was a licensing inspection conducted by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing on 04/16/2024.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Total Daily Staff: 64
Waking Staff: 48
Residents Served: 64
Residents Receiving Supplemental Security Income: 50
Residents 60 Years of Age or Older: 43
Residents Diagnosed with Mental Illness: 51
Residents Diagnosed with Intellectual Disability: 16
Residents with Mobility Need: 0
Residents with Physical Disability: 0
Current Hospice Residents: 0
Inspection Report — Feb 14, 2024
Renewal
Date: Feb 14, 2024
Visit Reason
The inspection was a renewal, provisional licensing review conducted by the Pennsylvania Department of Human Services to verify compliance with regulatory requirements and the submitted plan of correction.
Findings
The facility had multiple deficiencies related to incident reporting, abuse, resident equipment, cleanliness, furniture and equipment maintenance, medical evaluations, smoking area safety, medication self-administration assessments, medication storage, following prescriber's orders, and record storage. All deficiencies were addressed with directed plans of correction and were implemented by April 16, 2024. A follow-up inspection on April 16, 2024 found no regulatory citations.
Citations (11)
2600.16c - The home failed to report incidents to the Department within 24 hours, including a medication administration error and a verbal abuse allegation.
2600.42b - Resident #3 verbally abused Resident #2 over a long period; the home failed to prevent or timely address the abuse.
2600.81b - A mobility device on Resident #4's bed was unsecured and hazardous.
2600.88a - The refrigerator in the recreation room was soiled with liquid stains.
2600.95 - Faucet in shower/bathroom near room 107 was covered with calcium deposits and not in good repair.
2600.141a - Resident #5's medical evaluation lacked height, weight, pulse rate, and temperature information.
2600.144c1 - Approximately 20 cigarette butts were observed on the ground in and around the designated smoking area.
2600.181c - Residents #6 and #7 self-administer medications without a documented assessment by a qualified practitioner.
2600.185a - Medications prescribed for Residents #4 and #8 were not available in the home.
2600.187d - Resident #1 received medication at the wrong time; Resident #9 missed evening medication doses.
2600.254c - Resident privacy coding form was publicly posted with the License Inspection Summary.
Report Facts
Residents Served: 63
Residents Served: 64
Cigarette Butts: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff Member B | Named in medication administration error and subsequent removal from medication administration. | |
| Administrator | Involved in issuing house rule violation, directing plans of correction, and overseeing compliance. | |
| Care Manager | Involved in communication with physicians, resident assessments, and follow-up on medication and abuse issues. | |
| LPN | Conducted audits, retraining, and communication with physicians regarding medication and assessments. |
Inspection Report — Nov 21, 2023
Follow-Up
Date: Nov 21, 2023
Visit Reason
The inspection was a partial, unannounced follow-up visit conducted on 11/21/2023 to review the facility's plan of correction related to previous deficiencies and to ensure continued compliance.
Findings
The facility had multiple repeated violations including insufficient direct care staffing hours, heat source safety issues, infestation of dead fruit flies, building maintenance deficiencies, evacuation drill times exceeding safe limits, incomplete resident medical evaluations, and medication records lacking diagnosis for PRN medications. The submitted plan of correction was determined to be fully implemented as of the follow-up date.
Citations (8)
Direct care staff hours were below required levels on multiple dates.
Heat sources such as hot water radiator protective screens exceeded safe temperatures.
Thousands of dead fruit flies were found scattered throughout the basement including food storage areas.
Ceiling tiles, plastic light covers, and drywall were missing in basement areas exposing wires and beams; holes in ceiling and cracked floorboards in attic; broken emergency push bar on front door.
Evacuation drill times exceeded the safe evacuation time of 3 minutes and 30 seconds due to resident non-compliance with evacuation protocol.
Resident medical evaluations lacked required information including medical diagnosis, allergies, special health or dietary needs, body positioning/movement, and immunization history.
Resident annual medical evaluations were not completed timely.
Medication administration records for some residents did not indicate a purpose or diagnosis for PRN laxative medications.
Report Facts
Residents Served: 66
Total Daily Staff: 67
Waking Staff: 50
Evacuation Time: 244
Evacuation Time: 231
Inspection Report — Feb 15, 2023
Enforcement
Date: Feb 15, 2023
Visit Reason
The inspection was conducted due to renewal, complaint, and incident reasons, including multiple on-site visits from February 15-16 and February 22-23, 2023.
Complaint Details
The inspection included complaint investigations related to resident abuse incidents involving unwanted sexual behaviors between residents and verbal abuse by staff. Some incidents were not reported timely to the Department or designated persons. Investigations substantiated abuse allegations leading to staff termination.
Findings
The inspection found multiple violations including failure to report resident abuse, inadequate notification of abuse, incomplete medical evaluations, medication procedure deficiencies, staffing shortages, safety hazards such as non-functional carbon monoxide detectors, fire safety violations, and improper food storage temperatures. The facility was issued a provisional license with fines pending correction of violations.
Citations (19)
Failure to immediately report suspected resident abuse involving unwanted sexual behaviors between residents.
Failure to notify resident and designated person of suspected abuse.
Failure to submit written incident report within 24 hours for abuse incident.
Non-functional carbon monoxide detector in basement boiler room.
Commingling of resident funds and home funds in one non-interest bearing account.
Multiple instances of resident abuse by staff and residents, including sexual abuse and verbal abuse.
Direct care staff hours less than required for mobile residents.
Waking hours of personal care service less than required.
Interior of covered front porch ceiling exposed due to missing plank; hole in fire escape stairwell ceiling with mold.
Hot water temperatures exceeded 120°F in multiple bathrooms.
Freezer temperatures above required levels; missing thermometers in refrigerators.
Lint present in lint trap of clothes dryer, not cleaned as required.
Insufficient 3-day supply of nonperishable food and drinking water for residents.
No fire extinguisher present on 3rd floor attic.
Failure to conduct monthly fire drill in December 2022.
No recommended maximum safe evacuation time designated in writing by a fire safety expert within the past year.
Failure to conduct fire drill during sleeping hours once every 6 months.
Incomplete medical evaluations missing dates, pulse rate, temperature, and late annual evaluations.
Medication records missing diagnosis or purpose for medications.
Report Facts
Fine amount: 345
Fine amount: 207
Direct care hours provided: 66
Required direct care hours: 68
Waking hours provided: 50.5
Required waking hours: 51
Hot water temperature: 146.9
Hot water temperature: 125.8
Hot water temperature: 123.7
Freezer temperature: 10
Freezer temperature: 7.5
Emergency water supply: 29.71
Inspection Report — Feb 15, 2023
Renewal
Date: Feb 15, 2023
Visit Reason
The inspection was conducted as a renewal, complaint, and incident investigation of the Faith Friendship Villa of Mountville personal care home.
Complaint Details
The inspection included complaint and incident investigations related to alleged resident abuse, including sexual abuse by a staff member and resident-to-resident incidents. The abuse allegations were substantiated and resulted in staff termination and corrective actions.
Findings
The inspection found multiple violations including failure to report suspected resident abuse, inadequate personal care staffing hours, environmental hazards, medication procedure deficiencies, and fire safety noncompliance. The facility was issued a provisional license with mandated correction dates and fines pending compliance.
Citations (21)
2600.15a The home failed to immediately report suspected abuse involving Resident 4's unwanted sexual behavior towards Resident 6.
2600.15d The home did not notify Resident 6’s designated person of the suspected abuse report.
2600.16c The home failed to report the incident involving Resident 4 to the Department and AAA within 24 hours.
2600.18 The carbon monoxide detector in the basement boiler room was inoperable when tested.
2600.20b5 Resident funds were commingled in a non-interest bearing account under the facility's name.
2600.42b Staff member D sexually abused multiple residents over several years; additional verbal abuse incidents were substantiated.
2600.57b On 2/5/2023, direct care staff hours provided (66) were insufficient for 68 residents, violating minimum personal care hour requirements.
2600.57d The required waking hours of personal care (51) were not met; only 50.5 hours were provided on 2/5/2023.
2600.88a The front porch ceiling had a missing plank and the fire escape stairwell ceiling had a hole with mold-covered plywood.
2600.89b Hot water temperatures exceeded 120°F in multiple resident bathrooms.
2600.103f Freezer temperatures exceeded required limits and some refrigerators lacked thermometers.
2600.105g Lint was present in the lint trap of the 2nd floor dryer, posing a fire hazard.
2600.107c The facility did not maintain a 3-day supply of emergency drinking water for residents.
2600.131a The 3rd floor attic lacked a fire extinguisher.
2600.132a No fire drill was conducted in December 2022 as required.
2600.132d The facility lacked a current written fire safety expert evacuation time; multiple fire drills exceeded 2.5 minutes.
2600.132e No fire drill was conducted during sleeping hours within the past 6 months.
2600.141a Resident medical evaluations lacked required data such as evaluation date, pulse rate, and temperature.
2600.141b1 Resident annual medical evaluations were overdue, including Resident 3’s evaluation by over 30 days.
2600.185b Medication procedures lacked a system to account for missing controlled substances, specifically Ativan for Resident 3.
2600.187a Medication records for multiple residents lacked diagnosis or purpose for prescribed medications.
Report Facts
Residents served: 69
Fines calculated: 345
Fines calculated: 207
Direct care hours provided: 66
Waking care hours provided: 50.5
Hot water temperature: 146.9
Hot water temperature: 125.8
Hot water temperature: 123.7
Freezer temperature: 10
Freezer temperature: 7.5
Emergency water supply: 29.71
Inspection Report — Aug 22, 2022
Complaint Investigation
Date: Aug 22, 2022
Visit Reason
The inspection was conducted as a complaint and incident investigation following allegations of resident abuse and related incidents at Faith Friendship Villa of Mountville.
Complaint Details
The complaint investigation was triggered by allegations of abuse involving Staff Member A and Staff Member B toward residents. The abuse involving Staff Member B was substantiated by the state, resulting in termination. The facility disputed the substantiation due to lack of access to investigation details and inability to interview the alleged victim. The Department of Human Services used different criteria than law enforcement and found the abuse highly likely based on consistent and credible resident interviews.
Findings
The investigation found multiple violations related to failure to report suspected abuse timely, failure to implement supervision or suspension of staff involved in alleged abuse, failure to notify designated persons of abuse reports, and substantiated abuse by a staff member leading to termination. Additional deficiencies included incomplete medical evaluations and resident assessments. The facility implemented a plan of correction including staff training, increased supervision, and improved documentation.
Citations (6)
Failure to complete and submit Act 13 Mandatory Abuse form within 48 hours of alleged abuse incident.
Failure to develop or implement a plan of supervision or suspend staff person involved in alleged abuse.
Failure to immediately notify resident's designated person of suspected abuse report.
Substantiated abuse by Staff Member B toward Resident 2.
Resident 1's medical evaluation missing multiple required sections and no annual evaluation completed since 10/26/2020.
Resident 1's last Resident Assessment-Support Plan was completed on 12/29/2020, overdue for annual assessment.
Report Facts
Residents Served: 68
Staffing Hours - Total Daily Staff: 68
Staffing Hours - Waking Staff: 51
Residents Diagnosed with Mental Illness: 50
Residents Aged 60 or Older: 41
Residents Diagnosed with Intellectual Disability: 14
Residents with Physical Disability: 1
Current Hospice Residents: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Laura Smith | Administrator | Named in relation to medical evaluation deficiencies and staff training on abuse reporting. |
| Staff Member B | Named as the staff member involved in substantiated abuse leading to suspension and termination. | |
| Staff Member A | Named as staff member involved in alleged abuse for which supervision plan was not initially implemented. |
Inspection Report — Mar 8, 2022
Renewal
Date: Mar 8, 2022
Visit Reason
The inspection was conducted as a renewal licensing inspection of Faith Friendship Villa of Mountville on 03/08/2022 and 03/09/2022.
Findings
The inspection found multiple deficiencies including insufficient direct care staffing hours, fire safety inspection and drill overdue, roof leaks causing water damage, missing grab bars in bathrooms, fire evacuation times exceeding limits, smoking area hazards, incomplete medication records, and self-administration assessment issues. Plans of correction were accepted or directed with specified completion dates.
Citations (11)
Direct care staff hours were below the required minimum for residents on multiple days.
Insufficient direct care service hours during waking hours on multiple days.
Roof leak causing water damage, warped and rotted wood at stairway emergency exit.
No grab bar, hand rail or assist bar at toilets in bathrooms next to certain rooms.
Fire safety inspection and fire drill last conducted on 10/19/2020, overdue for annual completion.
No maximum safe evacuation time specified in writing by a fire safety expert; evacuation times exceeded 2 minutes 30 seconds on multiple drills.
Numerous cigarette butts found on wooden porch floor in designated smoking area, creating a fire hazard.
Resident #1 self-administers medications without assessment by physician or certified nurse practitioner.
Glucometer readings for Resident #2 and #3 were missing, incorrect, or not recorded properly on medication administration records.
Resident #2 prescribed medication not listed on medication administration record.
Menu for the week following 3/6 - 3/12/22 was not posted as required.
Report Facts
Residents present: 69
Direct care hours required: 69
Direct care hours provided: 64
Direct care hours required: 65
Direct care hours provided: 57.5
Direct care hours required during waking hours: 51.75
Direct care hours provided during waking hours: 50
Direct care hours required during waking hours: 48.75
Direct care hours provided during waking hours: 43.5
Evacuation time: 168
Evacuation time: 194
Evacuation time: 182
Notice — Jan 20, 2021
Date: Jan 20, 2021
Visit Reason
The document serves as a renewal notification and license issuance for Faith Friendship Villa of Mountville, a Personal Care Home, following receipt of the renewal application dated October 30, 2020.
Findings
The Department issued a regular license in response to the renewal application and advised that an onsite 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 | Signed the renewal notification letter. |
Inspection Report — Jul 13, 2020
Complaint Investigation
Date: Jul 13, 2020
Visit Reason
The inspection was conducted as a complaint investigation with unannounced partial inspections on 07/13/2020, 07/14/2020, and 07/15/2020 to review compliance and follow up on a plan of correction.
Complaint Details
The visit was complaint-related and included substantiation of an abuse allegation where the home failed to report the incident to the county agency as required.
Findings
The submitted plan of correction was determined to be fully implemented. Deficiencies included failure to report suspected resident abuse, incomplete medical evaluations, and overdue resident assessments, all of which had corrective plans accepted and implemented.
Citations (3)
The home failed to immediately report suspected abuse when Resident #1 touched Resident #2 inappropriately, and the incident was not reported to the county area agency on aging.
Resident #2's medical evaluation dated 1/16/2020 did not include the resident's ability to self-administer medications.
Resident #1’s most recent additional assessment was not completed annually, with the last assessment dated 4/19/2019.
Report Facts
Residents Served: 72
Staff Count: 74
Waking Staff: 56
Residents Receiving Supplemental Security Income: 52
Residents Age 60 or Older: 42
Residents Diagnosed with Mental Illness: 55
Residents Diagnosed with Intellectual Disability: 7
Residents with Mobility Need: 2
Residents with Physical Disability: 1
Inspection Report — Jul 1, 2020
Complaint Investigation
Date: Jul 1, 2020
Visit Reason
The inspection was conducted as a complaint investigation with a partial, unannounced review on 07/01/2020 and 07/06/2020 to assess compliance and plan of correction implementation.
Complaint Details
The inspection was complaint-driven and the submitted plan of correction was reviewed and accepted, confirming full implementation and continued compliance.
Findings
The submitted plan of correction was determined to be fully implemented and compliance was maintained. A deficiency was noted regarding incomplete resident initial assessments, which was corrected and verified through follow-up reviews.
Citations (1)
225a - A resident's initial assessment did not include all diagnoses such as Schizo-effective disorder, Narcolepsy, Chronic Motor Tic Disorder, Asperger's Syndrome, Hypertension, and Allergies. Staff corrected the assessment and were retrained on documentation procedures.
Report Facts
Residents Served: 72
Resident Support Staff: 0
Total Daily Staff: 74
Waking Staff: 56
Number of Residents Who Receive Supplemental Security Income: 52
Number of Residents Who Are 60 Years of Age or Older: 42
Number of Residents Diagnosed with Mental Illness: 55
Number of Residents Diagnosed with Intellectual Disability: 7
Number of Residents Who Have Mobility Need: 2
Number of Residents Who Have Physical Disability: 1
Inspection Report — Apr 15, 2020
Routine
Date: Apr 15, 2020
Visit Reason
The Department’s Bureau of Human Services Licensing Representative conducted a routine inspection of Faith Friendship Villa of Mountville on April 15 and 16, 2020.
Findings
No regulatory citations with 55 Pa. Code Ch. 2600 related to Personal Care Homes were identified as a result of this inspection.
Notice — Oct 29, 2019
Date: Oct 29, 2019
Visit Reason
The document serves as a renewal notification for the Personal Care Home license of Faith Friendship Villa of Mountville, confirming receipt of the renewal application and outlining the requirement for an annual onsite inspection within the next twelve months.
Findings
No inspection findings are reported in this document. It is a license renewal notice with no deficiencies or compliance issues mentioned.
Inspection Report — Oct 25, 2019
Renewal
Date: Oct 25, 2019
Visit Reason
The inspection was a renewal inspection conducted as an unannounced full review of Faith Friendship Villa of Mountville.
Findings
The inspection identified multiple violations including failure to post current license summaries, improper placement of a carbon monoxide detector, unsanitary conditions, inoperable lighting, damaged furniture, fire safety diagram issues, medication storage and recordkeeping problems, and deficiencies in evacuation procedures and assessments. Plans of correction were implemented for all findings.
Citations (22)
2600.3.c The facility did not post the most recent license inspection summaries in a conspicuous and public place.
2600.18 The carbon monoxide detector was installed too close to the boiler, violating proximity requirements.
2600.85.a Sanitary conditions were compromised by a staff member improperly administering medication and strong odors from a turtle tank and bathroom.
2600.87 Lighting was inadequate with multiple non-functioning lights in hallways, stairs, porches, and fire escape areas.
2600.88.a Floors, walls, ceilings, and furniture surfaces were damaged or soiled, including exposed insulation, peeling paint, and missing floor tile.
2600.95 Furniture and equipment were in poor repair with large upholstery tears and exposed foam on chairs and sofas.
2600.100.b The home failed to remove snow, ice, and obstructions from exterior walkways and ramps, causing hazards.
2600.101.j The mattress and box spring in resident #5's bedroom were torn and exposed springs and foam.
2600.103.e Food storage areas contained unlabeled and undated food items including vacuum sealed packages and canned goods.
2600.121.a A recliner chair obstructed the second floor fire escape exit, creating an egress hazard.
2600.123.c The emergency evacuation diagram did not include exits for the new section and was not properly oriented.
2600.132.c Fire drill records did not include evacuation routes used or full documentation of drills conducted.
2600.132.d Residents did not meet evacuation time requirements on some fire drills and failed to evacuate to designated meeting places.
2600.141.a Resident medical evaluations were missing key information and were not completed timely for some residents.
2600.141.b1 Annual medical evaluations were overdue for some residents and not completed as required.
2600.144.c Smoking areas contained cigarette butts and dead leaves creating fire hazards; signage and education were insufficient.
2600.183.e Medication storage was unsafe with taped packets and risk of medications falling out.
2600.183.f Discontinued medications were discarded improperly and medication disposal was not logged.
2600.185.a Procedures for safe storage and disposal of medications were not properly implemented or documented.
2600.187.a Medication records lacked diagnosis or purpose for some medications and were missing documentation.
2600.224.a Preadmission screening forms were incomplete or missing determinations of resident needs.
2600.225.c Additional assessments were not completed within the allotted time frames for some residents.
Report Facts
Residents Served: 70
Resident Support Staff: 0
Total Daily Staff: 70
Waking Staff: 53
Residents with Supplemental Security Income: 53
Residents Age 60 or Older: 38
Residents Diagnosed with Mental Illness: 52
Residents Diagnosed with Intellectual Disability: 14
Residents with Physical Disability: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Charis Gramm | Administrator | Named in multiple findings and plans of correction signatures |
Inspection Report — Sep 3, 2019
Complaint Investigation
Date: Sep 3, 2019
Visit Reason
The inspection was a partial, unannounced visit conducted due to an incident.
Complaint Details
The inspection was triggered by an incident complaint. Specific substantiation status is not stated.
Findings
Violations of 55 Pa.Code Ch. 2600 related to Personal Care Homes were found, including failure to update a resident's assessment after a significant change in condition. A plan of correction was submitted to address staff education and review of resident discharge information.
Citations (1)
225c - Additional Assessment: The most recent assessment of Resident 1, dated 1/15/2019, was not updated to include the identified needs of regular wound care after a surgery on 8/9/2019. This significant change was not addressed in the resident's current assessment and support plan.
Report Facts
Residents Served: 73
Current Residents in Hospice: 1
Residents Receiving Supplemental Security Income: 48
Residents Diagnosed with Mental Illness: 52
Residents Age 60 or Older: 39
Residents Diagnosed with Intellectual Disability: 14
Residents with Physical Disability: 1
Notice — Jul 17, 2019
Date: Jul 17, 2019
Visit Reason
This document is a response to a request for a waiver of qualifications for direct care staff persons under Pennsylvania Code 55 Pa.Code Ch. 2600.
Findings
The Department of Human Services determined that the individual meets the minimum educational requirements for a direct staff worker and therefore the waiver is not needed.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jill Kachmar | Regulatory Implementation Manager | Signed the waiver approval letter. |
Inspection Report — Jan 15, 2019
Renewal
Date: Jan 15, 2019
Visit Reason
The inspection was conducted as part of the Department's Bureau of Human Services Licensing annual licensing inspection on January 15 and 16, 2019, for renewal of the facility license.
Findings
The inspection found violations related to posting of the influenza awareness poster, availability of soap in bathrooms, and incomplete medical evaluation documentation for residents. Plans of correction were submitted and approved for all violations.
Citations (3)
55 Pa.Code §2600.18: The influenza poster was not posted in a public and conspicuous place as required by the Influenza Awareness Act of 2016.
55 Pa.Code §2600.102(i): A dispenser with soap was not provided within reach of each bathroom sink; bar soap was found in one restroom and no soap in another.
55 Pa.Code §2600.141(a)(2): Medical evaluation forms for two residents lacked documentation of immunization history, allergies, body positioning/movement, and cognitive functioning.
Report Facts
Number of Residents Served: 71
Total Daily Staff: 71
Waking Staff: 53
Residents Receiving Supplemental Security Income: 53
Residents Age 60 or Older: 41
Residents with Mental Illness: 55
Residents with Intellectual Disability: 18
Residents with Physical Disability: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Gwendolyn F. Didden | Executive Director | Named as legal entity representative and signed plan of correction |
| Michael Showers | Department representative conducting inspection | |
| Jason McCloskey | Department representative conducting inspection |
Notice — Oct 25, 2018
Date: Oct 25, 2018
Visit Reason
The document serves as a renewal approval for the Personal Care Home license and informs the facility of the requirement for an annual onsite inspection within the next twelve months.
Findings
No inspection findings are reported in this document. It confirms the issuance of a regular license following the renewal application.
Inspection Report — Jan 9, 2018
Annual Inspection
Date: Jan 9, 2018
Visit Reason
The Department of Human Services conducted an annual licensing inspection of Faith Friendship Villa of Mountville on January 9 and 10, 2018 to assess compliance with 55 Pa.Code Ch. 2600 relating to Personal Care Homes.
Findings
The facility was found to be in compliance with the applicable regulations during the annual licensing inspection.
Notice — Oct 31, 2017
Date: Oct 31, 2017
Visit Reason
This document serves as a renewal notification for the Personal Care Home license of Faith Friendship Villa of Mountville and includes the certificate of compliance.
Findings
The Department has received the renewal application and is issuing a regular license. The Department will conduct an annual onsite inspection within the next twelve months as required by regulation.
Inspection Report — Jan 12, 2017
Annual Inspection
Date: Jan 12, 2017
Visit Reason
The inspection was conducted as part of the Department of Human Services' annual licensing inspections for the facility.
Findings
The facility was found to be in compliance with 55 Pa.Code Ch. 2600 relating to Personal Care Homes during the inspection conducted on January 12 and 13, 2017.
Notice — Oct 27, 2016
Date: Oct 27, 2016
Visit Reason
The document is a renewal license approval and notification letter for Faith Friendship Villa of Mountville, confirming receipt of the renewal application and advising of the requirement for an annual onsite inspection within the next twelve months.
Findings
No inspection findings are reported in this document; it serves as a license renewal confirmation and notification of future inspection requirements.
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