22 Reports
Inspection Report — Jun 23, 2026
Renewal
Date: Jun 23, 2026
Visit Reason
The inspection was an unannounced full renewal inspection conducted to review compliance and verify the submitted plan of correction.
Findings
The facility was found to have multiple deficiencies related to incident reporting, record confidentiality, medication administration, medication storage, labeling, and staff training. The submitted plan of correction was accepted and fully implemented by the inspection date.
Citations (17)
16c - The home did not submit an incident report within 24 hours after flooding caused four residents to relocate.
17 - Resident files and narcotic record book were left unlocked and accessible in the 2nd floor medication room.
85a - Staff Person A did not wash or sanitize hands before administering medications to two residents.
105g - Approximately 1/2 inch lint accumulation was found in the lint trap of the 2nd floor laundry room dryer.
181c - Resident 3 self-administers medication without a required assessment by a medical professional.
181f - Resident 4 had incorrect strength Acetaminophen (500 mg) in their room, not matching the prescribed 325 mg.
182c - Staff person A failed to verify medications and documentation during Resident 5's medication administration, and staff person C's documentation was signed off by staff person A.
183b - Unlocked medications and medication cart were found unattended in multiple locations including resident rooms and medication rooms.
183c - An unlocked medication refrigerator contained insulin and other items while the medication tech left the area open.
183d - Resident 5 had unauthorized Systane eyedrops and an unlabeled bottle of Advil was found in medication carts.
183e - Resident 6's Lorazepam blister pack was damaged with punctured foil and taped spots.
184a - Resident 7's insulin medication containers lacked required pharmacy labels and had incomplete handwritten notes.
184b - OTC medications (Tums and Advil) were not labeled with resident names in medication carts.
187a - Resident 3's medication administration record lacked diagnosis or purpose for a prescribed cream.
187d - Multiple residents received medications late, not in accordance with prescriber orders and scheduled times.
190a - Staff person B and Staff person D had incomplete or outdated medication administration training and certification documentation.
190c - Staff person D's training record lacked required documentation elements; Staff person E's file lacked initial user report.
Report Facts
Residents served: 57
Staff count: 70
Waking staff count: 53
Hospice residents: 2
Residents aged 60 or older: 57
Residents with mobility need: 13
Residents diagnosed with mental illness: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff Person A | Named in findings related to hand hygiene and medication administration errors | |
| Staff Person B | Named in findings related to incomplete medication administration training and certification | |
| Staff Person C | Named in medication administration documentation error | |
| Staff Person D | Named in findings related to incomplete medication administration training and certification | |
| Staff Person E | Named in findings related to missing medication administration certification documentation | |
| Executive Director | Involved in corrective actions, education, and oversight of deficiencies | |
| Director of Resident Services | Involved in corrective actions, education, audits, and medication management | |
| Director of People and Operations | Involved in weekly management meetings to review audits |
Inspection Report — Apr 8, 2026
Renewal
Date: Apr 8, 2026
Visit Reason
The inspection was conducted as a renewal visit to review compliance with licensing requirements and verify the implementation of a previously submitted plan of correction.
Findings
The inspection identified multiple deficiencies related to sanitary conditions, medication administration, record keeping, and safety hazards. All deficiencies were addressed with corrective actions and staff re-education, and the plan of correction was fully implemented.
Citations (23)
85a Sanitary conditions were not maintained; decaying flower petals and sticky liquid were found in medication cart and kitchenette areas.
88a Surfaces including ceilings had peeling paint and drywall debris accumulating on stairs posing hazards.
91 Emergency telephone numbers were missing on or by the telephone in Resident 2's room.
100a Exterior fire exit stairs had a bottom step collapse, creating a hazard.
103f Refrigerators and freezers lacked required thermometers to monitor temperature.
181f Resident 3 had medications in their room not documented on their current medication list.
182c Medication administration was improper; medications were left unattended on Resident 4's nightstand.
183b Medications and syringes were not locked in residents' rooms for Residents 2, 4, and 5 who are not assessed as self-administering.
183d Medications without physician orders were found in Resident 4's room; Resident 5 had discontinued medications in pill pack.
183e Medications were stored improperly; torn pill pouch and punctured blister packs with medications still present were found.
183f Medications were improperly disposed of in a biohazard sharps container, not an approved method.
184a Medication labels did not match current physician orders for Resident 1's Ipratropium-Albuterol.
184b OTC medication Fish Oil was not labeled with a resident's name.
185a Medications were missing from medication cart; glucometer readings were inaccurately documented; medication wasting was not witnessed by two staff.
186c Verbal medication order was taken by unlicensed staff without written order obtained within 48 hours.
187a Medication record for Resident 4 lacked frequency, diagnosis, or purpose for Hibiclens medication.
187b Medication administration time and initials were documented for Hibiclens not actually administered.
187d Prescriber orders were not followed; missed notifications for insulin dosing and blood glucose monitoring.
190a Staff member administered medications without current certification and missed annual practicum.
191 Residents 1, 3, 7, and 8 were not educated on their right to refuse medication if they believed an error may occur.
225c Resident 1's assessment was not signed by the assessor.
251b Resident 5's narcotic inventory log had illegible entries due to overwritten numbers.
252 Resident files for Residents 1, 9, and 10 lacked a current photograph taken within the last two years.
Report Facts
Residents Served: 52
Current Hospice Residents: 3
Residents 60 Years or Older: 48
Residents with Mobility Need: 12
Residents Diagnosed with Mental Illness: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff Member A | Named in medication administration certification lapse finding | |
| Staff Person C | Named in medication administration and verbal order violations | |
| Director of Resident Services | Named in multiple findings related to medication management, record reviews, and corrective actions | |
| Executive Director | Named in staff education and policy revision related to medication administration and compliance | |
| Director of Housekeeping | Named in findings related to sanitary conditions and emergency telephone postings | |
| Director of Plant Operations | Named in findings related to fire exit stairway repair and safety audits | |
| Maintenance Technician | Named in findings related to repairs and cleaning of facility surfaces and fire exit stairs |
Inspection Report — Nov 6, 2025
Follow-Up
Date: Nov 6, 2025
Visit Reason
The inspection was a partial, unannounced follow-up visit triggered by a complaint and incident to verify the implementation of a previously submitted plan of correction.
Complaint Details
The inspection was complaint-related and incident-driven. The plan of correction was fully implemented and compliance was confirmed.
Findings
The facility was found to have fully implemented the submitted plan of correction. The inspection confirmed compliance with requirements related to resident-home contracts and criminal background checks.
Citations (2)
25a - Written Contract and Review: A resident admitted did not have a resident-home contract completed within 24 hours of admission. The facility implemented a standardized admission checklist to ensure contracts are completed and reviewed timely.
51 - Criminal Background Check: Two staff members were hired without timely completion of criminal background checks prior to employment. The facility revised hiring procedures to ensure all required checks are completed before staff start dates.
Report Facts
Residents Served: 48
Current Residents in Hospice: 8
Residents Age 60 or Older: 48
Residents with Mental Illness: 1
Residents with Mobility Need: 12
Notice — Mar 26, 2025
Date: Mar 26, 2025
Visit Reason
This document serves as a waiver approval for Harrison Senior Living Center of Coatesville to allow an administrator to serve while enrolled in the required 100-hour Personal Care Home Administrator training course.
Findings
The waiver is granted with conditions including enrollment and successful completion of the training and competency test by specified dates, and documentation of training to be maintained by the facility.
Report Facts
Training course duration: 100
Training course scheduled dates: February 10, 2025 through April 17, 2025
Orientation scheduled date: April 25, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Theresa Hartman | Bureau Director, Human Services Licensing | Signed the waiver approval letter |
Inspection Report — Mar 24, 2025
Renewal
Date: Mar 24, 2025
Visit Reason
The inspection was conducted as a renewal visit with an incident review, including an unannounced full inspection on 03/24/2025 and 03/25/2025.
Findings
The inspection identified multiple deficiencies related to staff annual training hours and topics, emergency telephone number postings, food storage, annual medical evaluations, medication record accuracy, medication labeling, medication storage procedures, adherence to prescriber's orders, and support plan signatures. All deficiencies had plans of correction accepted and were implemented by 06/03/2025.
Citations (11)
Direct care staff persons did not receive the required 12 hours of annual training in 2024.
Direct care staff persons did not receive required training on specific topics including medication self-administration, dementia care, infection control, and safe management techniques.
Direct care staff persons did not receive training in fire safety and falls and accident prevention during the 2024 training year.
Emergency telephone numbers were not posted on or near the telephone in the concierge area.
Seven ice cream containers in the main kitchen freezer were left unsealed or not properly closed.
Resident 1’s annual medical evaluation was seven days late.
Medication records for residents self-administering medications were incomplete or inaccurate, missing current medication lists or including discontinued medications.
OTC medication belonging to Resident 4 was not labeled with the resident's name.
Resident 4’s blood glucose readings were inaccurately documented or missing on multiple occasions.
Resident 4’s blood glucose measurements were taken outside prescribed times on multiple dates.
Residents 5 and 6 participated in support plan development but did not sign the support plans.
Report Facts
Residents Served: 48
Current Hospice Residents: 4
Residents with Mobility Need: 12
Direct Care Staff Training Hours: 0
Direct Care Staff Training Hours: 9.5
Unsealed Ice Cream Containers: 7
Days Late for Medical Evaluation: 7
Inspection Report — Apr 15, 2024
Renewal
Date: Apr 15, 2024
Visit Reason
The inspection was conducted as a renewal inspection of the Harrison Senior Living of Coatesville facility on 04/15/2024 and 04/16/2024.
Findings
The inspection identified multiple deficiencies including breaches in resident record confidentiality, delays in issuing resident refunds, inoperable bathroom ventilation fans, incomplete medical evaluations, medication storage and administration issues, incomplete resident assessments, and missing incident reports in resident records. The facility submitted and implemented plans of correction for all deficiencies.
Citations (12)
Staff member left computer screen open with resident information visible during medication pass.
Refund check for a resident was not issued within the required 30-day timeframe after discharge.
Bathrooms in rooms 218 and 220 lacked operable ventilation fans or windows.
Resident medical evaluations missing information pertinent to diagnosis and treatment.
Resident assessments inconsistent regarding ability to self-administer medications.
Medications stored improperly: torn blister packs, expired medications, and punctured blister packs found.
Medication count discrepancies and improper handling of medication dose changes.
Medication not available on medication cart as prescribed for a resident.
Medication administration not properly documented on narcotic log at time of administration.
Initial resident assessment not completed within 15 days of admission.
Resident support plans missing descriptions of needs or plans to meet needs, including dietary needs.
Incident report missing from resident's record after an incident with another resident.
Report Facts
Residents Served: 52
Hospice Residents: 4
Resident with Mental Illness: 1
Residents with Mobility Need: 10
Resident Assessments: 1
Medication Expiry Date: 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Resident Services | Director of Resident Services | Named in multiple findings related to resident confidentiality, medication storage, and support plan corrections. |
| Assistant Director of Resident Services | Assistant Director of Resident Services | Involved in monitoring compliance and conducting audits related to medication administration and resident assessments. |
| Executive Director | Executive Director | Reminded staff about confidentiality and reviewed quarterly audits. |
| Maintenance Director | Maintenance Director | Responsible for replacing bathroom ventilation fans and conducting audits. |
| Director of Admissions | Director of Admissions | Involved in in-service training on medical evaluation requirements. |
| LPN on Duty | Licensed Practical Nurse | Signed medication out on narcotic log and handled medication corrections. |
| SPN on Duty | Staff Person Nurse | Obtained physician order to discontinue medication for a resident. |
Inspection Report — Aug 15, 2023
Complaint Investigation
Date: Aug 15, 2023
Visit Reason
The inspection was conducted as a complaint investigation at Harrison Senior Living of Coatesville on 08/15/2023.
Complaint Details
The inspection was complaint-related, but no deficiencies or citations were found, indicating no substantiated issues.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Residents Served: 56
Current Residents in Hospice: 6
Residents Age 60 or Older: 56
Residents with Intellectual Disability: 1
Residents with Mobility Need: 10
Inspection Report — Jul 7, 2023
Complaint Investigation
Date: Jul 7, 2023
Visit Reason
The inspection was conducted as a complaint investigation during an unannounced partial licensing inspection of the facility.
Complaint Details
The inspection was triggered by a complaint; however, no deficiencies or citations were found.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Residents Served: 54
Current Residents in Hospice: 4
Residents Age 60 or Older: 54
Residents Diagnosed with Mental Illness: 2
Residents with Mobility Need: 12
Inspection Report — Nov 14, 2022
Routine
Date: Nov 14, 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 2, 2021
Renewal
Date: Sep 2, 2021
Visit Reason
The inspection was conducted as a renewal inspection of the Harrison Senior Living of Coatesville facility on 09/02/2021 and 09/03/2021.
Findings
The submitted plan of correction related to medication administration discrepancies involving glucometer readings was fully implemented and compliance was maintained. The facility corrected calibration issues and re-inserviced staff on proper procedures.
Citations (1)
Discrepancies in glucometer readings for resident 1, including incorrect time display and mismatched blood glucose values documented versus device readings.
Report Facts
Residents Served: 48
Current Residents in Hospice: 4
Residents Age 60 or Older: 47
Residents Diagnosed with Mental Illness: 1
Residents Diagnosed with Intellectual Disability: 1
Residents with Mobility Need: 7
Resident Support Staff: 0
Total Daily Staff: 55
Waking Staff: 41
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Resident Services | Director of Resident Services | Responsible for inspecting glucometers, re-inservicing nurses and med techs, and ongoing monitoring of glucometer calibrations |
Inspection Report — May 3, 2021
Date: May 3, 2021
Visit Reason
The inspection was conducted as a partial, unannounced licensing inspection due to an incident.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Residents Served: 44
Current Hospice Residents: 7
Resident Support Staff: 58
Waking Staff: 44
Notice — Jan 22, 2021
Date: Jan 22, 2021
Visit Reason
The document serves as a renewal notification and license issuance for Harrison Senior Living of Coatesville, confirming the facility's compliance and informing that an annual inspection will be conducted within the next twelve months.
Findings
The Department has issued a regular license in response to the renewal application and advises that an onsite inspection will be conducted within the next year 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 — Sep 4, 2020
Routine
Date: Sep 4, 2020
Visit Reason
The inspection was a licensing inspection conducted 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 — Dec 2, 2019
Renewal
Date: Dec 2, 2019
Visit Reason
The inspection was conducted as a renewal visit with an incident review for Harrison Senior Living of Coatesville on December 2 and 3, 2019.
Findings
The submitted plan of correction was found to be fully implemented as of March 31, 2020. The report includes multiple deficiencies related to resident care, medication administration, staff background checks, and safety audits, all addressed through corrective actions.
Citations (8)
Staff member A was suspended and later terminated following an incident involving inappropriate resident care and verbal abuse.
Staff person C was found working without a PA State Police Criminal Background Check, which was later obtained and documented.
Resident #2 was unable to recognize or self-administer medications properly, requiring removal of medications from the resident's room and implementation of supervised medication administration.
Resident #3 had unlocked medication containers found on his dresser, posing a safety risk.
Fire drills were conducted on inappropriate days, and the facility was cited for having three fire drills on Thursdays; corrective actions include scheduling drills on different days.
Exterior and interior safety hazards were identified, including rusted stairwell treads and unsecured doors; handrails were installed and safety audits initiated.
Annual medication administration training and documentation for staff were incomplete or not properly transcribed.
Initial assessments for residents 4, 5, 6, and 7 were not completed within 15 days of admission; corrective actions include re-service and improved documentation.
Report Facts
Residents Served: 69
Current Hospice Residents: 7
Staff Daily Total: 84
Waking Staff: 63
Residents Age 60 or Older: 66
Residents with Mobility Need: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jean C. Bryan | Executive Director | Signed multiple plans of correction and is listed as Director of Resident Services |
| Sandra Wooters | Human Services Licensing Supervisor | Department representative on-site during inspection |
Inspection Report — Oct 25, 2019
Renewal
Date: Oct 25, 2019
Visit Reason
The document is a renewal license issued to Harrison Senior Living of Coatesville for operation as a Personal Care Home. The Department received a renewal application on October 25, 2019, and will conduct an onsite inspection within the next twelve months as required by state code.
Findings
No inspection findings are reported in this document. It primarily communicates the issuance of a regular license renewal and the requirement for a future annual inspection.
Report Facts
Inspection Report — Jan 8, 2019
Annual Inspection
Date: Jan 8, 2019
Visit Reason
The inspection was conducted as a full annual renewal inspection with an incident trigger for Harrison Senior Living of Coatesville on January 8 and 11, 2019.
Findings
The inspection identified violations related to direct care staff training and medication administration errors, including unsupervised ADL services and insulin dosage errors. Plans of correction were submitted and partially implemented as of April 4, 2019.
Citations (3)
Regulation 55 Pa.Code §2600.65(d) - Direct care staff person hired on 07/11/2017 provided unsupervised ADL services without completing required training and competency tests.
Regulation 55 Pa.Code §2600.187(d) - Resident #1 was prescribed insulin but received an incorrect dose of 40 units instead of 4 units due to unclear MAR documentation.
Regulation 55 Pa.Code §2600.188(b) - A medication error involving wrong insulin dose for Resident #1 was not immediately reported to the resident, designated person, or prescriber.
Report Facts
Number of Residents Served: 69
Number of Current Hospice Residents: 7
Number of Hospice Residents in Past Year: 21
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jean C. Bryan | Executive Director | Signed plan of correction and legal entity representative on violation reports. |
Notice — Nov 8, 2018
Date: Nov 8, 2018
Visit Reason
This document serves as a renewal notification and license issuance for Harrison Senior Living of Coatesville pursuant to Title 55, PA Code, Chapter 2600. It informs the facility of the requirement for an onsite inspection within the next twelve months.
Findings
No inspection findings are reported in this document. It confirms the issuance of a regular license and outlines the Department's obligation to conduct an inspection within the next year.
Inspection Report — Apr 30, 2018
Complaint Investigation
Date: Apr 30, 2018
Visit Reason
The inspection was conducted as a complaint investigation following an incident involving alleged abuse of a resident and related concerns.
Complaint Details
The investigation was triggered by an allegation of abuse against resident #1. The home failed to report the allegation and did not submit required supervision plans for involved staff. The complaint was substantiated based on findings of neglect and inadequate supervision.
Findings
Multiple violations of 55 Pa.Code Chapter 2600 were found, including failure to report suspected abuse, failure to submit a plan of supervision for a staff person, inadequate supervision of a resident during an outing, neglect of a resident left unattended in a locked van, and failure to follow prescriber directions for medication administration.
Citations (5)
Regulation 55 Pa.Code 2600.15(a) requires immediate reporting of suspected abuse. The home did not report an allegation of abuse against resident #1 to the local area agency on aging.
Regulation 55 Pa.Code 2600.15(c) requires submission of a plan of supervision or suspension notice for affected staff. The home did not submit a plan of supervision for staff person B involved in the abuse allegation.
Regulation 55 Pa.Code 2600.23(a) requires assistance with activities of daily living as indicated in the resident's assessment. Resident #1 was left unattended outside the home for approximately two hours during an outing.
Regulation 55 Pa.Code 2600.42(b) prohibits neglect and abuse. Resident #1 was abandoned in a locked van for nearly three hours, unsupervised, with temperatures between 38 and 46 degrees Fahrenheit.
Regulation 55 Pa.Code 2600.187(d) requires following prescriber directions. Resident #1 did not receive insulin at the prescribed time while locked outside the home, though the insulin was later administered and documented.
Report Facts
Number of Residents Served: 63
Number of Current Hospice Residents: 5
Number of Hospice Residents in past year: 10
Staffing Hours - Total Daily Staff: 64
Staffing Hours - Waking Staff: 48
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jean C. Bryan | Executive Director | Named in relation to plan of correction and signature on multiple pages. |
Inspection Report — Nov 13, 2017
Renewal
Date: Nov 13, 2017
Visit Reason
The document is a renewal application and license issuance for Harrison Senior Living of Coatesville Personal Care Home. The Department received the renewal application and is issuing a regular license in response.
Findings
No inspection findings are reported in this document. It confirms the renewal of the facility's license and states that the Department will conduct an onsite annual inspection within the next twelve months.
Report Facts
Inspection Report — May 15, 2017
Renewal
Date: May 15, 2017
Visit Reason
The inspection was conducted as an annual licensing renewal inspection of Harrison Senior Living of Coatesville to assess compliance with 55 Pa.Code Chapter 2600 relating to Personal Care Homes.
Findings
The inspection identified violations related to staff criminal background checks, medication administration errors, and preadmission screening documentation. Plans of correction were submitted and partially implemented to address these issues.
Citations (3)
55 Pa.Code §2600.52 - Criminal background checks for new hires were not completed timely for two staff members.
55 Pa.Code §2600.187(d) - A medication administration error occurred where insulin dosing did not match glucometer readings for a resident.
55 Pa.Code §2600.224(a) - The preadmission screening form for a resident contained an incorrect date, affecting documentation of service needs.
Report Facts
Number of Residents Served: 63
Number of Current Hospice Residents: 5
Number of Hospice Residents in Past Year: 16
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jean C. Bryan | Executive Director | Named as legal entity representative and responsible for plan of correction. |
Inspection Report — Nov 7, 2016
Renewal
Date: Nov 7, 2016
Visit Reason
The document is a renewal application and license issuance for Harrison Senior Living of Coatesville pursuant to Title 55, PA Code, Chapter 2600. The Department notifies that an onsite annual inspection will be conducted within the next twelve months.
Findings
This document does not contain inspection findings but confirms the issuance of a regular license and the requirement for an annual onsite inspection within twelve months.
Report Facts
Inspection Report — May 12, 2016
Renewal
Date: May 12, 2016
Visit Reason
The inspection was conducted as part of the Department of Human Services' annual licensing inspections on May 12 and May 13, 2016, for renewal of the facility license.
Findings
Violations of 55 Pa.Code Chapter 2600 were found during the inspection. A fire drill during sleeping hours was not conducted as required, with the last drill held on March 30, 2016, instead of every six months.
Citations (1)
55 Pa.Code 2600.132(e) requires a fire drill during sleeping hours once every six months. The last fire drill during sleeping hours was conducted on March 30, 2016, exceeding the six-month requirement.
Report Facts
Number of Residents Served: 65
Total Daily Staff: 66
Waking Staff: 50
Number of Current Hospice Residents: 3
Number of Hospice Residents in past year: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jean Bryan | Administrator and Executive Director | Named in relation to the plan of correction for the fire drill violation |
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