27 Reports
Inspection Report — Jul 29, 2025
Renewal
Date: Jul 29, 2025
Visit Reason
The inspection was an unannounced renewal, provisional inspection conducted on 07/29/2025 to review compliance with licensing requirements and verify correction of previous deficiencies through a plan of correction submission.
Findings
The inspection identified multiple deficiencies including missing resident-home contracts, incomplete signed statements of resident rights, lack of thermometers in refrigerators/freezers, incomplete or untimely medical evaluations, untrained staff administering medications, missing preadmission screening forms, and incomplete resident discharge records. All deficiencies were addressed with detailed plans of correction, staff training, audits, and ongoing monitoring to ensure compliance.
Citations (9)
Resident 1 did not have a resident-home contract.
Resident 1's record lacked a signed statement acknowledging receipt of resident rights and complaint procedures.
No thermometer in one of the standalone freezers in the basement and no thermometer in the bottom freezer of a kitchen refrigerator.
Medical evaluations for Residents 1, 2, and 3 were not completed within 60 days prior to admission or within 30 days after admission.
Resident 1's medical evaluation did not include special health or dietary needs; Resident 3's medical evaluation lacked a general physical exam, allergies, and body positioning/movement stimulation details.
Resident 3's annual medical evaluation was not completed within the required timeframe.
Staff person A administered medications without completing required medication administration training.
Resident 1 did not have a preadmission screening form completed within 30 days prior to admission.
Resident 1's chart lacked a discharge record documenting previous discharge and return to the facility.
Report Facts
Residents Served: 37
Current Hospice Residents: 4
Residents with Mental Illness: 13
Residents with Intellectual Disability: 2
Residents with Mobility Need: 5
Residents 60 Years or Older: 37
Total Daily Staff: 42
Waking Staff: 32
Inspection Report — Feb 19, 2025
Complaint Investigation
Date: Feb 19, 2025
Visit Reason
The inspection was conducted as a complaint investigation triggered by an incident involving a resident fall during a power outage on February 16, 2025.
Complaint Details
The complaint investigation was triggered by an incident on 2/16/2025 where a resident with mobility and vision impairments fell down a darkened stairwell during a power outage and later died. The investigation substantiated neglect and abuse related to inadequate emergency lighting and supervision during the outage.
Findings
The inspection found multiple violations including abuse related to neglect during a power outage that left hallways dark, resulting in a resident fall and death; unsanitary conditions in a resident's room after their death; and inadequate emergency lighting on the second and third floors contributing to unsafe conditions. The facility was issued a provisional license due to these violations and required to implement corrective actions.
Citations (3)
Failure to provide sufficient emergency lighting during a power outage, resulting in a resident falling down stairs and dying.
Neglect and abuse due to inadequate supervision and emergency response during power outage, leading to resident injury and death.
Unsanitary conditions found in a resident's room after their death, including food remnants and toothpaste residue.
Report Facts
Residents Served: 39
Current Residents in Hospice: 3
Residents 60 Years or Older: 38
Residents Diagnosed with Mental Illness: 17
Residents Diagnosed with Intellectual Disability: 2
Staffing Hours: 41
Waking Staff: 31
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Juliet Marsala | Deputy Secretary | Signed the provisional license letter and correspondence regarding the inspection. |
Inspection Report — Oct 31, 2024
Renewal
Date: Oct 31, 2024
Visit Reason
The inspection was conducted as a renewal review of the facility's license by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing on 10/31/2024.
Findings
The report found violations related to outdated food storage, improper medication storage, and medication administration documentation errors. The facility submitted a plan of correction which was accepted and fully implemented by 12/10/2024.
Citations (3)
Unlabeled, undated green and red peppers and incorrectly labeled and undated red tomatoes in the freezer.
Unopened medication belonging to a resident was not stored according to manufacturer’s instructions requiring refrigeration until opening.
Medication prescribed as needed was not available in the home and glucometer readings were inaccurately documented on the Resident Medication Administration Record.
Report Facts
Residents Served: 39
Total Daily Staff: 41
Waking Staff: 31
Residents Receiving Supplemental Security Income: 5
Residents Diagnosed with Mental Illness: 17
Residents Aged 60 or Older: 39
Residents Diagnosed with Intellectual Disability: 2
Residents with Mobility Need: 2
Inspection Report — Sep 6, 2023
Renewal
Date: Sep 6, 2023
Visit Reason
The inspection was conducted as a renewal inspection of Hayes Manor to review compliance with licensing requirements and verify the implementation of the submitted plan of correction.
Findings
The inspection identified multiple deficiencies including failure to provide ambulating assistance as per resident support plans, incomplete staff training in required topics, improper scheduling of fire drills, incomplete medical evaluations, medication administration errors, failure to follow prescriber's orders, and medication error reporting deficiencies. Plans of correction were accepted and verified as implemented by November 2, 2023.
Citations (8)
Resident #1 did not receive ambulating assistance or bed-to-bed transfers as specified in the support plan.
Direct care staff persons A and B did not receive required annual training in medication self-administration, care for residents with dementia, infection control, safe management techniques, and falls and accident prevention during training year 2022.
Fire drills were routinely conducted during the first week of the month rather than on different days and times as required.
Resident #2's medical evaluation was incomplete, missing page two including special diet, special instructions, and medication regimen.
Staff member C did not place medication in resident #3's hand, mouth, or other route as ordered by the prescriber.
Resident #2 was not administered sliding scale insulin doses as prescribed and documentation was incomplete.
Resident #4 was without prescribed medication for 6 days due to medication not being available in the home.
Resident #4's medication error was not immediately reported to the resident, designated person, and prescriber as required.
Report Facts
Residents served: 37
Staffing hours: 39
Staffing hours: 29
Residents receiving Supplemental Security Income: 3
Residents diagnosed with mental illness: 11
Residents diagnosed with intellectual disability: 4
Residents aged 60 or older: 37
Residents with mobility need: 2
Residents with physical disability: 0
Fire drills documented: 5
Medication administration refresher date: Sep 11, 2023
Plan of correction completion date: Sep 26, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff Member C | Named in medication administration violation and subsequent retraining | |
| Staff person A | Named in training deficiencies and subsequent retraining | |
| Staff person B | Named in training deficiencies and subsequent retraining | |
| Nurse Manager | Provided training, audits, and oversight related to multiple deficiencies | |
| Human Resources Manager | Responsible for training audits and compliance | |
| Administrator | Reviewed violations and ensured corrective actions |
Inspection Report — Feb 22, 2023
Monitoring
Date: Feb 22, 2023
Visit Reason
The visit was a partial, unannounced monitoring inspection conducted to review compliance and the implementation of a previously submitted plan of correction.
Findings
The inspection found multiple medication management deficiencies including expired medications, incorrect glucometer times, unavailable PRN medications, incomplete medication records, failure to follow prescriber's orders, and medication error reporting issues. All deficiencies had corrective plans accepted and were implemented by May 23, 2023.
Citations (6)
Expired medication belonging to resident #1 was present in the medication cart.
Resident #1's glucometer did not have the correct time.
Resident #2's prescribed PRN medication was not available in the home on the inspection date.
Resident #1's medication administration record did not include a prescribed medication.
Resident #1 was not administered prescribed medication as ordered and the medication error was not reported to the resident, designated person, or prescriber.
Resident #2's initial assessment did not include a plan to meet medical needs as required.
Report Facts
Residents Served: 34
Total Daily Staff: 38
Waking Staff: 29
Residents Diagnosed with Mental Illness: 7
Residents 60 Years or Older: 34
Residents Diagnosed with Intellectual Disability: 3
Residents with Mobility Need: 4
Residents with Physical Disability: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse Manager | Named in multiple medication management deficiencies and corrective actions | |
| Administrator | Involved in review and monitoring of medication orders and audits |
Inspection Report — Jan 4, 2023
Complaint Investigation
Date: Jan 4, 2023
Visit Reason
The inspection was a complaint investigation conducted as an unannounced partial review to assess compliance with regulations following a complaint.
Complaint Details
The inspection was conducted as a complaint investigation triggered by concerns including resident refusal to eat or drink, failure to report incidents timely, and other care and safety issues. The complaint was substantiated with multiple violations found.
Findings
The inspection identified multiple deficiencies including failure to timely report incidents, inadequate assistance with activities of daily living, incomplete criminal background checks, medication management issues, safety hazards such as rotting porch railings and blocked egress, and incomplete resident assessments and support plans. Plans of correction were accepted and implemented by April 26, 2023.
Citations (20)
Failure to report an incident of resident dehydration and COVID infection to the Department within 24 hours.
Failure to submit a final incident report to the Department after resident's death.
Resident did not receive required assistance with toileting and bladder management; use of adult briefs not documented in support plan.
Criminal background checks not completed timely for certain staff members.
Resident #2 did not receive assistance with toileting or bladder management due to lack of available direct care staff.
Porch railing was rotting and poorly secured.
Thermostats in resident rooms and hallways were not working properly, causing high temperatures.
Hole in porch floor approximately eight inches in length.
No system to safeguard resident laundry from loss; clothing not returned within 24 hours.
Yellow tape blocked egress from left wing of building.
Failure to notify resident's primary care physician and designated person promptly when resident refused to eat or drink.
Discontinued medication remained in medication cart and was not removed timely.
Resident #3's prescribed PRN medications were not available in the home.
Resident #4's glucometer readings were not recorded on Medication Administration Record or glucose flow sheet.
Medication administration records lacked initials of staff administering medications and completing glucometer checks.
No written procedures for delivery and management of services from admission to discharge; resident requiring one-on-one supervision not properly documented.
Resident #5's preadmission screening form missing date of prescreening completion.
Resident #4's initial assessment was not completed within 15 days of admission.
Resident #4's assessment did not include need for one-on-one supervision and elopement risk.
Resident #2's support plan did not document bowel management needs or how they would be met.
Report Facts
Residents Served: 35
Staffing Hours: 40
Waking Staff: 30
Residents with Supplemental Security Income: 2
Residents 60 Years or Older: 35
Residents Diagnosed with Mental Illness: 4
Residents Diagnosed with Intellectual Disability: 3
Residents with Mobility Need: 5
Inspection Report — Aug 17, 2022
Renewal
Date: Aug 17, 2022
Visit Reason
The inspection was conducted as a renewal inspection of the facility license.
Findings
The report found deficiencies related to incomplete medical evaluations and missing completion dates on preadmission screening forms. The facility submitted a plan of correction which was determined to be fully implemented.
Citations (2)
Resident #1's medical evaluation did not include the completion of section 7 or the medication addendum; the form referenced an attachment that was missing.
Resident #2's preadmission screening form did not have a completion date, so it was unclear if the determination was made within 30 days prior to admission.
Report Facts
Residents Served: 32
Total Daily Staff: 37
Waking Staff: 28
Residents Receiving Supplemental Security Income: 2
Residents 60 Years or Older: 32
Residents Diagnosed with Mental Illness: 4
Residents Diagnosed with Intellectual Disability: 3
Residents with Mobility Need: 5
Residents with Physical Disability: 0
Hospice Residents: 1
Inspection Report — Jul 8, 2022
Complaint Investigation
Date: Jul 8, 2022
Visit Reason
The inspection was conducted as a complaint investigation with unannounced partial inspections on 07/08/2022 and 07/11/2022 to assess compliance with applicable regulations at Hayes Manor.
Complaint Details
The inspection was complaint-related and the reason for the visit was a complaint. Substantiation status is not stated.
Findings
Areas of non-compliance were found related to contract signatures, specifically that a resident was admitted with a boarding agreement rather than a Personal Care Home agreement as required by regulation.
Citations (1)
The contract was not properly signed as the resident was admitted with a boarding agreement rather than a Personal Care Home agreement.
Report Facts
Residents Served: 29
Total Daily Staff: 32
Waking Staff: 24
Residents Receiving Supplemental Security Income: 2
Residents 60 Years or Older: 29
Residents Diagnosed with Mental Illness: 6
Residents Diagnosed with Intellectual Disability: 2
Residents with Mobility Need: 3
Residents with Physical Disability: 1
Inspection Report — Mar 16, 2022
Follow-Up
Date: Mar 16, 2022
Visit Reason
The inspection was a partial, unannounced follow-up visit triggered by an incident to verify the implementation of a submitted plan of correction.
Findings
Multiple deficiencies were identified including abuse of a resident, failure to complete timely criminal background checks, lack of required qualifications and training for direct care staff, missing annual medical evaluations, improper medication record keeping, and failure to follow safe equipment usage procedures. Plans of correction were accepted and fully implemented by the facility.
Citations (10)
Resident #1 was verbally abused and physically mishandled during transfer, causing pain and mental anguish.
Criminal background check for Staff A was not requested until after employment started.
Direct care staff person B lacked documentation of required education or registry status.
No staff trained in first aid and CPR was present during the night shift on 03/06/2022.
Direct care staff person B provided unsupervised ADL services before completing required training and competency testing.
Resident #1’s annual medical evaluation was delayed and not completed timely.
Staff A operated the Sit-to-Stand Lift alone contrary to manufacturer instructions requiring two staff.
Resident #1’s March medication administration record did not include prescribed insulin injections.
Staff person B administered insulin without completing a Department-approved diabetes education program.
Resident #1's support plan lacked assessor information and was signed but not dated.
Report Facts
Residents served: 24
Total daily staff: 28
Waking staff: 21
Supplemental Security Income recipients: 2
Residents 60 years or older: 24
Residents diagnosed with mental illness: 3
Residents diagnosed with intellectual disability: 1
Residents with mobility needs: 4
Residents with physical disability: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Named in abuse incident and improper use of Sit-to-Stand Lift; removed from work schedule and dismissed. | |
| Staff person B | Direct care staff lacking required education and training; removed from direct care duties; involved in medication administration violations. | |
| Claire Mendez | Human Services Licensing Supervisor | Signed the initial letter confirming plan of correction implementation. |
Inspection Report — Jul 28, 2021
Complaint Investigation
Date: Jul 28, 2021
Visit Reason
The inspection was conducted as a complaint investigation with an unannounced partial inspection on July 28 and 29, 2021.
Complaint Details
The inspection was triggered by a complaint, as indicated by the inspection reason 'Complaint' and the unannounced partial inspection type.
Findings
The report found multiple deficiencies including lack of immediate access to resident records, physical facility issues such as cracks and water leaks in the restroom, incomplete medical evaluations for residents, and missing recent photographs in resident records. The submitted plan of correction was later determined to be fully implemented.
Citations (4)
Failure to provide immediate access to residents' records including contracts and financial information upon request.
Restroom located on the first floor next to the nurse's office had cracks on the wall and water was dripping from the ceiling.
Medical evaluations for residents #1, #2, and #3 did not include required assessments for medication self-administration and body positioning/movement.
Residents #2's and #4's records did not include a photograph taken within the last two years.
Report Facts
Residents Served: 29
Current Hospice Residents: 1
Total Daily Staff: 33
Waking Staff: 25
Residents with Supplemental Security Income: 2
Residents Age 60 or Older: 29
Residents with Mobility Need: 4
Residents with Physical Disability: 2
Inspection Report — Jun 29, 2021
Renewal
Date: Jun 29, 2021
Visit Reason
The inspection was conducted as a renewal visit to review compliance with licensing requirements and verify the implementation of the submitted plan of correction.
Findings
The inspection identified multiple deficiencies including staff qualification documentation, training plan content, bathroom ventilation, bedroom furnishings and lighting, refrigerator thermometer absence, emergency procedure submissions and postings, fire department notification, menu posting, and resident record content. All deficiencies had plans of correction accepted and were implemented by specified dates.
Citations (11)
Direct care staff person A does not have a high school diploma, GED, or active registry status on file.
The home's staff training plan does not include name, position and duties of each staff person.
The bathroom in bedroom does not have a window or an operable ventilation fan.
There is no bedside table or shelf beside resident #1’s bed in bedroom.
Resident #1 does not have access to a source of light that can be turned on/off at bedside.
There was no thermometer found in the refrigerator known as Box 1 to measure temperature.
The home’s written emergency procedures have not been submitted to the local emergency management agency since 2/28/2019.
The home’s emergency procedures posted in a conspicuous and public place did not include the local municipality's emergency procedure.
The home does not have documentation of written notification to the local fire department of the address, bedroom locations, and assistance needed to evacuate in an emergency.
The home's menu for the week of 6/25/21-7/4/2021 was posted, but the following week menu was not posted 1 week in advance.
Resident #2's record does not include a photograph taken no more than 2 years ago; last photo dated 1/15/19.
Report Facts
Residents Served: 29
Total Daily Staff: 33
Waking Staff: 25
Notice — Oct 7, 2020
Date: Oct 7, 2020
Visit Reason
The document serves as a license renewal notification and certificate of compliance for Hayes Manor Personal Care Home, 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 confirms issuance of a regular license and states that enforcement action will be taken if non-compliance is found during future inspections.
Report Facts
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary, Office of Long-Term Living | Signed the renewal notification letter |
Inspection Report — Jan 14, 2020
Renewal
Date: Jan 14, 2020
Visit Reason
The inspection was an unannounced renewal inspection of Hayes Manor to assess compliance with licensing regulations.
Findings
The inspection identified multiple violations including lack of carbon monoxide detector near the gas water heater, incomplete staff training, broken equipment, missing bedside furniture, privacy issues, food storage problems, fire extinguisher inspection lapses, fire drill documentation issues, medication administration errors, and incomplete resident assessments. All violations had approved plans of correction which were implemented by July 17, 2020.
Citations (19)
2600.18 - The home's main hot water heater is gas operated but lacks a carbon monoxide detector within 15 feet as required by law.
2600.65.f - A direct care staff person did not receive required training on personal care service needs and care for residents with mental health or intellectual disabilities in 2019.
2600.95 - The hinged folding lid of the home's ice machine in the main kitchen was held together with tape.
2600.101.j - There is no bedside table or shelf beside the resident's bed in bedroom #7.
2600.101.j7 - The resident in bedroom #7 lacks access to a lamp or other light source that can be turned on/off at bedside.
2600.102.e - The common bathroom on the 1st floor had no lock, failing to provide privacy while in use.
2600.103.g - Opened and unsealed packs of turkey burgers and chicken breasts were found in the freezer.
2600.103.i - Several items in the refrigerator were unlabeled and undated.
2600.131.f - The Ansul fire suppression system in the kitchen has not been inspected by a fire safety expert since December 2018.
2600.132.e - The fire drill conducted during sleeping hours occurred two months later than required.
2600.132.f - The home used all alternate exit routes during fire drills held from January to December 2019.
2600.141.a - Resident #1's medical evaluation did not include medical diagnoses or pertinent medical information.
2600.182.c - Medication technicians did not follow proper medication distribution procedures and documentation during a medication pass.
2600.187.a - Resident #3's medication administration record lacked diagnosis or purpose for prescribed medications.
2600.187.b - Resident #4's medication administration record was not properly documented for blood sugar checks and medication administration.
2600.185.a - PRN medication was not available for a resident as listed on their medication administration record.
2600.187.d - Resident #5's medication administration record was not properly checked for several dates, repeating a prior violation.
2600.190.b - Staff person B administered insulin without completing required diabetes education and competency testing.
2600.225.c - Annual resident assessments for residents #4, 6, and 7 were not completed on time due to staffing issues.
Report Facts
Residents Served: 42
Current Hospice Residents: 2
Residents with Mental Illness: 12
Residents 60 Years or Older: 42
Residents with Mobility Need: 7
Residents with Physical Disability: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Robyn Burns | Administrator | Named as administrator and legal entity representative signing plans of correction |
Inspection Report — Oct 10, 2019
Monitoring
Date: Oct 10, 2019
Visit Reason
The inspection was a monitoring visit conducted by the Pennsylvania Department of Human Services, Bureau of Human Services Licensing, to review compliance at Hayes Manor.
Findings
The facility had multiple violations including failure to request a timely criminal background check for a staff member, direct care staff lacking required qualifications, and incomplete resident assessments. Plans of correction were submitted and fully implemented as of April 29, 2020.
Citations (4)
2600.51 Criminal Background Check: Staff person A was hired on 9/16/19 but a criminal background check was not requested until 9/17/19.
2600.54(a) Direct Care Staff: Direct care staff person B did not have a high school diploma, GED, or active registry status on the Pennsylvania nurse aide registry.
2600.225(a) Assessment 15 Days: An assessment was not completed for resident #1 within 15 days of admission on 9/5/19.
2600.225(c) Additional Assessment: Resident #2's most recent assessment was completed on 8/9/18, not annually as required.
Report Facts
Residents Served: 44
Staffing: 51
Waking Staff: 38
Residents with Mental Illness: 15
Residents 60 Years or Older: 44
Residents with Mobility Need: 7
Residents with Physical Disability: 2
Residents Receiving Supplemental Security Income: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Robyn Burns | Administrator | Named in relation to plan of correction signatures and oversight |
Notice — Aug 8, 2019
Date: Aug 8, 2019
Visit Reason
The document serves as a renewal notice confirming receipt of the renewal application and informing 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 is an administrative notice regarding licensing and inspection requirements.
Report Facts
Inspection Report — Jul 22, 2019
Complaint Investigation
Date: Jul 22, 2019
Visit Reason
The inspection was conducted as a complaint investigation at Hayes Manor to assess compliance with 55 Pa. Code Ch. 2600 relating to Personal Care Homes.
Complaint Details
The inspection was triggered by a complaint regarding neglect and improper care practices at the facility.
Findings
Multiple violations were found including neglect related to improper use of a sit-to-stand lift, failure to conduct criminal background checks, unqualified direct care staff, incomplete direct care training, missing resident personal equipment repairs, untimely annual medical evaluations, improper medication administration documentation, and inadequate storage procedures for medications and medical equipment.
Citations (8)
2600.42b Abuse: Staff failed to provide immediate care when resident #1 was stuck in a sit-to-stand lift, resulting in injury and hospital admission.
2600.51 Criminal Background Check: Staff persons B and C did not hold permanent PA residency for two years and no FBI background check was run.
2600.54a Direct Care Staff: Direct care staff person C lacks a high school diploma, GED, or active registry status on the Pennsylvania nurse aide registry.
2600.65d Initial Direct Care Training: Staff person B pushed residents in wheelchairs but did not complete or pass the required direct care training and competency test.
2600.81b Resident Personal Equipment: Resident #2's electric wheelchair armrest was missing for about two weeks and needed replacement.
2600.141b1 Annual Medical Evaluation: Resident #2's most recent medical evaluation was completed late on 04/05/2019 instead of annually.
2600.185a Implement Storage Procedures: Staff person A operated the sit-to-stand lift alone without required assistance, violating safe equipment use procedures.
2600.187b Date/Time of Medication Admin.: Resident #1 was sent to hospital and staff initialed medications on 07/11/2019 without administering them.
Report Facts
Residents Served: 43
Staff Counts: 48
Waking Staff: 36
Residents with Mental Illness: 24
Residents with Intellectual Disability: 18
Residents 60 or Older: 43
Residents with Mobility Need: 5
Residents Receiving SSI: 3
Inspection Report — Dec 7, 2018
Annual Inspection
Date: Dec 7, 2018
Visit Reason
The inspection was conducted as a renewal and complaint investigation for Hayes Manor, a personal care home, on December 7, 2018.
Complaint Details
The inspection included a complaint investigation related to incidents of resident abuse and failure to report incidents properly. The complaint was substantiated based on findings of unreported and undocumented incidents.
Findings
Multiple violations were found related to incident reporting, documentation, staff qualifications, medication administration, resident dignity and respect, and positive intervention practices. Plans of correction were submitted addressing each violation with steps to ensure compliance.
Citations (12)
55 Pa.Code §2600.16(o): The home failed to report an incident involving resident #1 physically attacking resident #3 within 24 hours as required by regulation.
55 Pa.Code §2600.16(o): The home did not retain a copy of the incident report for the December 7, 2018 incident involving resident #1 and resident #3.
55 Pa.Code §2600.16(o): The home did not post the required influenza awareness poster in a public place as mandated by the Influenza Awareness Act.
55 Pa.Code §2600.42(c): Resident #1 was physically and verbally abused by resident #3 on the elevator, and the home failed to ensure resident dignity and respect during the incident.
55 Pa.Code §2600.54(a): Direct care staff person B lacked a high school diploma, GED, or active nurse aide registry status as required.
55 Pa.Code §2600.65(d): Direct care staff person B provided unsupervised ADL services without completing required training and competency testing.
55 Pa.Code §2600.65(f): Staff person B did not receive medication self-administration training in 2017 as required by annual training regulations.
55 Pa.Code §2600.183(d): Medication for resident #4 was discontinued but remained on the medication cart without proper removal procedures.
55 Pa.Code §2600.185(a): Resident #2 was prescribed medication but did not have the medication on hand during inspection.
55 Pa.Code §2600.187(d): Resident #2 did not receive prescribed Omeprazole medication on multiple dates as ordered by the prescriber.
55 Pa.Code §2600.201: The home failed to implement positive interventions to modify or eliminate resident #1's violent behavior toward other residents.
55 Pa.Code §2600.224(a): Resident #4's pre-admission screening form was incomplete and lacked documentation of medical, psychological, and behavioral history.
Report Facts
Number of Residents Served: 41
Number of Current Hospice Residents: 1
Number of Hospice Residents in Past Year: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Robyn Burns | Administrator | Named in multiple findings and plans of correction as the legal entity representative and responsible party. |
| Sabrina Freeman | Surveyor | Conducted the inspection on December 7, 2018. |
| Denise Gillespie | Surveyor | Conducted the inspection on December 7, 2018. |
Notice — Aug 2, 2018
Date: Aug 2, 2018
Visit Reason
The document serves as a renewal notification and license issuance for Hayes Manor Personal Care Home following receipt of a renewal application.
Findings
No inspection findings are reported in this document. It confirms the license issuance and states that an annual inspection will be conducted within the next twelve months.
Inspection Report — Jul 16, 2018
Complaint Investigation
Date: Jul 16, 2018
Visit Reason
The inspection was conducted as a complaint investigation triggered by an incident at Hayes Manor.
Complaint Details
The investigation was triggered by an incident involving resident care and staffing concerns. The violations were substantiated as described in the findings.
Findings
The facility was found to have multiple violations related to insufficient direct care staffing hours, inadequate provision of direct care during waking hours, failure to follow prescriber directions for resident care, and incomplete initial resident assessments.
Citations (4)
55 Pa.Code §2600.57(c) - Direct care staff did not provide the required minimum of 60 hours of direct care for 15 residents with mobility needs; only 56 hours were provided on 06/17/2018.
55 Pa.Code §2600.57(d) - Only 40 of the required 46 hours of direct care were provided during waking hours on 06/17/2018, representing 86 percent compliance.
55 Pa.Code §2600.187(d) - Resident #1's MAR was initiated for elevating legs above heart when sitting at 1 pm, but therapy was not applied and resident was taken to hospital at 11 am on 06/18/2018.
55 Pa.Code §2600.226(a) - Resident #1's initial assessment was completed late; admitted 02/06/2018 but assessment completed on 06/04/2018.
Report Facts
Number of Residents Served: 45
Direct Care Hours Required: 60
Direct Care Hours Provided: 56
Direct Care Hours Required During Waking Hours: 46
Direct Care Hours Provided During Waking Hours: 40
Residents with Mobility Needs: 15
Residents Age 60 or Older: 45
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Robyn Burns | Administrator | Named in relation to the plan of correction and signature on violation report pages. |
| David Carrion | Department representative conducting the inspection. |
Inspection Report — May 21, 2018
Complaint Investigation
Date: May 21, 2018
Visit Reason
The inspection was conducted as a complaint investigation at Hayes Manor to assess compliance with 55 Pa. Code Chapter 2600 relating to Personal Care Homes.
Complaint Details
The inspection was complaint-driven as stated on page 2. The violations were substantiated and detailed in the violation report.
Findings
Multiple violations were found including failure to post the current license conspicuously, privacy breaches with resident information, insufficient direct care staffing hours, inadequate personal care service hours during waking hours, missing lids on trash receptacles, unclean and disrepair conditions in the facility, lack of an emergency communication system, incomplete medical evaluations, and missing preadmission screening forms.
Citations (13)
Regulation 55 Pa.Code §2600.3(c): The home's current license was not posted in a conspicuous and public place in the home on 05/21/18.
Regulation 55 Pa.Code §2600.42(s): Personal information including dietary restrictions was printed and taped to dining hall tables on 05/21/18, violating resident privacy.
Regulation 55 Pa.Code §2600.57(c): On 05/06/18 and 05/16/18, direct care staffing hours were below the required 67 hours for 45 residents including 22 with mobility needs.
Regulation 55 Pa.Code §2600.57(d): Only 60% and 56% of required personal care service hours were provided during waking hours on 05/06/18 and 05/16/18 respectively.
Regulation 55 Pa.Code §2600.85(e): A recycle trash bin was missing a lid on the right side of the dumpster.
Regulation 55 Pa.Code §2600.88(a): Walls in the first floor bathroom off the sunroom were in disrepair and needed patching and painting.
Regulation 55 Pa.Code §2600.90(b): The home lacked a system to enable staff to communicate with each other in an emergency; on 05/21/18, the home served 45 residents without such a system.
Regulation 55 Pa.Code §2600.141(b)(1): Resident #1's last medical evaluation was completed on 05/16/18; the previous evaluation was 04/10/17, not meeting annual evaluation requirements.
Regulation 55 Pa.Code §2600.161(d): The home's kitchen staff did not have a system to identify residents' special dietary needs as prescribed by medical professionals.
Regulation 55 Pa.Code §2600.224(a): There was no preadmission screening form for resident #2 admitted 11/17/17.
Regulation 55 Pa.Code §2600.224(a): There was no preadmission screening form for resident #3 admitted 02/06/18.
Regulation 55 Pa.Code §2600.225(a): Resident #2 and #3 assessments were completed by 05/30/18; all resident charts were audited and checked for completed assessments by 06/19/18.
Regulation 55 Pa.Code §2600.225(c): Resident #1 assessment was completed on 06/04/18; all resident charts were audited and checked for completed assessments by 06/19/18.
Report Facts
Residents with Mobility Needs: 22
Direct Care Staffing Hours Required: 67
Direct Care Staffing Hours Provided: 56
Direct Care Staffing Hours Provided: 53.5
Personal Care Service Hours Required: 67
Personal Care Service Hours Provided: 40
Personal Care Service Hours Provided: 37.5
Residents Served: 45
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Robyn Burns | Administrator | Named in multiple findings and plans of correction throughout the report |
| Dean Gray | Inspector | Conducted the inspection on 05/21/2018 |
| Tahesia Thomas | Inspector | Conducted the inspection on 05/21/2018 |
Inspection Report — Jan 31, 2018
Complaint Investigation
Date: Jan 31, 2018
Visit Reason
The inspection was conducted due to an incident complaint involving allegations of abuse at Hayes Manor.
Complaint Details
The visit was complaint-related due to allegations of abuse involving resident #1 and staff persons A and B. The allegations were substantiated by the findings of failure to report and supervise staff and failure to complete required assessments.
Findings
The inspection found multiple violations related to failure to report suspected abuse, failure to develop supervision plans for staff involved in abuse allegations, failure to report incidents timely, and failure to complete an initial resident assessment.
Citations (4)
55 Pa.Code §2600.15(a): The home failed to immediately report suspected abuse of resident #1 by staff person A to the local area agency or State Department on Aging.
55 Pa.Code §2600.15(b): The home did not develop or implement a plan of supervision or suspend staff person B involved in an abuse allegation against resident #1.
55 Pa.Code §2600.16(c): The home did not submit an incident report to the department until 01-08-17 after an abuse allegation against staff member B involving resident #1.
55 Pa.Code §2600.225(a): The home failed to complete an initial assessment for resident #1 admitted on 08-29-17 within 15 days of admission.
Report Facts
Number of Residents Served: 44
Number of Residents who are 60 Years of Age or Older: 44
Number of Residents who Have Mental Illness: 17
Number of Residents who Have a Mobility Need: 25
Number of Residents who Have a Physical Disability: 3
Number of Residents who Receive Supplemental Security Income: 3
Number of Hospice Residents in Past Year: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Robyn Burns | Administrator | Named in relation to plan of correction and signature on violation reports |
| Shawn Parker | Human Services Licensing Supervisor | Department representative conducting the inspection |
Inspection Report — Aug 21, 2017
Annual Inspection
Date: Aug 21, 2017
Visit Reason
The inspection was conducted as a result of the Department of Human Services' Personal Care Homes annual licensing inspection and included renewal and incident reasons.
Findings
Multiple violations of 55 Pa.Code Chapter 2600 were found, including sanitary conditions, fire safety obstructions, inadequate resident furnishings, privacy issues, and medication management deficiencies. Plans of correction were partially or fully implemented for all violations.
Citations (12)
55 Pa.Code §2600.85(a) - Sanitary conditions were not maintained; a large area of dark mildew was found in the shower stall of bathroom in room #310.
55 Pa.Code §2600.100(b) - Ice, snow, and obstructions were not removed from outside walkways; metal lightning rods obstructed fire escapes on the second and third floors.
55 Pa.Code §2600.101(j)(2) - Resident bedroom furnishings were inadequate; room #219 shared by two residents had only one chair.
55 Pa.Code §2600.102(e) - Privacy was not provided; the shared shower in room #219 lacked a shower curtain.
55 Pa.Code §2600.102(h) - Toilet paper was not provided in the bathroom of room #219.
55 Pa.Code §2600.102(i) - Soap dispenser was inadequate; an unlabeled bar of soap was found at the sink of shared room #219.
55 Pa.Code §2600.103(f) - Food requiring refrigeration was not properly stored; defective thermometers were found in the basement freezer and refrigerator.
55 Pa.Code §2600.123(c) - Emergency evacuation diagram was missing on the third floor.
55 Pa.Code §2600.132(b) - Annual fire safety inspection and fire drill were not completed as required; fire safety expert was absent and miscommunication delayed inspection.
55 Pa.Code §2600.141(a)(2) - Medical evaluation for resident #1 did not include the resident's medication regimen.
55 Pa.Code §2600.185(a) - Procedures for safe storage, access, security, and distribution of medications were deficient; resident #2's medications were not available or monitored properly.
55 Pa.Code §2600.227(h) - The home failed to document a resident's inability or refusal to sign the support plan for resident #1.
Report Facts
Number of Residents Served: 44
Total Daily Staff: 56
Waking Staff: 42
Number of Hospice Residents in past year: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Robyn Burns | Administrator | Named in multiple findings and plans of correction signatures throughout the report. |
Inspection Report — Jul 27, 2017
Renewal
Date: Jul 27, 2017
Visit Reason
The document is a renewal application and license issuance for Hayes Manor, a Personal Care Home, indicating the Department will conduct an onsite inspection within the next twelve months as required by regulation.
Findings
No inspection findings are reported in this document. It serves as a license renewal notification and states that an inspection will be conducted within the next year.
Inspection Report — Mar 31, 2017
Complaint Investigation
Date: Mar 31, 2017
Visit Reason
The inspection was conducted due to an incident reported at the facility, triggering a complaint investigation.
Complaint Details
The investigation was triggered by an anonymous letter received on 03-27-17 alleging abuse of resident #1 by staff member B. The allegation was substantiated by witness statements and investigation, but the resident declined to prosecute.
Findings
Two violations related to abuse of a resident were found. Staff member B was witnessed abusing resident #1, and staff member A failed to report the abuse in a timely manner. Plans of correction were submitted and partially implemented.
Citations (2)
Regulation 55 Pa.Code §2600 2600.15(a): The home failed to immediately report suspected abuse of a resident as required by law. An anonymous letter reported abuse on 03-22-17, which was not promptly reported by staff member A.
Regulation 55 Pa.Code §2600 2600.42(b): Resident #1 was physically abused by staff member B on 03-22-17, involving slapping and hitting until the resident fell out of a chair onto the floor.
Report Facts
Staffing - Resident Support: 49
Staffing - Total Daily Staff: 107
Staffing - Waking Staff: 80
Residents with Mental Illness: 13
Residents with Physical Disability: 4
Residents with Mobility Need: 9
Residents Age 60 or Older: 49
Residents with Intellectual Disability: 1
Residents Receiving Supplemental Security Income: 3
Current Hospice Residents: 1
Hospice Residents in Past Year: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Robyn Burns | Administrator | Named in relation to the plan of correction and signature on violation reports |
Inspection Report — Aug 19, 2016
Renewal
Date: Aug 19, 2016
Visit Reason
The inspection was an annual licensing inspection conducted as part of the facility's license renewal process.
Findings
Several violations of Pennsylvania Code 2600 related to staff qualifications, furnace inspection, medication management, and resident support plan documentation were found. Plans of correction were submitted and partially implemented with adequate progress noted.
Citations (5)
55 Pa.Code §2600.54(a) - Direct care staff person A lacks a high school diploma, GED diploma, or active registration status on the Pennsylvania nurse aide registry.
55 Pa.Code §2600.126(a) - The professional furnace inspection expired on 7/31/16 and documentation was not current.
55 Pa.Code §2600.183(d) - Resident #1's Hydroxyzine medication was discontinued on 8/16/16 but remained in the medication cart on 8/19/16.
55 Pa.Code §2600.187(a) - Resident #1 received a prescribed order for Hydralazine 25mg on 8/16/16 that was not recorded on the medication administration record.
55 Pa.Code §2600.227(g) - Resident #1 participated in the development of their support plan on 4/7/16 but did not sign the plan.
Report Facts
Number of Residents Served: 46
Total Daily Staff: 54
Waking Staff: 41
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Robyn Burns | Administrator | Named as legal entity representative and signer of plans of correction related to multiple violations. |
Inspection Report — Aug 5, 2016
Renewal
Date: Aug 5, 2016
Visit Reason
The document is a renewal notice and license issuance for Hayes Manor Personal Care Home following receipt of a renewal application. It informs that the Department will conduct an onsite annual inspection within the next twelve months as required by regulation.
Findings
No inspection findings are reported in this document. It is a license renewal notification and certificate of compliance.
Report Facts
Document — September 27, 2021
Date: September 27, 2021
Visit Reason
The document includes a Certificate of Compliance issued to Hayes Manor for operation as a Personal Care Home and a renewal letter acknowledging receipt of the renewal application and advising of an upcoming annual inspection within the next twelve months.
Findings
No inspection findings are reported in this document. It confirms issuance of a regular license and states that the Department will conduct an inspection within the next twelve months to ensure compliance.
Report Facts
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Robyn Burns | Administrator | Named as legal entity representative on the renewal application |
| Jamie L. Buchenauer | Deputy Secretary, Office of Long-term Living | Signed the renewal letter |
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