Inspection Reports for
Linden Village

PA, 17042

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26 Reports

2016–2026

Inspection Report — Feb 25, 2026

Complaint Investigation
Date: Feb 25, 2026

Visit Reason
The inspection was a partial, unannounced complaint investigation conducted due to a complaint received by the Pennsylvania Department of Human Services.

Complaint Details
The inspection was triggered by a complaint alleging neglect and privacy violations. The complaint was substantiated based on findings of unreported neglect incidents and privacy breaches.
Findings
The inspection identified multiple deficiencies including failure to report alleged neglect incidents timely, privacy violations involving unauthorized photographs, incomplete and inaccurate medication records, failure to report medication refusals to prescribers, and outdated resident assessments. Plans of correction were submitted and accepted with follow-up dates scheduled.

Citations (8)
16c - The home failed to report incidents of alleged neglect involving a resident with soiled briefs and skin irritation to the Department within 24 hours as required.
42s - A staff member took unauthorized photographs of a resident with a personal cell phone, violating resident privacy rights.
141b1 - A resident's most recent annual medical evaluation was not completed as required.
187a - Medication records lacked documentation of diagnosis or purpose for prescribed medications for a resident.
187b - Medication administration records did not include staff initials for wound care treatments at the time of administration on multiple occasions.
187c - The home failed to report resident refusals of scheduled medications and wound care treatments to the prescriber within 24 hours.
187d - The home did not follow prescriber's orders for wound care treatment, prematurely discontinuing treatment without physician authorization.
225c - Resident assessments were not updated to reflect significant changes in condition, including mobility and incontinence needs.
Report Facts
Residents Served: 59 Secured Dementia Care Unit Residents Served: 45 Hospice Current Residents: 11 Residents 60 Years or Older: 59 Residents with Mobility Need: 49 Total Daily Staff: 108 Waking Staff: 81

Notice — Jun 9, 2025

Date: Jun 9, 2025

Visit Reason
Response to a facility request to use the Safely You Falls Management Program to support fall detection and management for individuals with cognitive impairment.

Findings
The Department reviewed the submitted information and determined that the informed consent process includes voluntary participation, the right to discontinue use of cameras, and notification of residents' rights. The letter clarifies that maintaining the outlined practices satisfies regulatory privacy requirements but does not endorse the program.

Inspection Report — Jan 7, 2025

Renewal
Date: Jan 7, 2025

Visit Reason
The inspection was conducted as a renewal inspection with an incident review at the facility on 01/07/2025 and 01/08/2025.

Findings
The inspection found violations related to resident abuse, medication procedures, and medication administration documentation. Immediate corrective actions were taken, and plans of correction were implemented and overseen by the Executive Director to ensure ongoing compliance.

Citations (3)
Resident #1 hit Resident #2 causing injury; failure to prevent abuse and ensure resident safety.
Discrepancy in narcotic medication count for Resident #6; failure to properly document medication administration on narcotic count sheet.
Medication administration documentation was completed before medications were actually administered to Resident #3.
Report Facts
Residents Served: 52 Residents Served in Dementia Unit: 36 Current Hospice Residents: 7 Residents 60 Years or Older: 51 Residents with Mobility Need: 38 Staff Total Daily: 90 Staff Waking: 68 Medication doses available: 43 Medication doses recorded: 44

Inspection Report — Sep 27, 2024

Complaint Investigation
Date: Sep 27, 2024

Visit Reason
The inspection was conducted as a complaint and incident investigation during an unannounced partial licensing inspection.

Complaint Details
The inspection was complaint-related and included an incident review; no deficiencies were found and no follow-up was required.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.

Report Facts
Total Daily Staff: 105 Waking Staff: 79 Resident Support Staff: 0 Residents Served: 57 Secured Dementia Care Unit Residents Served: 46 Hospice Current Residents: 9 Residents Age 60 or Older: 56 Residents with Mobility Need: 48

Inspection Report — Jan 31, 2024

Renewal
Date: Jan 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 01/31/2024 and 02/01/2024.

Findings
The inspection identified multiple deficiencies including lack of a carbon monoxide alarm near a gas stove, unsecured poisonous materials accessible to residents in the secured dementia care unit, unsanitary conditions with urine odor detected, unlabeled leftover food items, failure to evacuate to designated meeting places during fire drills, expired medications in the medication cart, medication administration errors, and missing resident signatures on support plans. Plans of correction were accepted and implemented by 02/16/2024.

Citations (9)
No carbon monoxide alarm installed within 15 feet of gas stove in main kitchen.
Poisonous materials (mouthwash, toothpaste, deodorant) unlocked and accessible to residents in secured dementia care unit.
Pungent odor of urine detected in family room near bedrooms 1-8 of Mt. Hope cottage.
Unlabeled, undated container of individually wrapped chocolate chip and sugar cookies found in bottom kitchenette cabinet in Tabor cottage.
Residents did not evacuate to designated meeting places during multiple fire drills in various cottages.
Expired medications found in home's medication cart for Resident 6.
Discrepancy in controlled substance log for Resident 4's lorazepam medication; packet contained fewer tablets than recorded.
Medication administration errors: Resident 3 missed prescribed medication doses; Resident 5 received medication daily instead of monthly.
Residents 1, 2, and 3 participated in support plan development but did not sign or indicate inability to sign the support plan.
Report Facts
Residents Served: 52 Residents in Secured Dementia Care Unit: 34 Staffing Hours: 87 Waking Staff: 65 Current Hospice Residents: 1 Residents with Mobility Need: 35 Residents Age 60 or Older: 52

Inspection Report — Mar 6, 2023

Date: Mar 6, 2023

Visit Reason
The inspection was conducted as a partial, unannounced visit due to an incident at the facility.

Findings
No regulatory citations or deficiencies were identified as a result of this inspection.

Report Facts
Total Daily Staff: 70 Waking Staff: 53 Residents Served: 38 Residents Served in Dementia Care Unit: 31 Current Residents in Hospice: 2 Residents Age 60 or Older: 37 Residents with Mobility Need: 32

Inspection Report — Jan 31, 2023

Renewal
Date: Jan 31, 2023

Visit Reason
The inspection was conducted as a renewal review of the facility's compliance with licensing regulations.

Findings
The report found multiple deficiencies including ventilation issues in bathrooms, overdue fire safety inspection and drill, missing annual medical evaluations for residents, discrepancies in medication storage and documentation, and incomplete preadmission screening forms. Plans of correction were accepted and implemented.

Citations (5)
Bathrooms in four buildings lacked operable windows and exhaust fans had no switches; vents in two buildings had no air circulation.
The last fire safety inspection and drill by a fire safety expert was overdue, last conducted on 01/21/2022 with a prior gap since 08/19/2019.
Two residents did not have annual medical evaluations completed for 2022.
Blood glucose readings for a resident did not match the numbers transcribed on the Medication Administration Record (MAR).
The preadmission screening form for a resident lacked the date of completion and signature.
Report Facts
Residents Served: 34 Memory Care Residents Served: 26 Hospice Current Residents: 3 Residents Age 60 or Older: 33 Residents with Mobility Need: 1

Inspection Report — Aug 2, 2022

Follow-Up
Date: Aug 2, 2022

Visit Reason
The inspection was a partial, unannounced follow-up visit triggered by an incident to verify the implementation of a previously submitted plan of correction.

Complaint Details
The visit was related to an incident involving alleged resident abuse reported by an outside agency on 07/14/2022. The complaint was substantiated by the facility's failure to timely report and notify as required, but corrective actions were accepted and implemented.
Findings
The facility was found to have fully implemented the plan of correction related to timely reporting and notification of suspected resident abuse. The Executive Director submitted required abuse reports and conducted in-service training for staff to ensure compliance with reporting regulations.

Citations (2)
Failure to immediately report suspected abuse of a resident within 48 hours as required by the Older Adult Protective Services Act.
Failure to immediately notify the resident's designated person of a report of suspected abuse involving the resident.
Report Facts
Residents Served: 40 Residents Served in Dementia Unit: 29 Current Hospice Residents: 2 Residents 60 Years or Older: 40 Residents with Mobility Need: 29 Total Daily Staff: 69 Waking Staff: 52

Employees mentioned
NameTitleContext
Employee ANamed in findings related to failure to timely report and notify suspected abuse; received in-service training by the Executive Director.
Executive DirectorSubmitted the Act 13 Mandatory Abuse form and conducted in-service training for staff regarding abuse reporting and notification requirements.

Inspection Report — Jun 9, 2021

Follow-Up
Date: Jun 9, 2021

Visit Reason
The inspection was conducted as a follow-up to verify the implementation of a previously submitted plan of correction, triggered by renewal and complaint reasons.

Findings
The submitted plan of correction was determined to be fully implemented. Multiple deficiencies related to contract signatures, multiple buildings staffing, medication administration, following prescriber's orders, support plan signatures, admission support plans, and support plan needs elements were identified and addressed with corrective actions and completion dates.

Citations (7)
The contract for Resident 2 was not signed by the resident; Resident 3 refused to sign the contract.
For a home with multiple buildings, direct care staffing requirements were not met as staff left the building for breaks leaving residents unattended.
Staff members poured medications into medication cups for multiple residents and administered them later, sometimes leaving cups with residents without staff supervision.
Resident 1 and Resident 2 had physician orders for daily blood glucose testing that were not completed on specified dates.
The support plan of Resident 3 was not signed by the resident and lacked notation of refusal to sign.
Resident 1 was admitted to the Secure Dementia Care Unit (SDCU) without completion of the initial support plan within 72 hours.
Resident 1 was admitted to the SDCU with a medical evaluation identifying need for secure dementia unit due to disorientation and confusion, but these needs were not addressed in Resident 1's support plan.
Report Facts
Residents Served: 37 Residents Served in Secured Dementia Care Unit: 27 Staffing Hours - Total Daily Staff: 65 Staffing Hours - Waking Staff: 49 Residents with Mobility Need: 28 Residents Age 60 or Older: 37

Inspection Report — Mar 8, 2021

Complaint Investigation
Date: Mar 8, 2021

Visit Reason
The inspection was conducted as a complaint investigation to review compliance with regulations following concerns about resident care and medical evaluations.

Complaint Details
The visit was complaint-related, focusing on Resident 1's care deficiencies including failure to provide assistance with ADLs, incomplete medical evaluations, and lack of documentation for securing medical care after health status decline. The complaint was substantiated as deficiencies were found.
Findings
The facility was found deficient in providing required assistance with activities of daily living (ADLs) for Resident 1, incomplete medical evaluations missing critical information about a deep brain stimulator, and failure to document and secure medical care related to the resident's health status decline, including multiple falls.

Citations (3)
Resident 1 did not receive required stand-by assistance for transfers as indicated in the assessment, resulting in multiple falls.
Resident 1's medical evaluation did not include information about the placement of the deep brain stimulator.
The home did not document the need for follow-up care related to Resident 1's deep brain stimulator or update the assessment and support plan accordingly.
Report Facts
Residents Served: 48 Falls: 15 Staffing: 74 Staffing: 56 Residents Served: 25

Notice — Dec 30, 2020

Date: Dec 30, 2020

Visit Reason
The document serves as a notification of approval for a revised license increasing the Secured Dementia Care Unit capacity from 32 to 48 beds while maintaining the total facility capacity at 64 residents.

Findings
The Department approved the capacity revision request for the Secured Dementia Care Unit and confirmed the total licensed capacity remains unchanged at 64 residents. The license expiration date remains the same.

Report Facts

Notice — Mar 3, 2020

Date: Mar 3, 2020

Visit Reason
This document serves as a renewal notification and license issuance for Linden Village Manor Care Health Services to operate as a Personal Care Home pursuant to Title 55, PA Code, Chapter 2600.

Findings
The Department confirms receipt of the renewal application and issues a regular license. It advises that an annual onsite inspection will be conducted within the next twelve months to ensure compliance with applicable laws and regulations.

Report Facts

Inspection Report — Feb 19, 2020

Renewal
Date: Feb 19, 2020

Visit Reason
The inspection was an unannounced renewal visit to review compliance with licensing regulations at Linden Village Manor Care Health Services.

Findings
The facility was found to have multiple violations related to safety, sanitary conditions, storage, and documentation. Plans of correction were submitted and fully implemented by the Executive Director, with ongoing compliance required.

Citations (11)
2600.18 - The facility lacked carbon monoxide detectors in the attic areas of several cottages, violating the Care Facility Carbon Monoxide Alarms Standards Act.
2600.85a - A strong urine odor was detected in Resident #4's bedroom, indicating unsanitary conditions.
2600.100a - There was a four-inch drop from the sidewalk to the ground at the courtyard sidewalk near the Mount Hope cottage, posing a fall hazard.
2600.102i - Two shower rooms in the Stoy cottage contained unlabeled bars of soap, violating soap dispenser regulations.
2600.103g - A plastic bag containing frozen waffles was stored open in the Mt. Hope cottage freezer, violating food storage regulations.
2600.121a - A dining room table chair obstructed the egress path in the Stoy cottage dining room.
2600.125a - The plastic protector of a mop handle contacted the hot water heater in the Stoy cottage, violating combustible storage regulations.
2600.185a - Medication administration records for Resident #1 contained incorrect blood sugar readings and the facility lacked a tracking system for medication discard dates.
2600.227g - The support plan for Resident #2 was not signed by the resident or documented refusal to sign.
2600.233c - Directions for operating the home's locking mechanisms were not conspicuously posted near exit doors in the Mount Hope Secure Dementia Care Unit.
2600.234a - Resident #3's initial support plan was developed more than 72 hours after admission to the Secure Dementia Care Unit.
Report Facts
Residents Served: 54 Residents Served in Dementia Unit: 32 Current Hospice Residents: 2 Residents 60 Years or Older: 53 Residents with Mobility Need: 33 Total Daily Staff: 87 Waking Staff: 65

Employees mentioned
NameTitleContext
Margie McCartyExecutive DirectorNamed in multiple findings and plans of correction signatures

Inspection Report — Jun 3, 2019

Complaint Investigation
Date: Jun 3, 2019

Visit Reason
The inspection was conducted as a partial, unannounced visit due to an incident at the facility.

Complaint Details
The inspection was triggered by an incident, as indicated by the inspection reason 'Incident'.
Findings
Multiple violations of 55 Pa.Code Ch. 2600 were found, including incomplete medical evaluations, medication administration record errors, and missing resident record information. Plans of correction were submitted and partially implemented to address these issues.

Citations (5)
Regulation 2600.141a: Resident #1's medical evaluation dated 2/11/19 did not include health status or cognitive functioning.
Regulation 2600.141b.1: Resident #2's most recent medical evaluation was completed on 4/9/19, but the previous evaluation was from 4/7/17, exceeding the annual requirement.
Regulation 2600.187a: Resident #1 was prescribed Levothyroxine but it was not included on the medication administration record (MAR).
Regulation 2600.187a: Resident #2 did not receive prescribed 9 am medications due to ingestion of another resident's medication and being sent to the emergency room.
Regulation 2600.252: Resident #1's record did not include eye color or hair color.
Report Facts
Residents Served: 53 Residents Served in Dementia Unit: 31 Current Hospice Residents: 2 Residents Age 60 or Older: 52 Residents with Mobility Need: 33

Employees mentioned
NameTitleContext
Margie McCartyExecutive DirectorNamed in multiple plans of correction and responsible for ensuring compliance with regulations

Inspection Report — Mar 27, 2019

Annual Inspection
Date: Mar 27, 2019

Visit Reason
The inspection was an annual licensing inspection with renewal and incident triggers conducted by the Department's Bureau of Human Services Licensing on March 27, 2019.

Findings
Violations of 55 Pa.Code Chapter 2600 related to Personal Care Homes were found, including resident altercation, inaccurate medication labeling, and improper glucometer calibration. Plans of correction were submitted and partially implemented as of April 24, 2019.

Citations (3)
Regulation 55 Pa.Code §2600.42(b): A resident was punched twice in the face by another resident in a Secured Dementia Care Unit, causing a bloody nose.
Regulation 55 Pa.Code §2600.184(a): The medication label for a resident did not accurately match the Medication Administration Record and was not updated accordingly.
Regulation 55 Pa.Code §2600.185(a): Glucometers for two residents were not calibrated for the dates and times the blood sugar readings were taken.
Report Facts
Number of Residents Served: 48 Total Daily Staff: 79 Waking Staff: 59 Number of Residents Age 60 or Older: 47 Number of Residents with Mobility Need: 31 Number of Residents Served in Secured Dementia Care Unit: 28 Number of Current Hospice Residents: 2

Employees mentioned
NameTitleContext
Margie McCartyExecutive DirectorNamed in relation to plan of correction signatures and in-service training for violations.
Hope SpringsDepartment representative present during inspection.
Israel O'PakeDepartment representative present during inspection and author of violation report.

Notice — Mar 8, 2019

Date: Mar 8, 2019

Visit Reason
Notification of renewal application approval to operate the Personal Care Home and information about the requirement for an annual onsite inspection within the next twelve months.

Findings
No inspection findings are reported in this document. It serves as a license renewal confirmation and outlines the Department's obligation to conduct an annual inspection.

Report Facts

Inspection Report — Apr 4, 2018

Annual Inspection
Date: Apr 4, 2018

Visit Reason
The visit was an annual licensing inspection conducted by the Department of Human Services' Adult Residential Licensing for Linden Village Manor Care Health Services.

Findings
Multiple violations of 55 Pa.Code Chapter 2600 related to sanitary conditions, medication storage and administration, and resident records were found. Plans of correction were partially implemented with adequate progress noted.

Citations (7)
Regulation 2600.85(a): Sanitary conditions were not maintained due to an overwhelming odor of urine in the bedroom occupied by Resident #1.
Regulation 2600.181(d): Resident #2 self-administered medications stored in an unsecured container and did not lock the door when leaving the room.
Regulation 2600.181(j): Resident #2's medication record did not include a current list of medications stored in the resident's room.
Regulation 2600.183(d): Expired medication (Nystatin powder) was present in Resident #3's medication cart.
Regulation 2600.183(e): Prescription medications and CAM were not stored in an organized manner with proper conditions of sanitation, temperature, moisture, and light.
Regulation 2600.184(a): Medication label for Resident #4's eye drops was incorrectly documented and did not match the current prescriber's order.
Regulation 2600.187(a): Medication record for Resident #3 did not include the dosage form for Lasix 40mg.
Report Facts
Number of Residents Served: 49 Number of Current Hospice Residents: 3 Number of Hospice Residents in Past Year: 11 Number of Residents Served in Secured Dementia Care Unit: 30

Employees mentioned
NameTitleContext
Margie McCartyExecutive DirectorNamed as the Executive Director and legal entity representative signing plans of correction.
Jason McCloskeyOn-site inspector conducting the inspection.
Cyril BombergerOn-site inspector conducting the inspection.

Notice — Feb 16, 2018

Date: Feb 16, 2018

Visit Reason
The document serves as a renewal approval for the Personal Care Home license of Linden Village Manor Care Health Services and notifies 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 — Nov 2, 2017

Date: Nov 2, 2017

Visit Reason
The inspection was conducted as a licensing inspection by the Pennsylvania Department of Human Services on November 2, 2017, to assess compliance with 55 Pa.Code Chapter 2600 relating to Personal Care Homes.

Findings
Violations were found related to incomplete documentation of medical evaluations and failure to document resident and designated person objections to admission or transfer to the secured dementia care unit. A plan of correction was submitted and partially implemented to address these issues.

Citations (2)
55 Pa.Code §2600.141(a)(2) - The medical evaluation form for Resident #1 did not include documentation of weight, blood pressure, and the printed name and license number of the medical professional who performed the evaluation.
55 Pa.Code §2600.231(e) - The home lacked documentation that Resident #1 and the resident's designated person had no objection to admission or transfer to the secured dementia care unit.
Report Facts
Number of Residents Served: 38 Total Daily Staff: 71 Waking Staff: 63 Number of Residents Served in Secured Dementia Care Unit: 17 Number of Current Hospice Residents: 3 Number of Hospice Residents in Past Year: 17 Number of Residents Age 60 or Older: 55 Number of Residents with a Mobility Need: 33

Employees mentioned
NameTitleContext
Margie McCartyExecutive DirectorNamed as signatory on plan of correction documents

Inspection Report — Sep 27, 2017

Routine
Date: Sep 27, 2017

Visit Reason
The inspection was a licensing inspection conducted by the Pennsylvania Department of Human Services on September 27, 2017, to assess compliance with 55 Pa.Code Chapter 2600 relating to Personal Care Homes.

Findings
Multiple violations of 55 Pa.Code Chapter 2600 were found, including insufficient CPR-certified staff for residents, delayed medical evaluations, incomplete hospice service documentation, and lack of accessible resident support plans. Plans of correction were submitted and partially implemented as of November 1, 2017.

Citations (4)
Regulation 55 Pa.Code 2600.63(a) requires at least one staff person certified in CPR for every 50 residents. Only one CPR-certified staff was present for 64 residents during the inspection.
Regulation 55 Pa.Code 2600.141(a)(1) requires medical evaluation within 60 days prior to admission or 30 days after. Resident #3's evaluation was completed more than 60 days prior to admission.
Regulation 55 Pa.Code 2600.227(d) requires hospice services to be identified in the resident's support plan. Resident #3's support plan did not identify hospice care provided.
Regulation 55 Pa.Code 2600.227(i) requires resident support plans to be accessible to direct care staff at all times. Staff did not have access to support plans for Residents #4, #5, and #7 during the inspection.
Report Facts
Number of Residents Served: 58 Number of Residents Served in Secured Dementia Care Unit: 30 Number of Current Hospice Residents: 3 Number of Hospice Residents in Past Year: 10 Residents Age 60 or Older: 56 Residents with Mobility Needs: 31

Employees mentioned
NameTitleContext
Margie McCartyExecutive DirectorSigned plan of correction documents related to multiple violations.
Gloria EmickHuman Services Licensing SupervisorSigned cover letter transmitting the inspection report.

Inspection Report — Apr 18, 2017

Annual Inspection
Date: Apr 18, 2017

Visit Reason
The inspection was conducted as part of the Department of Human Services' annual licensing inspections for the facility.

Findings
Multiple violations of 55 Pa.Code Chapter 2600 related to personal care home regulations were found, including issues with contract signatures and medication administration documentation. Plans of correction were partially implemented with ongoing progress noted.

Citations (4)
Regulation 55 Pa.Code 52800 2600.25(b): Resident #1's contract was not signed by the payer as required.
Regulation 55 Pa.Code 52800 2600.182(c): Direct Care Staff Member A signed the medication administration record for Resident #2 prior to giving the medication.
Regulation 55 Pa.Code 52800 2600.187(a): Medication records for Resident #3 lacked diagnoses or purposes for certain medications in the April 2017 MAR.
Regulation 55 Pa.Code 52800 2600.187(d): Residents #4 and #5 did not receive prescribed medications because the facility did not have the medications available.
Report Facts
Residents in Secured Dementia Unit: 27 Hospice Residents: 1 Hospice Residents in Past Year: 7 Residents 59 Years or Older: 53 Residents with Mobility Needs: 27

Employees mentioned
NameTitleContext
Margie McCartyExecutive DirectorNamed as the legal entity representative signing plans of correction on multiple pages.
Douglas HooverDepartment representative conducting the inspection as noted on page 2.

Inspection Report — Mar 13, 2017

Renewal
Date: Mar 13, 2017

Visit Reason
This document is a renewal notification and license issuance for Linden Village Manor Care Health Services, confirming the renewal application received on March 13, 2017, and advising that an onsite inspection will be conducted within the next twelve months as required by regulation.

Findings
No inspection findings are reported in this document. It serves as a license renewal confirmation and notification of upcoming annual inspection requirements.

Report Facts

Notice — May 6, 2016

Date: May 6, 2016

Visit Reason
The document serves as a renewal notice and license issuance for the operation of a Personal Care Home pursuant to Title 55, PA Code, Chapter 2600.

Findings
No inspection findings are reported in this document. It confirms the issuance of a regular license following a renewal application.

Report Facts

Inspection Report — Apr 27, 2016

Renewal
Date: Apr 27, 2016

Visit Reason
The inspection was conducted as part of the Department of Human Services' annual licensure renewal inspections on April 27 and April 28, 2016, for Linden Village Manor Care Health Services.

Findings
Violations related to 55 Pa.Code Chapter 2600 (Personal Care Homes) were found during the inspection. The report details deficiencies in support plans and staff training in the secured dementia care unit.

Citations (2)
Regulation 55 Pa.Code §2600.227(c): The support plan was not revised within 30 days to address Resident 1's ambulation dysfunction and Resident 2's frequent falls. The service plan lacked documentation for addressing these issues.
Regulation 55 Pa.Code §2600.236: A direct care staff person in the secured dementia care unit did not complete the required 6 hours of annual training related to dementia care and services during the 2015 training year.
Report Facts
Number of Residents Served: 57 Number of Residents Served in Secured Dementia Care Unit: 29 Number of Current Hospice Residents: 2 Number of Hospice Residents in Past Year: 6

Employees mentioned
NameTitleContext
Margie McCartyExecutive DirectorNamed as legal entity representative and signer of plan of correction.
Laura HeemerDepartment representative conducting the inspection on April 27 and April 28, 2016.

Notice — Feb 25, 2016

Date: Feb 25, 2016

Visit Reason
The document serves to notify Linden Village Manor Care Health Services that a waiver request related to admission requirements under 55 Pa.Code § 2600.231(b)-(c) has been granted.

Findings
The waiver allows the facility to use a cognitive preadmission screening form called 'Initial Documentation of Medical Evaluation Attachment' instead of the Department’s cognitive preadmission screening form. The waiver remains in effect as long as conditions are met and will be reviewed annually during inspections.

Employees mentioned
NameTitleContext
Matthew JonesDirectorSigned the waiver approval letter.

Inspection Report — Jan 20, 2016

Complaint Investigation
Date: Jan 20, 2016

Visit Reason
The inspection was conducted as a complaint investigation based on concerns related to Personal Care Homes regulations under 55 Pa.Code Chapter 2600.

Complaint Details
The inspection was complaint-driven, with substantiation implied by the violations found related to incident reporting, medication administration, and resident assessments.
Findings
Multiple violations were found including failure to report an incident involving Resident #2, incomplete medication administration records for Resident #3, and inadequate resident assessments for Resident #1. Plans of correction were partially implemented with adequate progress noted.

Citations (4)
55 Pa.Code 2600.16(c) - The home failed to report an incident where Resident #1 grabbed and attempted to hit Resident #2 repeatedly. The incident was not reported to the Department as required.
55 Pa.Code 2600.187(a) - Medication administration record for Resident #3 lacked identification of staff initials on the master key for medication administration.
55 Pa.Code 2600.187(b) - Medication administration records for Resident #3 were incomplete; staff initials did not correspond with administered medications and resident was not present to receive medications.
55 Pa.Code 2600.225(c) - Resident #1's assessment did not reflect exhibited physically aggressive behaviors and was not revised to address changes in condition.
Report Facts
Number of Residents Served: 56 Total Daily Staff: 90 Waking Staff: 68 Number of Residents Served in Secured Dementia Care Unit: 32 Number of Current Hospice Residents: 2 Number of Hospice Residents in past year: 5

Employees mentioned
NameTitleContext
Margie HoffmanExecutive DirectorNamed as legal entity representative signing plans of correction
Laura HeemerDepartment representative conducting inspection

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