Inspection Reports for
Juniper Village at Mount Joy

PA, 17552

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21 Reports

2016–2026

Inspection Report — Jan 13, 2026

Complaint Investigation
Date: Jan 13, 2026

Visit Reason
The inspection was conducted as a complaint and incident investigation with an unannounced partial inspection on 01/13/2026 and 01/14/2026.

Complaint Details
The inspection was complaint-related and incident-based, with findings substantiated through review of medication administration records, resident assessments, and documentation of medication refusals and errors.
Findings
The inspection identified multiple deficiencies related to medication administration, refusal of medication notification, following prescriber's orders, medication error reporting, resident assessments, and record content. Plans of correction were accepted and implemented by 03/03/2026.

Citations (8)
187b - Medication Administration Records did not include initials of staff who administered medications to a resident in November and December 2025.
187c - The home failed to notify the physician of a resident's refusals of prescribed medications on multiple dates in 2025.
187d - The home did not follow prescriber's orders by administering discontinued medication and under-administering prescribed medication doses.
188b - A medication error was not reported immediately to the resident, designated person, or prescriber as required.
225a - Resident initial assessment did not include assessment of medical need or plan to meet medical need for diagnosed conditions.
225c - Resident's assessment was not updated to reflect increased supervision needs after exit-seeking behavior and elopement.
251c - Resident medical evaluation records were not completed on the Department’s current standardized form.
252 - Resident's record did not include hospital records or discharge summaries for a hospitalization.
Report Facts
Residents Served: 53 Current Hospice Residents: 2 Resident Medication Refusals: 6 Total Daily Staff: 66 Waking Staff: 50

Inspection Report — Sep 3, 2025

Renewal
Date: Sep 3, 2025

Visit Reason
The inspection was conducted as a renewal visit to review compliance with licensing regulations at Juniper Village at Mount Joy.

Findings
The inspection identified multiple deficiencies including unsecured bedrails posing entrapment hazards, uncovered food items in storage, lint accumulation in dryer lint traps, dietary needs not fully met, presence of discontinued medication in the medication cart, loose medication pills found on the floor, and incomplete resident assessments and support plan signatures. All deficiencies had plans of correction accepted and were implemented by October 14, 2025.

Citations (8)
Bedrails located on both sides of resident #1's bed were not firmly secured, posing a potential entrapment or injury hazard.
Uncovered 3-gallon container of vanilla ice cream and uncovered box of lettuce, carrots and celery stored in walk-in freezer and refrigerator.
Approximate 1/2-inch accumulation of lint in the lint trap of the dryer located in the 200-hall laundry room.
Resident #1 was prescribed an advanced chopped diet but was served half of a bologna, lettuce and tomato sandwich.
Calmoseptine ointment prescribed for resident #1 was in the medication cart but was discontinued on 7/30/25.
One loose pink pill was found on the floor in the 400-hallway near resident room #402.
Resident #2’s current assessment did not indicate the need for the resident to sleep in a recliner rather than a bed.
Resident #2 participated in the development of support plan but neither the resident nor the assessor signed the support plan.
Report Facts
Residents Served: 55 Current Hospice Residents: 1 Residents 60 Years or Older: 55 Residents Diagnosed with Mental Illness: 1 Residents with Mobility Need: 3 Total Daily Staff: 58 Waking Staff: 44

Employees mentioned
NameTitleContext
Medical ConciergeReviewed RASP with resident, obtained resident signature and provided assessor signature at time of survey
EVS DirectorTightened bedrails, audited bedrails and dryer lint traps, educated team on regulations
Dining DirectorDiscarded unprotected food items, audited refrigerators, educated team on food protection and dietary needs
DOWRemoved discontinued medication, educated medication team, audited medication carts and administration
EDEducated team on dietary needs, medication regulations, additional assessments, and support plan requirements

Inspection Report — Jun 30, 2025

Complaint Investigation
Date: Jun 30, 2025

Visit Reason
The inspection was conducted as a complaint investigation with unannounced partial inspections on 06/30/2025 and 07/02/2025 to review compliance with submitted plans of correction.

Complaint Details
The visit was complaint-related, triggered by concerns about resident safety and care following multiple elopement incidents. The complaint was substantiated as deficiencies were found related to supervision, safety checks, and resident assessments.
Findings
The inspection identified multiple deficiencies including failure to complete required 15-minute safety checks for residents following elopements, incomplete resident contracts lacking required level of care assessments, incidents of resident elopement resulting in injury and hospitalization, unlocked medication cart drawer exposing medications, difficulty unlocking an egress door, and incomplete resident assessments including medication self-administration ability. Plans of correction were accepted and implemented by 09/29/2025.

Citations (6)
Failure to complete 15-minute safety checks on residents following elopements as required by their assessment and support plans.
Resident home contract did not include the level of care assessment required to determine personal care services upon admission.
Resident elopement incident resulting in resident being found approximately 1 mile from home, diagnosed with dehydration, heat exhaustion, and acute kidney injury.
Left side of doubled-door in 400-Hallway activity room was difficult to unlock and took considerable effort to open.
Top drawer of medication cart was unlocked, unattended, and accessible exposing resident medications.
Resident assessments did not include critical information such as inability to communicate needs, allergies, financial management, mobility status, and ability to self-administer medications.
Report Facts
Residents Served: 59 Current Hospice Residents: 5 Total Daily Staff: 60 Waking Staff: 45

Inspection Report — May 29, 2025

Follow-Up
Date: May 29, 2025

Visit Reason
The inspection was a partial, unannounced incident review conducted on 05/29/2025 to evaluate the facility's compliance with submitted plans of correction.

Findings
The facility was found to have medication administration errors and incomplete resident assessments, but the submitted plan of correction was determined to be fully implemented and compliance maintained.

Citations (2)
Medication administration errors including missed and mistimed medications for multiple residents.
Resident initial assessment did not include an assessment for moderate mobility as indicated on the resident’s initial medical evaluation.
Report Facts
Residents Served: 58 Total Daily Staff: 59 Waking Staff: 44 Medication Errors: 6 Plan of Correction Completion Date: Jun 25, 2025

Employees mentioned
NameTitleContext
Director of WellnessProvided live training on medication administration and responsible for audits
Executive DirectorResponsible for education and audits related to resident assessments and medication administration

Inspection Report — Jan 8, 2025

Follow-Up
Date: Jan 8, 2025

Visit Reason
The inspection was a partial, unannounced follow-up visit conducted due to an incident, to review the submitted plan of correction for the facility.

Findings
The facility was found to have multiple deficiencies related to medication administration and record confidentiality, including an unlocked computer with resident medication records, ungloved medication counting, unlocked medication carts, unlabeled OTC medications, and incomplete medication administration records. All deficiencies had accepted plans of correction and were implemented by early February 2025.

Citations (5)
The computer on top of the 300-hallway medication cart was unlocked, unattended, and accessible, allowing anyone to view medication and treatment records.
Staff was observed using an ungloved hand to count resident tablets.
A medication cart containing treatments was unlocked, unattended, and accessible in the corner of the 300-hallway lounge.
A tube and two tubs of OTC medications belonging to a resident were not labeled with the resident's name.
Resident medication administration record did not include the initials of the staff person who administered medication at 0600.
Report Facts
Residents Served: 64 Total Daily Staff: 66 Waking Staff: 50 Current Residents in Hospice: 1 Residents Diagnosed with Mental Illness: 3 Residents Age 60 or Older: 64 Residents with Mobility Need: 2 Residents with Physical Disability: 1

Inspection Report — Dec 4, 2024

Follow-Up
Date: Dec 4, 2024

Visit Reason
The inspection visit was conducted as a follow-up to verify the correction of previously identified deficiencies related to medication errors and incident reporting.

Complaint Details
The inspection was complaint-related and incident-related as indicated by the reason for inspection. Specific substantiation status is not stated.
Findings
The facility was found to have multiple medication administration errors, including missed doses, extra doses, and inaccurate medication records. The facility submitted a plan of correction which was accepted and implemented by January 8, 2025.

Citations (3)
Failure to report medication errors to the Department within 24 hours as required.
Medication administration record (MAR) inaccurately documented medications as given when they were not administered.
Failure to follow prescriber's orders resulting in missed doses and extra doses of medications.
Report Facts
Residents served: 61 Staffing hours: 61 Staffing hours: 46 Current residents in hospice: 2 Residents age 60 or older: 61 Residents with physical disability: 1

Notice — Nov 8, 2024

Date: Nov 8, 2024

Visit Reason
The document is a response to a 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 training requirements including successful completion of a Department-approved medication administration course, in-person training by a licensed health care professional, and annual training hours related to GLP-1 agonist medications and diabetes management. The facility must have policies and clinical contacts in place to monitor and support medication administration.

Employees mentioned
NameTitleContext
Theresa HartmanBureau Director, Human Services LicensingSigned the waiver approval letter.

Inspection Report — Oct 24, 2024

Complaint Investigation
Date: Oct 24, 2024

Visit Reason
The inspection was conducted as a complaint and incident investigation at Juniper Village at Mount Joy.

Complaint Details
The inspection was triggered by a complaint and incident, 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
Total Daily Staff: 63 Waking Staff: 47 Resident Support Staff: 0 Residents Served: 63 Current Hospice Residents: 2 Residents Age 60 or Older: 63 Residents Diagnosed with Mental Illness: 2 Residents with Physical Disability: 1

Inspection Report — Sep 6, 2023

Renewal
Date: Sep 6, 2023

Visit Reason
The inspection was conducted as a renewal review of the assisted living facility license, including a full unannounced inspection from 09/06/2023 to 09/08/2023.

Findings
The inspection identified multiple deficiencies including failure to post the current licensing inspection summary, missing medical evaluations prior to admission, lack of involvement in quality management plans, staff qualification issues, inadequate first aid/CPR coverage, incomplete staff training documentation, missing items in the first aid kit, missed fire drills and incomplete fire drill records, incomplete medical evaluations and assessments, medication storage and usage issues, and failure to conduct quarterly reviews of resident support plans. All deficiencies had plans of correction accepted and were implemented by late November 2023.

Citations (16)
Failure to post the current Licensing Inspection Summary in a conspicuous and public place.
No documentation of a medical evaluation prior to admission for Resident #1.
Assisted living portion of the community not involved in quality management plan reviews or meetings.
Direct care staff persons A and B lacked required high school diploma, GED, or active nurse aide registry status.
No staff trained in first aid and certified in obstructed airway techniques and CPR present during specified shifts.
Direct care staff persons A and B providing unsupervised assisted living services without completing required direct care training and competency test.
Monthly staff training documentation ceased in April 2023 and was incomplete for required courses.
First aid kit at nurse's station missing tweezers.
Unannounced fire drills not held during January, July, and August 2023.
Fire drill records for 5/9/23 and 6/15/23 missing key information including evacuation time, number of residents and staff evacuated, and exit routes used.
Medical evaluations for Residents #2 and #3 missing documentation of tuberculin skin test or chest X-ray results.
Resident #1's most recent medical evaluation and previous evaluation dates missing or incomplete.
Medication prescribed for Resident #2 was not available in the residence as required.
Used tube of medication found in first aid kit belonged to a discharged resident.
Resident #1 and #3 assessments were not completed annually as required.
Resident #1, #2, and #3 support plans were not reviewed quarterly as required.
Report Facts
Residents served: 26 Total daily staff: 26 Waking staff: 20 Dates of inspection: 3 Fire drills missed: 3 Residents without medical evaluation prior to admission: 1

Employees mentioned
NameTitleContext
Denise GeibAdministratorEducated staff on posting Licensing Inspection Summary and other regulatory requirements
Clinical CoordinatorResponsible for maintaining ADME tracking tool, staff education, medication audits, and training coordination
Human Resource DirectorEducated on direct care staff qualification requirements and new hire paperwork
Nursing AssistantScheduled staff for CPR/First Aid training and provided tracking sheet to Administrator
Maintenance DirectorReviewed fire drill regulations and coordinated fire drill documentation

Inspection Report — May 4, 2022

Renewal
Date: May 4, 2022

Visit Reason
The inspection was conducted as a renewal and complaint-related visit to assess compliance and review the submitted plan of correction.

Complaint Details
The inspection included a complaint investigation component, but no substantiation status was explicitly stated.
Findings
The facility was found to have deficiencies related to hospice care physician certification, hot water temperature exceeding 120°F in multiple locations, lack of operable thermometers in the kitchen refrigerator and freezer, and incomplete preadmission screening forms. All plans of correction were accepted and fully implemented by the follow-up dates.

Citations (4)
Resident receiving hospice care was not evacuated during a fire drill without a written physician certification that the resident is actively dying and may suffer injury or hastened death.
Hot water temperature exceeded 120°F at multiple bathroom sinks and laundry tub.
No operable thermometer in the refrigerator or freezer in the 300 hallway kitchen.
Preadmission screening form for a resident was incomplete, missing the title of the person completing the screening and other required information.
Report Facts
Residents Served: 70 Hot Water Temperature: 125.1 Hot Water Temperature: 124.4 Hot Water Temperature: 124.1 Hot Water Temperature: 122.3 Total Daily Staff: 71 Waking Staff: 53 Current Hospice Residents: 6

Employees mentioned
NameTitleContext
Executive ChefNamed in relation to replacing non-operable thermometers in kitchen refrigerator and freezer.
Environmental Services Director (ESD)Responsible for checking and adjusting hot water temperatures and ensuring compliance.
Medical Concierge or Director of WellnessResponsible for obtaining physician orders for hospice residents not to evacuate during fire drills.
AdministratorResponsible for ensuring completion of preadmission screening forms.

Inspection Report — Feb 3, 2022

Plan of Correction
Date: Feb 3, 2022

Visit Reason
The inspection was conducted as a follow-up to verify that the submitted plan of correction was fully implemented following a prior incident.

Findings
The facility was found to have fully implemented the submitted plan of correction related to medication refusal documentation. Continued compliance must be maintained.

Citations (1)
Resident 1 refused to take a scheduled dose of multiple medications and the home did not document this in the resident's record nor notify the prescriber of the refusals.
Report Facts
Residents Served: 72

Employees mentioned
NameTitleContext
Gloria EmickSigned the letter confirming plan of correction implementation
Director of WellnessProvided verbal education to medication technician as part of plan of correction

Notice — Mar 14, 2021

Date: Mar 14, 2021

Visit Reason
This document serves as a renewal notification and license issuance for Juniper Village at Mount Joy, a Personal Care Home, confirming the facility's compliance and informing that an annual onsite 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 annual inspection will be conducted to ensure compliance with applicable regulations.

Report Facts

Employees mentioned
NameTitleContext
Jamie L. BuchenauerDeputy Secretary, Office of Long-term LivingSigned the renewal notification letter.

Inspection Report — Dec 17, 2019

Renewal
Date: Dec 17, 2019

Visit Reason
The inspection was a renewal visit conducted by the Pennsylvania Department of Human Services, Bureau of Human Services Licensing, to review compliance at Juniper Village at Mount Joy.

Findings
The submitted plan of correction was found to be fully implemented following the inspection. Two deficiencies related to medication storage and medication administration documentation were identified and corrected.

Citations (2)
2600.181d: Resident self-administered medications were found unlocked and unattended in a resident's room, violating secure storage requirements.
2600.185a: Blood sugar readings in Resident #2's glucometer did not match readings documented on the medication administration record.
Report Facts
Residents Served: 60 Current Hospice Residents: 4

Employees mentioned
NameTitleContext
Debra K. MillerExecutive DirectorNamed in plan of correction signatures and correspondence.
Kellie CorgileOn-site department representative during inspection.
Michael PalermoOn-site department representative during inspection.
Gloria EmickHuman Services Licensing SupervisorSigned letter confirming plan of correction implementation.

Notice — Nov 27, 2019

Date: Nov 27, 2019

Visit Reason
The document serves as a renewal notice and certificate of compliance for Juniper Village at Mount Joy LLC to operate a Personal Care Home. It 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 — Feb 6, 2019

Renewal
Date: Feb 6, 2019

Visit Reason
The visit was a renewal licensing inspection conducted by the Department's Bureau of Human Services Licensing on February 6, 2019.

Findings
The inspection found violations related to medication administration, specifically incorrect insulin dosing for a resident. A plan of correction was submitted and partially implemented.

Citations (1)
Regulation 55 Pa.Code 62600 2600.187(d): The home did not follow the directions of the prescriber when a resident was prescribed 6 units of Humalog insulin three times daily unless blood sugar was below 150. On 1/31/2019, the resident had a blood sugar reading of 143 but was administered 6 units of insulin by Staff Person A.
Report Facts
Number of Residents Served: 56 Number of Current Hospice Residents: 4 Number of Hospice Residents in Past Year: 10 Number of Residents 60 Years or Older: 56 Number of Residents with Mobility Need: 3 Number of Residents with Physical Disability: 1

Notice — Nov 28, 2018

Date: Nov 28, 2018

Visit Reason
This document serves as a renewal notification for the Personal Care Home license of Juniper Village at Mount Joy and includes the certificate of occupancy specifying the maximum capacity.

Findings
No inspection findings are reported in this document. It confirms the issuance of a regular license and states the Department's requirement to conduct an annual onsite inspection within the next twelve months.

Inspection Report — Feb 8, 2018

Renewal
Date: Feb 8, 2018

Visit Reason
The inspection was a renewal licensing inspection conducted by the Pennsylvania Department of Human Services on February 8, 2018.

Findings
A violation was found related to training topics for direct care staff for the 2017 training year. The facility did not provide required training in several areas for two direct care staff members.

Citations (1)
55 Pa.Code §2600.65(f) requires annual training for direct care staff on specified topics. Two direct care staff members did not receive training on meeting resident needs, personal care service needs, and care for residents with mental illness for the 2017 training year.
Report Facts
Number of Residents Served: 61 Total Daily Staff: 63 Waking Staff: 47 Number of Current Hospice Residents: 6 Number of Hospice Residents in past year: 17 Number of Residents Age 60 or Older: 61 Number of Residents with Mental Illness: 8 Number of Residents with Mobility Need: 2

Inspection Report — Nov 29, 2017

Renewal
Date: Nov 29, 2017

Visit Reason
The document is a renewal application and license issuance for Juniper Village at Mount Joy Personal Care Home. 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 certificate issuance.

Inspection Report — Mar 20, 2017

Renewal
Date: Mar 20, 2017

Visit Reason
The inspection was conducted as an annual licensing renewal inspection of Juniper Village at Mount Joy to assess compliance with 55 Pa.Code Chapter 2600 relating to Personal Care Homes.

Findings
Violations were found related to the failure to document a resident's refusal or inability to sign the support plan. A plan of correction was submitted to address the documentation deficiencies and ensure proper review and signatures on support plans.

Citations (1)
55 Pa.Code §2600.227(h) requires documentation if a resident is unable or refuses to sign the support plan. The support plans dated 11/30/2016 and 12/20/2016 were not signed by the resident and did not document refusal or inability to sign.
Report Facts
Number of Residents Served: 58 Total Daily Staff: 58 Waking Staff: 44 Number of Current Hospice Residents: 1 Number of Hospice Residents in past year: 12 Number of Residents Age 60 or Older: 58 Number of Residents with Physical Disability: 1

Employees mentioned
NameTitleContext
Debra K. MillerAdministratorNamed in plan of correction and violation report
Laura HeemerOn-site inspector conducting the inspection
Kelly ComstockOn-site inspector conducting the inspection

Notice — Nov 23, 2016

Date: Nov 23, 2016

Visit Reason
Notification of renewal application and issuance of a regular license for Juniper Village at Mount Joy Personal Care Home pursuant to Title 55, PA Code, Chapter 2600.

Findings
The Department will conduct an onsite inspection within the next twelve months to ensure compliance with applicable laws and regulations. Enforcement action will be taken if noncompliance is found.

Inspection Report — Mar 3, 2016

Annual Inspection
Date: Mar 3, 2016

Visit Reason
The Department of Human Services conducted an annual licensing inspection of Juniper Village at Mount Joy on March 3, 2016.

Findings
The facility was found to be in compliance with 55 Pa.Code Chapter 2600 relating to Personal Care Homes.

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