24 Reports
Notice — Nov 5, 2025
Date: Nov 5, 2025
Visit Reason
This document serves as a waiver approval for a direct care staff member at Legacy Place Cottages who obtained their education outside the United States, exempting them from the standard Pennsylvania nurse aide registry qualification.
Findings
The waiver is granted under specific conditions including documentation of education equivalency and record keeping by the facility. The Department will review the waiver annually during inspections to ensure compliance.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Theresa Hartman | Bureau Director, Human Services Licensing | Signed the waiver approval letter. |
Inspection Report — Sep 23, 2025
Renewal
Date: Sep 23, 2025
Visit Reason
The inspection was conducted as a renewal visit to review compliance with licensing requirements for Legacy Place Cottages.
Findings
The inspection identified multiple deficiencies related to safety, medication storage, food handling, and fire safety procedures. Plans of correction were accepted and implemented to address these issues.
Citations (11)
82c Poisonous materials were found unlocked and accessible to residents in the memory care unit and hair salon. None of the residents were assessed capable of safely using or avoiding these materials.
85d Trash receptacles in shared memory care bathrooms were missing lids, allowing potential insect and rodent penetration.
89b Hot water temperature in a bathroom sink exceeded the maximum allowed 120°F.
103e Food items in the memory care refrigerator were unlabeled and undated, including orange juice and eggs, violating food safety rules.
103f The memory care refrigerator lacked a thermometer, preventing temperature monitoring.
132d The facility exceeded the maximum safe evacuation time during multiple fire drills, with times ranging from 2 minutes 56 seconds to over 7 minutes.
132h During a fire drill, a resident under COVID-19 isolation precautions did not evacuate to a designated meeting place.
183b Medication cart and first aid kit were found unlocked and accessible; some medications were stored in residents' rooms without proper authorization.
183f Discontinued medication was found in the medication cart and not removed promptly.
184b Several opened bottles of OTC medication (TUMS) lacked resident identification labels.
233c Directions for operating key-locking devices were not conspicuously posted at the main exit door of the Secure Dementia Care Unit; keypad code was posted near the floor.
Report Facts
Residents Served: 36
Secured Dementia Care Unit Residents Served: 17
Current Hospice Residents: 8
Fire Drill Evacuation Times: 7
Inspection Report — Oct 17, 2024
Renewal
Date: Oct 17, 2024
Visit Reason
The inspection was conducted as a renewal visit to assess compliance with licensing requirements at Legacy Place Cottages.
Findings
The inspection identified several deficiencies related to food labeling, medication management, and adherence to prescriber orders. All deficiencies were addressed with plans of correction that were fully implemented by the time of the report.
Citations (5)
A partially used bag of frozen corn was found in the freezer without a label indicating the date it was opened.
A discontinued ointment medication was found in the medication cart for Resident #1.
Medication label for Resident #2 did not match the current PRN order and had incorrect administration instructions.
Medication administration record for Resident #2 lacked initials indicating medication was administered as scheduled on 10/2/24 at 9pm.
Resident #2 was administered a nasal saline spray instead of the prescribed nasal gel as per prescriber’s order.
Report Facts
Residents Served: 37
Secured Dementia Care Unit Residents Served: 16
Current Hospice Residents: 7
Residents with Mobility Need: 16
Residents 60 Years or Older: 37
Total Daily Staff: 53
Waking Staff: 40
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Wellness Director | Wellness Director | Named in medication-related deficiencies and responsible for training and compliance |
| Dining Manager | Dining Manager | Named in food storage deficiency and responsible for compliance audits |
Inspection Report — Mar 19, 2024
Follow-Up
Date: Mar 19, 2024
Visit Reason
The inspection was a partial, unannounced follow-up visit triggered by an incident to review the submitted plan of correction.
Findings
The submitted plan of correction was determined to be fully implemented. The incident involved unauthorized use of a resident's credit card by a staffing agency employee, who was blocked from the facility. Measures including staff training, criminal background checks, and resident education on financial safety were implemented.
Citations (1)
Unauthorized use of a resident's credit card by a staffing agency employee.
Report Facts
Residents Served: 40
Staffing Hours: 57
Waking Staff: 43
Secured Dementia Care Unit Residents Served: 16
Hospice Current Residents: 6
Residents Age 60 or Older: 40
Residents with Mobility Need: 17
Inspection Report — Sep 6, 2023
Renewal
Date: Sep 6, 2023
Visit Reason
The inspection was conducted as a renewal inspection with an incident review on 09/06/2023 at Legacy Place Cottages.
Findings
The submitted plan of correction was determined to be fully implemented. Deficiencies were found related to food storage labeling, refrigerator/freezer temperature monitoring, menu posting, medication management, and support plan revisions, all of which had corrective actions planned and implemented.
Citations (5)
An undated white frozen beverage in an Arby's cup, resembling a milkshake, was found in the freezer of the home's kitchen.
The freezer located in the kitchen of the Personal Care Home did not contain a thermometer.
On 9-6-23 menus were posted through 9-9-23, not a week in advance as required.
Resident 1 had a discontinued prescription medication (Guggul Extract 500 MG) still available in the medication cart on 9-6-23.
The Resident Assessment Support Plan for Resident 2 was not updated to include the significant change of multiple rib fractures.
Report Facts
Residents Served: 42
Secured Dementia Care Unit Residents Served: 16
Hospice Current Residents: 7
Total Daily Staff: 58
Waking Staff: 44
Resident with Mobility Need: 16
Residents 60 Years or Older: 42
Inspection Report — Jun 15, 2022
Renewal
Date: Jun 15, 2022
Visit Reason
The inspection was an unannounced full renewal inspection conducted on 06/15/2022 to review the facility's compliance with licensing requirements.
Findings
The submitted plan of correction was found to be fully implemented. Two medication-related deficiencies were identified involving incorrect medication administration records and failure to follow prescriber's orders, both of which were immediately remediated with staff training and process improvements.
Citations (2)
Medication record did not correctly indicate that a tablet should be cut in half and administered once daily.
Medication was withheld when it should have been administered due to a med tech misreading the order.
Report Facts
Residents Served: 38
Resident Support Staff: 15
Total Daily Staff: 68
Waking Staff: 51
Current Hospice Residents: 4
Residents with Mobility Need: 15
Residents 60 Years or Older: 38
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Wellness | Named in relation to medication record deficiency and corrective actions |
Inspection Report — Mar 28, 2022
Follow-Up
Date: Mar 28, 2022
Visit Reason
The inspection was a partial, unannounced follow-up visit triggered by an incident at the facility, specifically related to a plan of correction submission and review of compliance with prior deficiencies.
Findings
The facility was found to have fully implemented the submitted plan of correction related to failure to submit a final incident report and failure to update a resident's support plan after a significant incident. Continued compliance was emphasized.
Citations (2)
Failure to submit a final incident report regarding resident #1's hospitalization, skilled nursing rehabilitation discharge dates, and follow-up medical care.
Failure to update resident #1's support plan after a hospital evaluation and subsequent fall resulting in a hip fracture.
Report Facts
Residents Served: 40
Residents Served in Dementia Unit: 16
Hospice Residents: 7
Resident Support Staff Hours: 40
Total Daily Staff: 96
Waking Staff Hours: 72
Notice — Aug 27, 2021
Date: Aug 27, 2021
Visit Reason
The document serves as a renewal notification and license issuance for the Personal Care Home 'Legacy Place Cottages' following receipt of the renewal application dated June 4, 2021. It also advises that an annual inspection will be conducted within the next twelve months as required by regulation.
Findings
No inspection findings are reported in this document; it is a license renewal notice and certificate of compliance confirming the facility meets regulatory requirements as of the renewal date.
Report Facts
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary | Signed the renewal notification letter. |
Inspection Report — Aug 10, 2021
Renewal
Date: Aug 10, 2021
Visit Reason
The inspection was conducted as a renewal inspection of the facility's license.
Findings
The inspection identified deficiencies related to sanitary conditions, medical evaluation documentation, and medication storage procedures. Plans of correction were submitted and determined to be fully implemented.
Citations (3)
The strap holding the blood glucose monitor for Resident #1 had dried red material that appeared to be dried blood, creating unsanitary conditions.
Resident #2's medical evaluation form had edits made after being signed by non-licensed staff, which is not compliant with regulations.
Narcotic count sheets were not signed by the required staff on multiple dates and times, violating medication storage procedures.
Report Facts
Residents Served: 33
Residents Served in Dementia Unit: 14
Current Hospice Residents: 3
Residents with Mobility Need: 17
Staffing Hours - Resident Support Staff: 68
Staffing Hours - Total Daily Staff: 118
Staffing Hours - Waking Staff: 89
Inspection Report — Apr 15, 2021
Routine
Date: Apr 15, 2021
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.
Notice — Aug 10, 2020
Date: Aug 10, 2020
Visit Reason
This document serves as a license renewal notification and certificate of compliance for Legacy Place Cottages, a Personal Care Home. It informs the facility 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 issuance of a regular license following the renewal application.
Report Facts
Inspection Report — Jun 19, 2019
Annual Inspection
Date: Jun 19, 2019
Visit Reason
The visit was an annual inspection conducted by the Department’s Bureau of Human Services Licensing to assess compliance with 55 Pa. Code Ch. 2600 for Personal Care Homes.
Findings
Violations of 55 Pa. Code Ch. 2600 were found during the inspection, specifically related to resident record confidentiality. A binder containing confidential resident information was found unattended in a laundry room.
Citations (1)
55 Pa. Code Ch. 2600, Record Confidentiality: A binder containing confidential resident care information was found unattended on a counter in the North Wing laundry room.
Report Facts
Residents Served: 42
Secured Dementia Care Unit Residents Served: 16
Hospice Current Residents: 4
Residents with Mobility Need: 21
Residents 60 Years of Age or Older: 42
Notice — Jun 4, 2019
Date: Jun 4, 2019
Visit Reason
The document serves as a renewal approval for the Personal Care Home license and notifies the facility that an onsite annual inspection will be conducted within the next twelve months as required by state regulations.
Findings
No inspection findings are reported in this document. It confirms issuance of a license renewal and outlines the requirement for a future annual inspection.
Report Facts
Notice — Mar 1, 2019
Date: Mar 1, 2019
Visit Reason
The document serves as a notification of approval for a revised license increasing the capacity of the Secured Dementia Care Unit from 14 to 18 beds while maintaining the total personal care home capacity.
Findings
The Department of Human Services approved the capacity increase request for the Secured Dementia Care Unit. The overall licensed capacity for the personal care home remains unchanged at 48 beds.
Report Facts
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jacqueline L. Rowe | Director | Signed the approval letter for the revised license. |
Notice — Dec 13, 2018
Date: Dec 13, 2018
Visit Reason
The document is a license capacity revision approval for Legacy Place Cottages, increasing the maximum licensed capacity from 44 to 48 residents.
Findings
The Department of Human Services approved an increase in the facility's licensed capacity from 44 to 48 residents. The certificate and related documents confirm compliance with applicable regulations and the revised license is effective from December 17, 2018.
Report Facts
Inspection Report — Jun 13, 2018
Annual Inspection
Date: Jun 13, 2018
Visit Reason
The inspection was an annual licensing inspection conducted on June 13, 2018, with reasons listed as Renewal and Incident.
Findings
Multiple violations of 55 Pa. Code Chapter 2600 were found, including missing fee schedules in contracts, unsafe storage of poisonous materials, unlabeled food items, lint accumulation in laundry dryers, medication tampering, lack of resident education on medication refusal, incomplete pre-admission screening, missing resident assessment plans, and incomplete resident records.
Citations (9)
55 Pa.Code §2600.25(c)(2) - Resident contracts did not include a fee schedule listing allowable resident charges.
55 Pa.Code §2600.82(c) - Poisonous materials were not kept locked and inaccessible; bottles in resident rooms lacked proper warnings.
55 Pa.Code §2600.103(e) - Food items including tater tots and fish were not labeled or dated in the freezer.
55 Pa.Code §2600.105(9)(1) - Lint was found in the dryer lint trap, creating a fire hazard.
55 Pa.Code §2600.185(a) - Medication tampering was noted with missing medications and altered narcotic count sheets.
55 Pa.Code §2600.191 - Residents were not educated on their right to refuse medication and documentation was missing.
55 Pa.Code §2600.224(a) - Pre-admission screening was not completed for a resident prior to admission.
55 Pa.Code §2600.225(a) - Resident assessment plans were missing or misplaced for a resident.
55 Pa.Code §2600.252 - Resident records lacked required information including hair and eye color.
Report Facts
Number of Residents Served: 36
Number of Residents Served in Secured Dementia Care Unit: 12
Number of Current Hospice Residents: 6
Number of Hospice Residents in Past Year: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jessica Robbins | Administrator | Named as Administrator and legal entity representative responsible for plan of correction and violations. |
| Ryan Novak | Department representative on-site during inspection. |
Notice — Jun 6, 2018
Date: Jun 6, 2018
Visit Reason
This document serves as a renewal notification for the Personal Care Home license of Legacy Place Cottages and informs the facility of the Department's requirement to conduct 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.
Report Facts
Inspection Report — Jun 21, 2017
Renewal
Date: Jun 21, 2017
Visit Reason
The inspection was a renewal licensing inspection conducted by the Department of Human Services for Legacy Place Cottages.
Findings
Multiple violations of 55 Pa.Code Chapter 2600 were found, including missing carbon monoxide detectors, improper hot water temperatures, lack of thermometers in freezers, unreviewed emergency procedures, and issues with exit door signage and key-locking devices. Plans of correction were submitted for each violation with partial implementation noted.
Citations (11)
55 Pa.Code §2600 - The home lacks a Carbon Monoxide Detector in the basement where two natural gas fired hot water heaters are installed.
55 Pa.Code §2600.89(b) - Hot water temperature at sinks in resident rooms exceeded the maximum of 120°F, measuring 126.1°F and 125°F.
55 Pa.Code §2600.103(f) - The chest freezer in the secured building pantry lacks a thermometer to ensure proper food storage temperature.
55 Pa.Code §2600.103(g) - Food was stored in two unsealed bags in the main kitchen freezer without labeling or dating.
55 Pa.Code §2600.103(i) - A dented 105 oz. can of red beets was found in the dry food storage area and was discarded.
55 Pa.Code §2600.107(d) - The facility did not review, update, or submit emergency procedures to the local emergency management agency.
55 Pa.Code §2600.121(a) - The front door leading to the patio was locked without an exit sign, though it was posted as not an exit during inspection.
55 Pa.Code §2600.123(a) - The secondary egress door keypad was not working properly but was repaired during the inspection period.
55 Pa.Code §2600.124 - The home failed to notify the local fire department in writing of the home's address, capacity, floor plans, and memory care unit layout.
55 Pa.Code §2600.185(a) - The glucometer prescribed to resident #1 was not calibrated to the current date and time, and policies for safe storage and use of medication and equipment were not implemented.
55 Pa.Code §2600.233(c) - Directions for operation of key-locking devices and electronic cards were not posted near the devices in the secured dementia building.
Report Facts
Number of Residents Served: 24
Total Daily Staff: 33
Waking Staff: 25
Number of Residents Served in Secured Dementia Care Unit: 9
Number of Current Hospice Residents: 1
Number of Hospice Residents in Past Year: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jessica Robbins | Administrator | Named in multiple violation findings and plans of correction |
Notice — Jun 6, 2017
Date: Jun 6, 2017
Visit Reason
This document serves as a renewal approval for the Personal Care Home license and notifies 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 issuance of a regular license following the renewal application.
Report Facts
Notice — Apr 4, 2017
Date: Apr 4, 2017
Visit Reason
The document serves to notify the facility of a correction to the total licensed capacity on their recently issued license.
Findings
The revised license corrects the total licensed capacity of the personal care home to 44 residents or the maximum capacity permitted by the Certificate of Occupancy, whichever is smaller.
Report Facts
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jacqueline L. Rowe | Director | Signed the letter issuing the revised license. |
Notice — Oct 19, 2016
Date: Oct 19, 2016
Visit Reason
Issuance of a revised license due to recent adjustment of the use of physical space at the facility.
Findings
The revised license indicates a secured dementia care unit licensed capacity of 14 and a total maximum capacity of 30 residents. The license expiration date remains unchanged.
Report Facts
Inspection Report — Jun 28, 2016
Renewal
Date: Jun 28, 2016
Visit Reason
The inspection was a licensing inspection for renewal and provisional purposes conducted by the Department of Human Services on June 28, 2016, at Legacy Place Cottages, a personal care home.
Findings
Multiple violations of 55 Pa.Code Chapter 2600 were found, including issues with resident privacy, financial transaction accounting, resident contracts, quality management, criminal background checks, staff qualifications, staffing levels, staff orientation, direct care competency training, hot water temperature, bedroom lighting, food labeling, fire drills, medication management, and resident assessment updates. Plans of correction were submitted for each violation.
Citations (17)
2600.17 - Resident records were not kept confidential as privacy coding documents exposing residents' confidential information were posted publicly.
2600.20(b)(8) - The home failed to provide an itemized account of financial transactions on a quarterly basis for residents or their designated persons.
2600.25(a)(1) - A resident contract was not signed by the resident within 24 hours after admission.
2600.26(a) - The home did not develop or implement a quality management plan.
2600.51 - Criminal background checks for two direct care staff were not completed prior to their hire dates.
2600.54(a) - A direct care staff person did not have a high school diploma, GED, or active Pennsylvania nurse aide registry status as required.
2600.60(a) - Staffing was inadequate from 11pm to 7am on two dates, failing to meet residents' assessed needs for assistance and support.
2600.65(a) - A direct care staff person hired did not complete the department's initial direct care competency course before providing unsupervised ADL services.
2600.89 - Hot water temperature in the nurses' office was 122.3°F, exceeding the maximum allowed 120°F.
2600.101(j)(7) - A bedside lamp in a resident's room was not operable.
2600.103(i) - The freezer contained unlabeled and undated food items including waffles, chicken patties, and a bag of banana pieces.
2600.132(a) - The home failed to conduct fire drills in June 2015 and March 2016 as required monthly.
2600.132(e) - Fire drills were not conducted during sleeping hours every six months as required.
2600.171(b)(5) - The community vehicle's first aid kit did not contain a breathing shield.
2600.183(a)(1) - Prescription, OTC, and CAM medications were not kept in original labeled containers and were removed more than two hours before scheduled administration.
2600.185(a) - The home had not developed or implemented a policy for safe storage, access, security, distribution, and use of medications and medical equipment.
2600.225(c) - Resident #1's assessment and support plan were not updated annually or when significant changes occurred.
Report Facts
Total Daily Staff: 13
Waking Staff: 10
Number of Residents Age 60 or Older: 11
Number of Residents with Mental Illness: 1
Number of Residents with Mobility Need: 2
Number of Residents with Physical Disability: 3
Number of Current Hospice Residents: 0
Number of Hospice Residents in Past Year: 1
Hot Water Temperature: 122.3
Date of Previous Violation: Nov 6, 2015
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Michael Cimerola | Administrator | Signed multiple pages of the violation report and plan of correction |
| Micha Killgore | Administrator | Named as administrator on violation report header |
| Ryan Novak | On-site inspector for the Department of Human Services | |
| Cindy Yellenic | On-site inspector for the Department of Human Services |
Notice — Mar 15, 2016
Date: Mar 15, 2016
Visit Reason
This document serves as a waiver approval for a direct care staff person at Legacy Place Cottages to be employed while finishing her GED, under specific conditions.
Findings
The waiver is granted under conditions including attendance at an accredited educational institution and submission of GED documentation. The waiver expires on December 31, 2016, after which full compliance is expected.
Report Facts
Waiver expiration date: Dec 31, 2016
Pa.Code Chapter: 2600
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Matthew Jones | Director | Signed the waiver approval letter. |
Inspection Report — Jan 21, 2016
Interim
Date: Jan 21, 2016
Visit Reason
The inspection was an interim licensing inspection conducted to identify violations related to Personal Care Homes under 55 Pa.Code Chapter 2600.
Findings
Multiple violations were found including failure to post the current licensing inspection summary, failure to immediately report suspected abuse, failure to evacuate a hospice resident during fire drills, incomplete resident assessments and support plans, inadequate staff training on emergency procedures, unsecured medications, and incomplete medication administration records.
Citations (10)
55 Pa.Code §2600.3(c): The most current Licensing Inspection Summary report completed on 11/6/2015 was not posted in a public and conspicuous place within the facility.
55 Pa.Code §2600.15(a): The home failed to immediately report suspected abuse of a resident as required by the Older Adults Protective Services Act.
55 Pa.Code §2600.29a(b)(2): Resident receiving Hospice Services was not evacuated during fire drills on 11/30/15 and 12/15/15, and no written informed consent was obtained from the resident or legal representative indicating no evacuation.
55 Pa.Code §2600.29a(b)(4): Staff failed to immediately evacuate a hospice resident during fire drills and did not receive training on evacuation procedures.
55 Pa.Code §2600.29a(b)(10): Resident's assessment and support plan did not include evacuation procedures for fire drills or actual fire events.
55 Pa.Code §2600.65(a): Direct care staff persons C, D, and E were not trained in required emergency preparedness areas prior to or during their first work day.
55 Pa.Code §2600.141(a)(2): Medical evaluation for resident #1 did not indicate the requirement or need for 3/4 length bed rails in place.
55 Pa.Code §2600.183(b): Medications and syringes were not kept locked; resident #2's medication cabinet door was unlocked and accessible to other residents.
55 Pa.Code §2600.187(a): Medication administration records for multiple residents did not include diagnosis or purpose for medications administered.
55 Pa.Code §2600.225(c): Resident #1's assessment and support plan did not indicate that bed rails were in place or how staff would ensure safety while bed rails are used.
Report Facts
Number of Residents Served: 11
Total Daily Staff: 12
Walking Staff: 9
Number of Residents Age 60 or Older: 11
Number of Residents with Mobility Need: 1
Number of Residents with Physical Disability: 3
Number of Current Hospice Residents: 1
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