Inspection Reports for
The Manor at Market Square
803 Penn St, Reading, PA 19601, United States, PA, 19601
Back to Facility Profile39 Reports
Inspection Report — Jun 3, 2026
Follow-Up
Date: Jun 3, 2026
Visit Reason
The inspection was a partial, unannounced follow-up visit triggered by a complaint and incident to verify the implementation of a submitted plan of correction.
Complaint Details
The inspection was complaint-related and incident-driven. The plan of correction was accepted and fully implemented, indicating the complaint was addressed.
Findings
The submitted plan of correction was determined to be fully implemented. The facility demonstrated compliance with the regulation requiring annual medical evaluations for residents.
Citations (1)
141b1 Annual Medical Evaluation: A resident's most recent medical evaluation was completed late. The facility conducted a comprehensive audit and implemented corrective actions to ensure timely evaluations.
Report Facts
Residents Served: 70
Secured Dementia Care Unit Residents Served: 16
Hospice Current Residents: 15
Residents Age 60 or Older: 70
Residents with Mental Illness: 2
Residents with Mobility Need: 32
Residents with Physical Disability: 1
Inspection Report — Mar 31, 2026
Follow-Up
Date: Mar 31, 2026
Visit Reason
The inspection was a follow-up review to verify that the previously submitted plan of correction was fully implemented following an incident and related deficiencies.
Findings
The facility was found to have fully implemented the plan of correction related to incident reporting, assistance with activities of daily living, treatment of residents with dignity, and direct care staff qualifications. Continued compliance is required.
Citations (4)
16c - Written Incident Report: The home failed to report a reportable incident involving a resident to the Department within 24 hours as required.
23a - Activities of Daily Living Assistance: Staff failed to provide assistance with wheelchair mobility as required by the resident's support plan, including unsafe handling of the wheelchair.
42c - Treatment of Residents: Staff treated a resident without dignity and respect by forcing the resident upstairs against their wishes and using an inappropriate tone.
54a - Direct Care Staff: A direct care staff person did not have a high school diploma, GED, or active registry status on the Pennsylvania nurse aide registry.
Report Facts
Residents Served: 73
Secured Dementia Care Unit Residents Served: 16
Hospice Current Residents: 15
Inspection Report — Jan 30, 2026
Date: Jan 30, 2026
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 during the inspection.
Report Facts
Residents Served: 71
Secured Dementia Care Unit Residents Served: 15
Hospice Current Residents: 16
Inspection Report — Dec 5, 2025
Follow-Up
Date: Dec 5, 2025
Visit Reason
The inspection was an unannounced partial interim review conducted to verify the full implementation of a previously submitted plan of correction.
Findings
The facility was found to have fully implemented the plan of correction with ongoing quality assurance actions in place. Several deficiencies related to medication errors, lighting, prohibited space heaters, medication storage, and following prescriber's orders were identified and corrected with education and monitoring plans.
Citations (7)
16c Written Incident Report: The home failed to report a medication error involving a missed blood glucose check and medication administration to the Department within 24 hours.
101j7 Lighting/Operable Lamp: Three residents did not have access to a bedside lamp that could be turned on/off manually; lamps were only operable by wall switches out of reach.
127a Portable Space Heaters: A portable space heater was found in use in the administration office, which is prohibited.
181d Storing Medication: Several unlocked, unattended medications were found in a resident's room, including medications for a resident not assessed to self-administer.
183e Storing Medications: A resident's inhaler was found in the medication cart without a date indicating when it was removed from the tray, violating manufacturer instructions.
185a Implement Storage Procedures: Blood glucose readings were documented on the MAR but not saved in the resident's glucometer; medications were missing from the medication cart when needed.
187d Follow Prescriber's Orders: Insulin doses were not administered as required based on blood glucose readings; a medication was not held despite blood pressure exceeding the hold threshold; a resident missed a blood glucose check and medication administration while out of the home.
Report Facts
Residents Served: 72
Secured Dementia Care Unit Residents Served: 15
Hospice Current Residents: 13
Residents Age 60 or Older: 71
Residents with Mobility Need: 31
Inspection Report — Oct 8, 2025
Renewal
Date: Oct 8, 2025
Visit Reason
The inspection was conducted as a renewal visit to review compliance with licensing requirements and verify correction of previous deficiencies.
Findings
The facility had multiple deficiencies including medication errors, contract signature issues, sanitary conditions, fire drill documentation, medication storage and administration errors, and incomplete preadmission screening for dementia care. Plans of correction were accepted and implemented with ongoing quality assurance measures.
Citations (21)
16c - Written Incident Report: The home failed to report medication errors to the Department when residents were not administered prescribed medications due to being out of the home without medications.
25b - Contract Signatures: A resident-home contract was not signed by the resident as required.
64a - Admin Training: The home's administrator had not completed the required orientation program and competency-based training test prior to initial employment.
85a - Sanitary Conditions: A bathmat in a resident's shower had orange stains and black substance on the underside around suction cups.
101j7 - Lighting/Operable Lamp: A resident did not have access to a source of light that can be turned on/off at bedside.
103e - Left Overs: Unlabeled and undated food items including cheese packs, broccoli, and bread were found in the kitchen.
103g - Storing Food: An opened and unsealed container of chocolate chips was found in the kitchen storage area.
103i - Outdated Food: A pack of hot dog buns with green, furry substance was found in the kitchen storage area.
107d - Procedure Emergency Management Agency Submission: The home's written emergency procedures were not submitted annually to the local emergency management agency.
132a - Monthly Fire Drill: Unannounced fire drills were not held during March 2025 and August 2025.
132c - Fire Drill Records: Fire drill records were not documented correctly; discrepancies in evacuation data and resident counts were noted.
132f - Alternate Exit Routes: Fire drill logs showed only one exit route used repeatedly instead of alternate exit routes.
144c1 - Smoking Area Guidelines: Cigarette butts were found in the designated smoking area, and the area lacked adequate safeguards and signage.
181d - Storing Medication: Unlocked and unattended medications were found in a resident's shared bedroom.
183b - Meds and Syringes Locked: Medication cart on the 4th floor was unlocked and unattended by staff.
184c - Sample Prescription Meds: Sample prescription medications lacked written instructions from the prescriber.
185a - Implement Storage Procedures: A resident's glucometer was not calibrated correctly, leading to inaccurate documentation.
187a - Medication Record: A resident's medication administration record incorrectly indicated medication timing, conflicting with the prescription.
187d - Follow Prescriber's Orders: Residents were not administered medications as prescribed, including missed doses and incorrect timing.
188b - Medication Error Reporting: Medication errors were not immediately reported to the resident, designated person, or prescriber as required.
231c - Preadmission Screening: A resident admitted to the secured dementia care unit did not have a completed written cognitive preadmission screening.
Report Facts
Residents Served: 72
Secured Dementia Care Unit Residents Served: 15
Hospice Current Residents: 13
Residents Age 60 or Older: 71
Residents with Mobility Need: 31
Total Daily Staff: 103
Waking Staff: 77
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Megan Baronitis | DHS Department Representative | Educated Executive Director on contract signature requirements |
| Jennie Heinberg | DHS Department Representative | Educated Executive Director on emergency procedures submission |
Inspection Report — Sep 30, 2025
Complaint Investigation
Date: Sep 30, 2025
Visit Reason
The inspection was conducted as a complaint and incident investigation to review allegations of resident abuse and compliance with reporting and supervision requirements.
Complaint Details
The visit was complaint-related and involved allegations of resident abuse. The complaint was substantiated with findings of delayed reporting and inadequate supervision.
Findings
The inspection found multiple violations related to failure to immediately report suspected resident abuse, failure to submit required supervision plans for suspended staff, delayed incident reporting, improper discharge notice and refund handling, and medication administration errors including failure to report medication errors.
Citations (7)
15a - Resident Abuse Report: The home failed to immediately report suspected abuse of a resident to the Area Agency on Aging as required by law.
15c - Supervision: The home did not submit a plan of supervision or notice of suspension for a staff person suspended due to abuse allegations until after the investigation was unsubstantiated.
16c - Written Incident Report: The home failed to report the abuse incident to the Department’s personal care home regional office within 24 hours as required.
25c10 - Advance Notice: The home failed to provide a resident with a 30-day written advance notice before changing the contract and billing for 1:1 services.
28a - Refunds: The home failed to issue a refund for a resident’s security deposit within the required timeframe after discharge.
187d - Follow Prescriber's Orders: The home failed to administer prescribed medications at scheduled times for a resident on multiple occasions.
188b - Medication Error Reporting: The home failed to immediately report medication errors to the resident, designated person, prescriber, and department as required.
Report Facts
Residents Served: 72
Secured Dementia Care Unit Residents Served: 15
Hospice Current Residents: 13
Residents with Mobility Need: 31
Residents Age 60 or Older: 72
Residents with Physical Disability: 4
Inspection Report — Sep 18, 2025
Follow-Up
Date: Sep 18, 2025
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.
Findings
The facility was found to have fully implemented the plan of correction related to resident abuse allegations involving a staff person. The report details multiple violations regarding abuse reporting, supervision, notification, and resident treatment, all of which have been addressed with corrective actions including staff termination, retraining, and ongoing quality assurance measures.
Citations (6)
2600.15.a The home failed to immediately report suspected abuse when staff person A was observed shaking a resident's chair and spraying residents with a water gun, upsetting them.
2600.15.b The home did not immediately develop and implement a plan of supervision or suspend staff person A after the abuse allegations.
2600.15.c The home failed to submit a plan of supervision or notice of suspension for staff person A to the Department’s regional office.
2600.15.d The home did not immediately notify the resident and their designated person of the suspected abuse report.
2600.16.c The home failed to report the incident to the Department’s regional office within 24 hours as required.
2600.42.c Residents were not treated with dignity and respect when staff person A sprayed them with a water gun and shook a resident’s chair, causing distress.
Report Facts
Residents Served: 58
Secured Dementia Care Unit Residents Served: 15
Current Hospice Residents: 13
Inspection Report — Sep 3, 2025
Date: Sep 3, 2025
Visit Reason
The inspection was conducted as a licensing inspection due to an incident, with an unannounced partial inspection on 09/03/2025.
Findings
No regulatory citations or deficiencies were identified during this licensing inspection.
Report Facts
Residents Served: 73
Secured Dementia Care Unit Residents Served: 15
Current Hospice Residents: 1
Residents with Mobility Need: 15
Residents Age 60 or Older: 73
Inspection Report — Dec 17, 2024
Plan of Correction
Date: Dec 17, 2024
Visit Reason
The inspection was a partial, unannounced visit conducted due to an incident involving resident behavior.
Findings
The report documents a physical altercation between residents resulting in injury requiring surgery. The facility implemented immediate corrective actions including 1:1 supervision and a 30-day discharge notice for the aggressive resident. Ongoing quality assurance measures were established to ensure resident safety and compliance.
Citations (1)
A resident caused another resident to fall resulting in injury requiring surgery; the incident involved physical aggression and inadequate supervision.
Report Facts
Residents Served: 64
Secured Dementia Care Unit Residents Served: 14
Current Hospice Residents: 11
Residents Age 60 or Older: 78
Residents with Mobility Need: 20
Total Daily Staff: 84
Waking Staff: 63
Inspection Report — Oct 16, 2024
Renewal
Date: Oct 16, 2024
Visit Reason
The inspection was conducted as a renewal visit for the facility license, with a full, unannounced inspection on 10/16/2024 and exit conference on 10/17/2024.
Findings
The inspection found multiple deficiencies including failure to complete annual fire safety training, missing emergency telephone numbers, improperly labeled food, incomplete evacuation during fire drills, unlocked medication carts, improper medication storage, inaccurate narcotic counts, incomplete medication records, and failure to follow prescriber's orders. All deficiencies had accepted plans of correction with proposed completion dates by 12/31/2024 and were implemented by 11/21/2024.
Citations (9)
Staff persons A, B, and C did not complete annual fire safety education by a fire safety expert for the training year 2023.
The phone located in the main lobby area did not have the required emergency numbers posted on or near the phone.
The main kitchen freezer contained a 10-pound box of sausage links with an open bag of sausage that was not dated when opened.
Fire drills conducted on 10/19/23, 11/30/23, 12/26/23, and 1/9/23 indicated more residents were in the home than were evacuated; the record does not indicate why all residents were not evacuated.
On 10/17/24, the medication cart located in the nursing office was unlocked and unattended; the nursing office door was also unlocked.
Insulin pens for Residents #1, #2, and #3 were located in the medication cart but were not refrigerated as instructed.
Narcotic counts were not accurate for Resident #5; staff signed medications out on the Medication Administration Record but did not sign the controlled drug record. Medication Administration Records for Residents #6, #7, and #8 had incorrect or missing blood glucose readings.
Resident #6's medication administration record did not indicate administration of prescribed medication at the correct times, despite staff interviews confirming administration.
Staff C was unable to administer medications to Residents #7 and #8 due to medications not being available in the medication cart.
Report Facts
Residents Served: 72
Secured Dementia Care Unit Residents Served: 14
Hospice Current Residents: 9
Total Daily Staff: 93
Waking Staff: 70
Inspection Report — Oct 1, 2024
Complaint Investigation
Date: Oct 1, 2024
Visit Reason
The inspection was conducted as a complaint and incident investigation at the secured dementia care unit of the facility.
Complaint Details
The visit was complaint-related and included investigation of incidents involving resident falls and behavioral issues. The complaint was substantiated by findings of neglect and documentation deficiencies.
Findings
The inspection found multiple deficiencies including resident abuse due to neglect of fall prevention, incomplete medical evaluations lacking required signatures, unsigned cognitive preadmission screenings, and failure to update support plans to reflect residents' increased supervision needs and fall interventions.
Citations (4)
Resident experienced multiple falls resulting in injury with inadequate documented interventions or supervision.
Resident medical evaluation did not include a medical professional's name, signature, or license number.
Cognitive preadmission screening was not signed prior to admission to the secured dementia unit.
Support plan was not updated to reflect numerous falls and increased supervision needs for residents.
Report Facts
Residents Served: 72
Residents Served in Secured Dementia Care Unit: 13
Resident Falls: 6
Staffing: 91
Waking Staff: 68
Inspection Report — May 14, 2024
Date: May 14, 2024
Visit Reason
The inspection was a partial, unannounced visit conducted due to an incident at the facility on 05/14/2024.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Residents Served: 72
Secured Dementia Care Unit Residents Served: 14
Hospice Current Residents: 9
Total Daily Staff: 82
Waking Staff: 62
Resident Support Staff: 0
Residents 60 Years or Older: 71
Residents with Mobility Need: 10
Inspection Report — Mar 12, 2024
Follow-Up
Date: Mar 12, 2024
Visit Reason
The inspection was a partial, unannounced follow-up visit conducted on 03/12/2024 to review the submitted plan of correction related to an incident.
Findings
The submitted plan of correction was determined to be fully implemented as of the inspection date. The report notes a deficiency related to incomplete resident medical evaluations, specifically missing medical information pertinent to diagnosis and treatment, which was corrected by the Resident Care Director through audits and obtaining necessary physician orders.
Citations (1)
Resident Documentation of Medical Evaluation is not complete; the section of Medical Information Pertinent to Diagnosis and Treatment is blank and was not reviewed during the process.
Report Facts
Residents Served: 67
Residents Served in Secured Dementia Care Unit: 13
Hospice Residents: 7
Residents with Mobility Need: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Resident Care Director | Named in corrective actions related to medical evaluation deficiencies | |
| Executive Director | Involved in ongoing quality assurance actions for medical evaluations |
Inspection Report — Jul 20, 2023
Complaint Investigation
Date: Jul 20, 2023
Visit Reason
The inspection was conducted as a complaint and incident investigation, as indicated by the unannounced partial inspection on 07/20/2023.
Complaint Details
The visit was complaint-related and incident-driven. The report references a complaint and incident as the reason for inspection. No substantiation status is explicitly stated.
Findings
The inspection found rodent feces in a chemical closet inside the kitchen and an ongoing rodent infestation problem reported in multiple areas of the facility including the kitchen, dining rooms, resident room, break room, atrium, and offices. The facility has implemented corrective actions including cleaning and increased pest control visits.
Citations (2)
Rodent feces were found on the floor of a chemical closet inside the kitchen with no evidence of cleanup.
Ongoing rodent infestation reported in multiple areas of the facility with no evidence that pest control visits occurred as scheduled.
Report Facts
Residents Served: 60
Secured Dementia Care Unit Residents Served: 13
Current Residents Receiving Hospice: 5
Residents with Mobility Need: 22
Residents Age 60 or Older: 60
Residents with Physical Disability: 1
Inspection Report — Dec 20, 2022
Complaint Investigation
Date: Dec 20, 2022
Visit Reason
The inspection was conducted as a complaint and interim investigation at the facility.
Complaint Details
The inspection was complaint-related and partial in nature, with no deficiencies found and no follow-up required.
Findings
No regulatory citations or deficiencies were identified during this inspection.
Report Facts
Current Residents in Hospice: 2
Residents Age 60 or Older: 56
Residents with Mobility Need: 14
Total Daily Staff: 70
Waking Staff: 53
Inspection Report — Nov 3, 2022
Follow-Up
Date: Nov 3, 2022
Visit Reason
The inspection was conducted as a partial, unannounced incident review following multiple review dates in November and December 2022, to verify the implementation of a previously submitted plan of correction.
Findings
The facility was found to have implemented the plan of correction related to privacy violations involving unauthorized video and audio recording, bedrail safety concerns posing entrapment risks, and failure to timely assess a resident after a fall. The facility outlined corrective actions including policy reinforcement, staff education, and equipment updates.
Citations (3)
Unauthorized video and audio recording by a designated person in a resident's room violating privacy rights.
Bedrail without cover and openings wider than 4 3/4 inches posing an entrapment risk.
Failure to timely assess a resident after a fall, resulting in delayed medical care by approximately 2 hours.
Report Facts
Residents Served: 60
Secured Dementia Care Unit Residents Served: 14
Current Hospice Residents: 1
Residents Age 60 or Older: 60
Residents with Mobility Need: 19
Residents with Physical Disability: 2
Inspection Report — Oct 12, 2022
Renewal
Date: Oct 12, 2022
Visit Reason
The inspection was conducted as a renewal review of the facility license on 10/12/2022 and 10/13/2022 to determine compliance with applicable regulations.
Findings
The inspection identified multiple deficiencies related to safety, staffing, training, sanitary conditions, medication administration, and resident care plans. All deficiencies had accepted plans of correction which were fully implemented by 12/29/2022.
Citations (15)
CO2 monitor in the kitchen lacked date and battery checks as required by Pennsylvania law.
Insufficient staffing during night shift to meet evacuation needs of immobile residents.
Not enough CPR trained staff on duty as required.
New staff did not complete first day orientation and 40 hours of required training timely.
Resident bed enablers and bed rails were not properly secured or covered.
Resident bed sheets found with fecal smears.
Hot water temperatures in resident rooms exceeded the maximum allowed 120°F.
Resident in room 3 did not have an operable bedside lamp.
Shared bathroom soap bars were not labeled or separated.
Food in memory care freezer was not covered, exposing it to contamination.
Outdated or undated food items found in memory care refrigerator and freezer.
Discontinued medication was found in a resident's medication cart.
Medication Administration Records (MAR) were inaccurately transcribed and glucometers were not calibrated correctly.
Resident missed prescribed medication doses as per prescriber's orders.
Resident's support plan did not document special dietary needs as indicated by DME.
Report Facts
Residents served: 63
Staff persons scheduled: 3
Residents needing evacuation assistance: 26
Hot water temperature: 142.6
Hot water temperature: 123.5
Hot water temperature: 129.1
Staff persons: 8
CPR trained nursing staff: 8
Breakfast sausage links: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Resident Care Director | Named in multiple findings related to resident mobility assessment, medication audits, and training oversight | |
| Executive Director | Named in multiple findings related to compliance reviews, training, and plan of correction implementation | |
| Maintenance Assistant | Responsible for checking CO2 units quarterly and ensuring bed enablers are properly fastened | |
| Maintenance Director | Responsible for water heater adjustments and periodic compliance checks | |
| Business Office Manager | Responsible for overseeing staff orientation, CPR training, and competency test compliance | |
| Food Service Director | Responsible for food storage training and weekly compliance checks | |
| Marketing Director | In-serviced staff on bed enabler requirements and informs families at admission |
Inspection Report — Jun 9, 2022
Follow-Up
Date: Jun 9, 2022
Visit Reason
The inspection was a partial, unannounced review conducted due to an incident, with multiple on-site and off-site dates, to follow up on a previously submitted plan of correction.
Findings
The facility was found to have implemented the submitted plan of correction related to medication storage and resident support plan documentation. The deficiencies involved failure to send all prescribed PRN medications with a resident leaving the facility and outdated resident support plan documentation regarding challenging behaviors.
Citations (2)
Resident #1 left the facility on 6/2/22 on a family visit. The home did not send all the residents prescribed PRN medications with the family.
Resident #1's RASP was not updated regarding the resident's current care needs, including challenging behaviors and care acceptance.
Report Facts
Residents Served: 55
Secured Dementia Care Unit Residents Served: 14
Hospice Residents: 2
Resident Support Staff: 16
Total Daily Staff: 87
Waking Staff: 65
Residents with Mobility Need: 16
Residents with Physical Disability: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Anne Graziano | Signed letter approving plan of correction implementation | |
| Resident Care Director | Conducted training on medication administration and protocols | |
| Executive Director | Led training on RASP and challenging behaviors; responsible for periodic chart reviews |
Inspection Report — Nov 2, 2021
Renewal
Date: Nov 2, 2021
Visit Reason
The inspection was conducted as a renewal visit with an incident review at THE MANOR AT MARKET SQUARE on 11/02/2021 and 11/03/2021.
Findings
The facility was found to have deficiencies related to menu posting in the main dining room and secured dementia care unit, and incomplete resident record content regarding identifiable body marks. The submitted plan of correction was accepted and fully implemented.
Citations (2)
The home's main dining room did not have the upcoming week's menu posted; the menu posted was only for the week of 10/31/21 thru 11/06/21. The secured unit did not have a menu posted for the present and upcoming week in a public and conspicuous space.
Resident #1's resident record did not state if the resident had any identifiable body marks in their resident information.
Report Facts
Residents Served: 60
Secured Dementia Care Unit Residents Served: 13
Hospice Residents: 2
Resident Diagnosed with Mental Illness: 6
Residents with Mobility Need: 16
Residents with Physical Disability: 2
Total Daily Staff: 76
Waking Staff: 57
Notice — Aug 31, 2021
Date: Aug 31, 2021
Visit Reason
The document serves as a renewal notification and license issuance for The Manor at Market Square Personal Care Home, with a reminder that an annual onsite inspection will be conducted within the next twelve months.
Findings
No inspection findings are reported; the document confirms receipt of the renewal application and issuance of a regular license.
Report Facts
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary | Signed the renewal notification letter |
Inspection Report — Jun 3, 2021
Renewal
Date: Jun 3, 2021
Visit Reason
The inspection visits on 05/13/2021 and 06/03/2021 were conducted as licensing inspections by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing.
Findings
No regulatory citations were identified as a result of these inspections.
Notice — Oct 6, 2020
Date: Oct 6, 2020
Visit Reason
This document serves as a certificate of compliance and notification of license renewal for The Manor at Market Square 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
The Department has issued a regular license in response to the renewal application. No findings or deficiencies are reported in this document.
Report Facts
Inspection Report — Sep 23, 2020
Renewal
Date: Sep 23, 2020
Visit Reason
The inspection visits on 09/09/2020 and 09/23/2020 were conducted as part of the Pennsylvania Department of Human Services, Bureau of Human Service Licensing's licensing inspections for the facility.
Findings
No regulatory citations were identified as a result of these inspections.
Document — Jan 24, 2020
Date: Jan 24, 2020
Visit Reason
The document is a letter and license approving an increase in the maximum licensed capacity of The Manor at Market Square Personal Care Home from 65 to 80 residents.
Findings
The Department of Human Services approved the facility's request to increase its licensed capacity to 80 residents. The revised license reflects this change and the expiration date remains unchanged.
Report Facts
Notice — Oct 25, 2019
Date: Oct 25, 2019
Visit Reason
The document serves as a license renewal approval and notification that a regular license is being issued for The Manor at Market Square Personal Care Home. It also informs 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 is an administrative notice confirming license renewal and outlining future inspection requirements.
Report Facts
Inspection Report — Oct 10, 2019
Date: Oct 10, 2019
Visit Reason
Partial inspection conducted as a new inspection visit for The Manor at Market Square.
Findings
The inspection identified issues with non-operable exhaust fan lights in bathrooms of rooms 6 and 9, a missing toilet seat in room 9, and a bedside lamp without a light bulb in room 6. All issues were corrected promptly with plans to audit equipment regularly.
Citations (2)
Regulation 2600.95 requires furniture and equipment to be in good repair and free of hazards. The exhaust fan lights in bathrooms of rooms 6 and 9 were not operable and the toilet in room 9 lacked a toilet seat.
Regulation 2600.101.j requires each resident bedroom to have an operable lamp. The bedside lamp in room 6 did not have a light bulb.
Report Facts
Residents Served: 53
Secured Dementia Care Unit Residents Served: 0
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Katie Catchmark | Personal Care Home Administrator | Named in relation to plan of correction and inspection findings. |
Inspection Report — Sep 4, 2019
Annual Inspection
Date: Sep 4, 2019
Visit Reason
The inspection was an annual inspection conducted by the Department’s Bureau of Human Services Licensing on September 4, 2019, with reasons listed as renewal and complaint.
Complaint Details
The inspection included complaint investigation as part of the reason for the visit, but no explicit substantiation status was provided.
Findings
Multiple violations were found related to medication administration, financial record keeping, contract signatures, storage of poisonous materials, fire safety evacuation procedures, annual medical evaluations, prescriber order compliance, preadmission screening, and resident support plans. Plans of correction were implemented with varying degrees of progress.
Citations (11)
2600.16c. The home failed to report medication errors to the Department within 24 hours as required.
2600.20b1. Financial transaction records for residents #2 and #3 were only available starting 8/1/19, missing earlier records.
2600.20b3. Resident #3 withdrew $40 on 8/10/19 without signing a receipt for the transaction.
2600.20b6. Resident #2 carried a balance of $600 for more than two consecutive months without being offered an interest-bearing account.
2600.25b. Resident #4’s contract dated 2/23/19 was not signed by the Administrator or designee.
2600.82a. Two bottles of pink liquid in the kitchen cleaning closet were not stored in original labeled containers.
2600.132h. Residents were not evacuated to designated meeting places within fire-safe areas during fire drills on the 3rd and 4th floors.
2600.141b1. Resident #5’s most recent annual medical evaluation was completed on 4/17/19, with the previous on 2/27/18, indicating a delay.
2600.187d. Resident #1 did not receive prescribed 12 units of NovoLog on 7/12/19 and 8/9/19 at 11:30am as ordered.
2600.224a. Resident #7’s pre-admission screening dated 7/15/19 did not indicate if the home could meet the resident’s needs.
2600.227d. Resident #4’s support plan did not document the need for a grab assist bar used for transferring in and out of bed.
Report Facts
Residents Served: 50
Resident with Mobility Need: 9
Resident with Physical Disability: 2
Resident with Mental Illness: 3
Resident with Intellectual Disability: 1
Hospice Residents: 1
Resident Age 60 or Older: 49
Financial Balance: 600
Cash Withdrawal: 40
Medication Dose: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Katie Catchmark | Personal Care Home Administrator | Named in multiple findings and plans of correction including medication error reporting, financial record keeping, contract signatures, fire safety training, and resident support plan updates. |
Inspection Report — Jun 10, 2019
Complaint Investigation
Date: Jun 10, 2019
Visit Reason
The inspection was conducted as a result of an incident complaint regarding suspected abuse and care concerns at The Manor at Market Square.
Complaint Details
The complaint was substantiated based on findings that staff failed to provide adequate care and respect to resident #1, did not report suspected abuse, and did not follow prescriber's orders. The home partially implemented corrective actions with adequate progress as of 8-8-19.
Findings
Multiple violations related to resident abuse, supervision, assistance with activities of daily living, treatment with dignity, following prescriber's orders, and support plan access were found. The facility implemented disciplinary actions, re-education, supervisory plans, and audits as corrective measures.
Citations (6)
2600.15a: The home failed to immediately report suspected abuse of a resident as required by law. The home did not report the suspected abuse complaint to the Area Agency on Aging.
2600.15b: The home did not immediately develop and implement a supervision plan or suspend the staff person involved in the alleged abuse incident.
2600.23a: The home failed to provide resident #1 with adequate assistance with activities of daily living, including help getting up from a recliner to the bathroom.
2600.42c: The home failed to treat resident #1 with dignity and respect, as staff told the resident she was lazy and did not provide needed assistance.
2600.187d: The home did not follow the prescriber's orders when a staff person turned off resident #1's oxygen tank, leaving the resident without required oxygen for 2 to 3 hours.
2600.227j: The home failed to provide a copy of the support plan to the resident's designated person upon request.
Report Facts
Residents Served: 55
Total Daily Staff: 58
Waking Staff: 44
Residents Age 60 or Older: 54
Residents Diagnosed with Mental Illness: 2
Residents with Mobility Need: 3
Residents with Physical Disability: 3
Inspection Report — Apr 9, 2019
Complaint Investigation
Date: Apr 9, 2019
Visit Reason
The inspection was conducted as a complaint investigation with unannounced visits on April 9, 2019 and May 7, 2019 at The Manor at Market Square.
Complaint Details
The inspection was complaint-driven and unannounced. The violations found were related to medication management, prescriber order adherence, and support plan documentation. Plans of correction were partially implemented with adequate progress.
Findings
Multiple violations related to personal care home regulations were found, including unlabeled soap dispensers, missing PRN medications, failure to follow prescriber's orders, and incomplete support plan documentation. Plans of correction were partially implemented with adequate progress as of July 31, 2019.
Citations (4)
2600.102.i A dispenser with soap shall be provided within reach of each bathroom sink. Two bar soaps with no labels were found in room 324 shared by two residents.
2600.185.a The home shall develop and implement procedures for safe storage and use of medications. Several PRN medications were not on hand as listed on resident #1's DME dated 01/14/19.
2600.187.d The home shall follow the directions of the prescriber. Resident #1 was prescribed Morphine 0.5 ml as PRN at bedtime but did not receive this medication from 03/04-03/23.
2600.227.d Each home shall document in the resident’s support plan the medical and behavioral care services available. Resident #2’s RASP was not updated retroactively to reflect hospice services and oxygen discontinuation.
Report Facts
Residents Served: 48
Current Residents in Hospice: 2
Staff Count: 56
Waking Staff: 42
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Katie Catchmark | Executive Director | Named in relation to plan of correction signatures and oversight |
Inspection Report — Aug 29, 2018
Renewal
Date: Aug 29, 2018
Visit Reason
The inspection was a full, unannounced renewal inspection conducted on August 29, 2018, to assess compliance with 55 Pa. Code Chapter 2600 relating to Personal Care Homes.
Findings
Multiple violations were found related to quality management, staff training, emergency preparedness, medication administration, resident assessments, and support plans. Plans of correction were developed and partially implemented for all deficiencies.
Citations (9)
Regulation 55 Pa.Code §2600.26(b): The home's quality management review dated 5/16/18 did not address reportable incidents and conditions.
Regulation 55 Pa.Code §2600.63(a): On 8/10 & 8/11/18, the home served 44 residents from 10:30pm-6:30am with no staff certified in first aid present.
Regulation 55 Pa.Code §2600.65(b): Ancillary staff hired on 7/16/18 did not receive required training on evacuation procedures, staff duties, smoking safety, fire extinguishers, alarms, and emergency notification before first day of work.
Regulation 55 Pa.Code §2600.65(b): Ancillary staff hired on 7/16/18 did not complete training within first 40 hours on resident rights, emergency medical plan, and mandatory abuse reporting.
Regulation 55 Pa.Code §2600.185(a): The home's narcotic count policy was not followed; staff failed to sign controlled substance inventory sheets on multiple dates and recorded inaccurate blood glucose readings.
Regulation 55 Pa.Code §2600.187(a): Resident #2's medications were not initialed as administered on 8/15/18 and 8/24/18, and resident #2 received incorrect insulin dosage due to transcription errors.
Regulation 55 Pa.Code §2600.187(d): Resident #1 received incorrect units of NovoLog insulin and resident #2's blood pressure medication was administered when it should have been held.
Regulation 55 Pa.Code §2600.225(a): Resident #3 admitted on 3/31/17 did not have an initial assessment completed until 9/15/17, more than 15 days after admission.
Regulation 55 Pa.Code §2600.227(a): Resident #3 did not have a support plan completed until 9/15/17, more than 30 days after admission.
Report Facts
Number of Residents Served: 52
Number of Residents Served during violation: 44
Notice — Jul 2, 2018
Date: Jul 2, 2018
Visit Reason
The document is a renewal notification and license issuance for The Manor at Market Square Personal Care Home following receipt of a renewal application.
Findings
The Department confirms issuance of a regular license and advises that an onsite annual inspection will be conducted within the next twelve months as required by regulation.
Inspection Report — Oct 4, 2017
Complaint Investigation
Date: Oct 4, 2017
Visit Reason
The inspection was conducted as a complaint investigation at The Manor at Market Square facility on October 4, 2017.
Complaint Details
The inspection was triggered by a complaint. Specific substantiation status is not stated.
Findings
The resident's annual Resident Assessment and Support Plan (RASP) was not completed within the required 12-month timeframe. The resident's most recent support plan was completed on 8/4/2017, but the previous assessment was from 5/20/2016, indicating a lapse in timely reassessment.
Citations (1)
Regulation 55 Pa.Code §2600.225(c) requires residents to have annual assessments. Resident #1's annual Resident Assessment and Support Plan was not completed within 12 months as required.
Report Facts
Number of Residents Served: 53
Number of Current Hospice Residents: 3
Number of Hospice Residents in past year: 11
Inspection Report — Aug 2, 2017
Renewal
Date: Aug 2, 2017
Visit Reason
The inspection was an annual licensing renewal inspection conducted by the Pennsylvania Department of Human Services on August 2, 2017, for The Manor at Market Square.
Findings
Multiple violations of 55 Pa.Code Chapter 2600 were found related to resident records confidentiality, contract signatures, fee schedules, refund processing, staff qualifications and training, medical evaluations, fire safety, and resident assessments. Plans of correction were submitted with timelines for compliance.
Citations (17)
Regulation 55 Pa.Code 2600.17: Resident records were left unattended with personal information visible in the narcotic book on the medication cart.
Regulation 55 Pa.Code 2600.25(b): The contract for Resident #2 was not signed by the resident due to hospice status at the time of omission.
Regulation 55 Pa.Code 2600.25(c)(2): The home’s contract fee schedule did not list fees for several residents’ admission dates.
Regulation 55 Pa.Code 2600.28(f)(2): Refund for Resident #8 was not submitted until after discharge and POA notification deadline.
Regulation 55 Pa.Code 2600.54(a): Direct Care Staff Member A lacked a high school diploma, GED, or active registry status beyond the 30-day provisional hiring period.
Regulation 55 Pa.Code 2600.65(e): Staff members B and C did not receive the required 12 hours of annual training related to job duties in 2016.
Regulation 55 Pa.Code 2600.65(f): Staff members B, C, and D did not receive required annual training on fire safety, emergency preparedness, and falls prevention in 2016.
Regulation 55 Pa.Code 2600.96(a): The first aid kit was missing bandage tape and a thermometer.
Regulation 55 Pa.Code 2600.125(b): Combustible materials were found behind the dryer in the laundry room posing a fire hazard.
Regulation 55 Pa.Code 2600.141(a)(2): Medical evaluations for Residents #3, #4, and #7 lacked required information including vital signs and assessments.
Regulation 55 Pa.Code 2600.141(b)(1): Resident #4’s medical evaluation was completed more than one year late.
Regulation 55 Pa.Code 2600.144(c)(1): Cigarette butts were found outside the building in a non-designated smoking area.
Regulation 55 Pa.Code 2600.187(d): Resident #1 did not receive insulin as ordered on a sliding scale for several days.
Regulation 55 Pa.Code 2600.224(a): Resident #5’s preadmission screening did not indicate that the home could meet the resident’s needs.
Regulation 55 Pa.Code 2600.225(a): Initial Resident Assessment Support Plans for Residents #2, #5, #7 were not completed within 15 days of admission.
Regulation 55 Pa.Code 2600.225(c): Resident #4’s additional assessments were not completed annually as required.
Regulation 55 Pa.Code 2600.252: Resident records for multiple residents were missing required elements such as race, marital status, allergies, and DNR status.
Report Facts
Number of Residents Served: 54
Number of Current Hospice Residents: 3
Number of Hospice Residents in Past Year: 12
Notice — Jul 5, 2017
Date: Jul 5, 2017
Visit Reason
The document is a letter granting a waiver request for specific Pennsylvania Code regulations related to reportable incidents, admissions, resident medical evaluation, and preadmission screening for The Manor at Market Square.
Findings
The waiver is granted under conditions including use of specific forms for documentation in lieu of the Department's forms. The waiver remains in effect as long as conditions are met and will be reviewed annually during inspections.
Report Facts
Waiver references: 55
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jacqueline L. Rowe | Director | Signed the waiver approval letter |
Inspection Report — Jul 3, 2017
Renewal
Date: Jul 3, 2017
Visit Reason
The document is a renewal application and license issuance for The Manor at Market Square Personal Care Home. The Department of Human Services will conduct an onsite inspection within the next twelve months as part of the annual inspection requirement.
Findings
No inspection findings are reported in this document. It serves as a license renewal confirmation and notification of future inspection requirements.
Report Facts
Inspection Report — Apr 26, 2017
Complaint Investigation
Date: Apr 26, 2017
Visit Reason
The inspection was conducted as a complaint investigation at The Manor at Market Square.
Complaint Details
The inspection was triggered by a complaint. The violation involved unsanitary conditions found in laundry equipment.
Findings
A violation was found related to sanitary conditions involving a Samsung washing machine with a black substance around the gaskets. The facility took corrective actions including cleaning, taking machines out of service, and educating staff and residents.
Citations (1)
55 Pa.Code §2600.85(a) requires sanitary conditions to be maintained. The Samsung washing machine on the first floor contained a black substance around the gaskets.
Report Facts
Number of Residents Served: 54
Total Daily Staff: 66
Waking Staff: 50
Number of Current Hospice Residents: 3
Number of Hospice Residents in past year: 8
Residents Age 60 or Older: 54
Residents with Mental Illness: 1
Residents with Mobility Need: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Katie Catchmark | Administrator | Named as facility administrator and signed plan of correction |
| Julienne Rushin | Department Representative | On-site inspector |
| Jason Harvey | Department Representative | On-site inspector |
Inspection Report — Aug 9, 2016
Renewal
Date: Aug 9, 2016
Visit Reason
The inspection was an annual licensing renewal inspection conducted by the Pennsylvania Department of Human Services on August 9, 2016, for The Manor at Market Square personal care home.
Findings
Multiple violations of 55 Pa.Code Chapter 2600 were found, including issues with resident contracts, staffing, fire safety, training, storage of poisonous materials, pest control, food labeling, fire hazards, medication administration, and resident assessments. Plans of correction were submitted with partial implementation and adequate progress noted.
Citations (19)
2600.25(b) - Resident #1 did not sign the contract prior to or within 24 hours of admission.
2600.64(c) - The home's administrator completed only 23 of the required 24 hours of annual training in 2015.
2600.65(g) - Direct care and ancillary staff hired in 2016 did not receive required resident rights and fire safety training.
2600.82(c) - Poisonous materials were left unlocked and accessible on an open housekeeping cart in the hallway.
2600.85(e) - The dumpster was open, allowing penetration of insects and rodents.
2600.103(i) - The refrigerator contained unlabeled and undated wrapped sandwiches.
2600.105(g)(1) - Excessive lint was found in the lint traps of dryers on the 2nd and 3rd floors.
2600.125(b) - Combustible materials were found near heat sources in laundry rooms.
2600.132(c) - Fire drill documentation did not include exit routes used and times were rounded.
2600.132(d) - Fire safety expert to observe unannounced fire drill on September 6, 2016, and provide recommendations.
2600.132(e) - A sleeping hours fire drill will be conducted September 30, 2016, and every six months thereafter.
2600.132(f) - Resident #2 refused to evacuate during fire drill; safe transfer plan updated and staff in-serviced.
2600.182(b) - The home lacked documentation for medication administration training at the time of inspection.
2600.183(b) - Prescription medications were unlocked and accessible in resident rooms; medications removed and staff re-educated.
2600.184(a) - Residents #3 and #5 did not have pharmacy labels on their medications.
2600.185(a) - Missing signature on narcotic count sheet and medication count sheet not signed by oncoming/offgoing staff.
2600.187(a) - Resident #6's blood glucose test orders were not properly documented or administered as prescribed.
2600.187(c) - Residents #4 and #5 refused medications; refusals were not properly reported to prescribers.
2600.225(a) - Residents #7 and #8 did not have timely completed resident assessments and support plans.
Report Facts
Number of Residents Served: 52
Number of Current Hospice Residents: 2
Number of Residents 60 Years or Older: 52
Number of Residents with Mental Illness: 1
Number of Residents with Mobility Need: 10
Number of Residents Served in Secured Dementia Care Unit: 0
Total Daily Staff: 62
Waking Staff: 47
Notice — Jul 5, 2016
Date: Jul 5, 2016
Visit Reason
The document serves as a renewal notice and license issuance for The Manor at Market Square Personal Care Home, confirming receipt of the renewal application 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 a licensing and renewal notification without compliance or deficiency details.
Inspection Report — May 20, 2016
Complaint Investigation
Date: May 20, 2016
Visit Reason
The inspection was conducted as a complaint investigation triggered by an incident reported at the facility.
Complaint Details
The complaint involved suspected abuse where a resident was bruised by another resident. The allegation was not reported timely to the local Area Agency on Aging or the Department. The complaint was substantiated by the findings of delayed reporting and failure to notify the Department within 24 hours.
Findings
The facility failed to immediately report suspected abuse of a resident and delayed notification to the Department. Additionally, the resident's support plan lacked documentation for assistance with transfers and required updates.
Citations (3)
55 Pa.Code §2600.15(a) - The home failed to immediately report suspected abuse of a resident and delayed reporting and investigation of the incident.
55 Pa.Code §2600.16(c) - The home failed to notify the Department of an alleged resident abuse within 24 hours as required.
55 Pa.Code §2600.227(d) - The resident's support plan did not document the assistance needed to transfer out of bed and out of a chair, requiring updates after assessment.
Report Facts
Number of Residents Served: 50
Total Daily Staff: 52
Waking Staff: 39
Number of Current Hospice Residents: 1
Number of Hospice Residents in past year: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Katie Catchmark | Administrator | Named as legal entity representative and signer of plan of correction |
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