Inspection Reports for
John Paul II Manor
856 CAMBRIA STREET,, CRESSON, PA, 16630
Back to Facility Profile14 Reports
Inspection Report — Apr 8, 2025
Complaint Investigation
Date: Apr 8, 2025
Visit Reason
The inspection was conducted as a complaint investigation with an unannounced partial inspection on 04/08/2025.
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: 28
Current Hospice Residents: 3
Resident Support Staff Hours: 0
Total Daily Staff Hours: 30
Waking Staff Hours: 23
Inspection Report — Aug 8, 2024
Renewal
Date: Aug 8, 2024
Visit Reason
The inspection was conducted as a full, unannounced renewal inspection with an incident review on 08/08/2024.
Findings
The inspection identified multiple deficiencies including an expired boiler certificate, hot water temperature exceeding 120°F, lack of annual fire drill by a fire safety expert, missing annual medical evaluation documentation for a resident, invalid vehicle registration for a transport vehicle, improper medication storage labeling, and a privacy violation involving resident names posted publicly. All deficiencies had plans of correction with specified completion dates and were implemented by 10/01/2024.
Citations (8)
Expired Certificate of Boiler or Pressure Vessel Operation; boiler certificate expired on 7/19/24.
Hot water temperature in room #15 measured 126°F, exceeding the 120°F limit.
The home had not completed an annual supervised fire drill by a fire safety expert.
Fire drill during sleeping hours not conducted every 6 months as required.
Resident #1’s most recent annual medical evaluation documentation was missing.
The home’s vehicle used to transport residents did not have a valid PA registration.
Resident #1's Humalog KwikPen and Lantus SoloStar injection pen lacked date markings indicating when opened.
Privacy coding document containing resident names was posted publicly on a bulletin board.
Report Facts
Residents Served: 31
Current Hospice Residents: 4
Residents 60 Years or Older: 30
Residents Diagnosed with Mental Illness: 3
Residents Diagnosed with Intellectual Disability: 1
Residents with Mobility Need: 1
Residents with Physical Disability: 0
Total Daily Staff: 32
Waking Staff: 24
Inspection Report — Jun 7, 2023
Renewal
Date: Jun 7, 2023
Visit Reason
The inspection was conducted as a renewal inspection of the facility license.
Findings
The inspection found multiple deficiencies including failure to post current license documents, lack of written incident policies, unsigned resident contracts, absence of a quality management plan, hot water temperature exceeding limits, incomplete first aid kits, unlabeled soap, improper refrigerator/freezer temperatures, insufficient emergency water supply, incomplete fire drill records, failure to evacuate residents properly during fire drills, incomplete medical evaluations, medication administration and storage issues, and lack of policies for managing records. Plans of correction were submitted and implemented for all deficiencies.
Citations (20)
The home’s current violation report, dated 2/15/2022, was not posted in a public place in the home.
The home does not have a written policy on the prevention, reporting, notification, investigation and management of reportable incidents.
Resident home contracts for Resident #1 and Resident #2 were not signed by the residents; no notation indicated opportunity to sign.
The home does not have a policy in place to implement a quality management plan and lacks documentation of annual completion.
Hot water temperature in resident room #9 measured 126°F, exceeding the 120°F limit.
First aid kits in the nurse's station and welcome desk lacked thermometer, adhesive tape, scissors, and eye coverings.
An unlabeled used bar of soap was found in resident room #4, occupied by 2 residents.
Temperature in the walk-in freezer was 12°F, exceeding the required 0°F or below.
The home served 32 residents requiring 96 gallons of emergency drinking water but had only 72 gallons and no water supplier contract.
The home lacks documentation that written emergency procedures were reviewed, updated, and submitted annually to the local emergency management agency.
Fire drill record for 5/10/2023 indicated 33 residents evacuated but only 32 evacuated as Resident #3 remained in bed.
Resident #3 did not evacuate to a designated meeting place during the fire drill on 5/10/2023.
Resident #4's medical evaluation did not include special health or dietary needs, immunization history, body positioning and movement.
Resident #5's medical evaluation did not include the date the resident was evaluated.
Resident #5 has not been assessed by a physician, physician's assistant, or certified registered nurse practitioner regarding ability to self-administer medications.
Resident #2's prescribed medication via nebulizer was not available in the home.
Blood glucose checks on the glucometer did not match the numbers documented on the home's June 2023 Monthly Blood Sugar sheet for Resident #1.
Resident #5's medication record did not include the amount of units given on the Monthly Blood Sugar record.
Resident #5's blood glucose was low and incorrect units of Humalog were administered; per physician's orders, 2 units should have been given.
The home does not have policies and procedures for managing records.
Report Facts
Residents Served: 32
Hot Water Temperature: 126
Walk-in Freezer Temperature: 12
Emergency Drinking Water Required: 96
Emergency Drinking Water Available: 72
Residents Evacuated: 32
Residents Present During Fire Drill: 33
Inspection Report — Feb 15, 2022
Renewal
Date: Feb 15, 2022
Visit Reason
The inspection was conducted as a renewal inspection of the facility license.
Findings
The submitted plan of correction was determined to be fully implemented. Deficiencies were related to medication record documentation, staff medication administration training, and support plan signature documentation, all of which were corrected with directed completion dates and verified implementation.
Citations (3)
Medication Administration Record did not indicate a diagnosis for a prescribed medication for Resident #2.
Staff persons administering medications had outdated or incomplete medication administration course reviews and observations.
The most recent support plan was not signed by Resident #1 and no notation was made regarding inability or refusal to sign.
Report Facts
Residents Served: 24
Current Residents in Hospice: 1
Residents Receiving Supplemental Security Income: 2
Residents Age 60 or Older: 24
Residents Diagnosed with Intellectual Disability: 1
Notice — Sep 14, 2021
Date: Sep 14, 2021
Visit Reason
The document serves as a renewal notification and issuance of a regular license for John Paul II Manor, a Personal Care Home, following receipt of the renewal application dated September 7, 2021.
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 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 and certificate of compliance. |
Notice — Nov 18, 2020
Date: Nov 18, 2020
Visit Reason
This document serves as a renewal notification and issuance of a regular license for John Paul II Manor Personal Care Home. It also advises that an annual onsite inspection will be conducted within the next twelve months as required by regulation.
Findings
No inspection findings are reported in this document. It confirms the issuance of a license following the renewal application and outlines the Department's intent to conduct a future inspection.
Inspection Report — Oct 2, 2019
Renewal
Date: Oct 2, 2019
Visit Reason
The inspection was a renewal visit to review compliance and verify the implementation of the submitted plan of correction for John Paul II Manor.
Findings
The facility was found to have fully implemented the plan of correction. Violations included lint accumulation in the laundry dryer, fire drill evacuation time exceeding the required limit, and unsecured medications in the staff room. Corrective actions and staff re-education were completed.
Citations (3)
2600.105.g: A dryer in the Laundry Room had a thick accumulation of lint in the filter and was not in use at the time of observation.
2600.132.d: The fire drill held on 8/16/19 took 6 minutes and 38 seconds to evacuate 35 residents, exceeding the designated 5 minutes 30 seconds limit.
2600.183.b: Medications and syringes were found unlocked on a table in a staff room with no staff present, accessible to residents.
Report Facts
Residents Served: 33
Evacuation time: 398
Residents evacuated: 35
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sister Mary Andrew | Administrator | Named in multiple findings and plan of correction approvals. |
Notice — Sep 13, 2019
Date: Sep 13, 2019
Visit Reason
The document is a renewal application acknowledgment and license issuance for John Paul II Manor, a Personal Care Home, confirming the facility's licensed capacity and informing about the requirement for annual inspections.
Findings
No inspection findings are reported in this document. It serves as a license renewal confirmation and notification of future annual inspections.
Report Facts
Inspection Report — Oct 3, 2018
Renewal
Date: Oct 3, 2018
Visit Reason
The inspection was a renewal licensing inspection conducted by the Department's Bureau of Human Services Licensing on October 3, 2018.
Findings
Multiple violations of 55 Pa.Code Chapter 2600 were found, including issues with contract signatures, food storage, medical evaluations, medication storage, and controlled substance accountability. Plans of correction were submitted addressing each violation with partial implementation progress noted.
Citations (6)
55 Pa.Code §2600.25(b) - The contract for Resident 1 was not signed by the administrator or designee, and resident and payer signatures were not dated.
55 Pa.Code §2600.103(g) - Food was found opened and unsealed in the freezer and walk-in refrigerator.
55 Pa.Code §2600.141(a)(2) - Medical evaluation forms for Residents 2 and 3 lacked documentation for body positioning, movement stimulation, and health status.
55 Pa.Code §2600.141(b)(1) - Resident 25's most recent medical evaluation was conducted on 5/2/18, with the previous one on 12/16/16, exceeding the annual requirement.
55 Pa.Code §2600.183(b) - Prescription and OTC medications were unlocked and accessible in Resident 4's bedroom.
55 Pa.Code §2600.185(b) - The home lacked a system of accountability for controlled substances, evidenced by no narcotic count for Lorazepam tablets for Resident 2.
Report Facts
Number of Residents Served: 30
Total Daily Staff: 30
Waking Staff: 23
Number of Violations: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary Andrew | Administrator | Named in relation to contract signature violation and plan of correction. |
| Jason McCloskey | Inspector conducting the inspection. | |
| Laura Hesmer | Inspector conducting the inspection. |
Notice — Sep 14, 2018
Date: Sep 14, 2018
Visit Reason
The document serves as a renewal notice for the Personal Care Home license for John Paul II Manor, confirming receipt of the renewal application and informing about the upcoming annual inspection within the next twelve months.
Findings
No inspection findings are reported in this document; it only confirms the license renewal and states that an annual inspection will be conducted within the next year.
Inspection Report — Nov 30, 2017
Renewal
Date: Nov 30, 2017
Visit Reason
The inspection was a renewal licensing inspection conducted by the Department of Human Services on November 30, 2017, for John Paul II Manor.
Findings
The inspection found violations of 55 Pa.Code Chapter 2600 related to Personal Care Homes, including incomplete medical evaluations and unsecured resident records. Plans of correction were submitted to address these issues.
Citations (2)
55 Pa.Code 2600.141(a)(1) - Medical evaluations for residents #1 and #2 did not include the dates of the evaluations as required within 60 days prior to admission or within 30 days after admission.
55 Pa.Code 2600.254(c) - Resident records were stored in an unlocked and accessible green filing cabinet containing confidential information, violating secure storage requirements.
Report Facts
Number of Residents Served: 32
Number of Residents Age 60 or Older: 30
Number of Residents with Mental Illness: 3
Number of Residents with Intellectual Disability: 3
Number of Residents Receiving Supplemental Security Income: 7
Number of Hospice Residents in Past Year: 3
Notice — Sep 15, 2017
Date: Sep 15, 2017
Visit Reason
This document serves as a renewal notification and license issuance for John Paul II Manor, a Personal Care Home, confirming the facility's authorized capacity and informing about 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 confirming license renewal and outlining future inspection requirements.
Report Facts
Inspection Report — Nov 17, 2016
Renewal
Date: Nov 17, 2016
Visit Reason
The inspection was conducted as an annual licensing renewal inspection of John Paul II Manor under 55 Pa.Code Ch. 2600 for Personal Care Homes.
Findings
The inspection identified multiple violations including missing emergency service phone numbers, improper documentation of blood glucose readings, absence of a current weekly activity calendar, and incomplete resident records. Plans of correction were submitted and some were fully implemented while others showed adequate progress.
Citations (4)
55 Pa.Code §2600.091 - Emergency service numbers posted near the main resident phone did not include the personal care home complaint hotline number.
55 Pa.Code §2600.187(b) - Medication administration records for Residents #1 and #2 did not properly document blood glucose readings as required.
55 Pa.Code §2600.221(c) - The home did not have a current weekly activity calendar posted in a public and conspicuous place.
55 Pa.Code §2600.252 - Records for Residents #2 and #4 did not include pictures that are less than 2 years old as required.
Report Facts
Number of Residents Served: 32
Total Daily Staff: 32
Waking Staff: 24
Residents Age 60 or Older: 29
Residents with Mental Illness: 3
Residents with Intellectual Disability: 3
Residents with Physical Disability: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sister Mary Andrew | Administrator | Named in relation to plan of correction signatures and administration |
| Jason McCloskey | On-site inspector for the inspection | |
| Laura Heemer | On-site inspector for the inspection |
Inspection Report — Sep 21, 2016
Renewal
Date: Sep 21, 2016
Visit Reason
The document is a renewal license issued in response to the facility's renewal application to operate a Personal Care Home. The Department advises that an onsite inspection will be conducted within the next twelve months as part of the annual inspection requirement.
Findings
No inspection findings are reported in this document. It primarily serves as a license renewal notification and outlines the Department's inspection policy for the upcoming year.
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