Inspection Reports for
Maple Shade Meadows Senior Living
50 E Locust St, Nesquehoning, PA 18240, United States, PA, 18240
Back to Facility Profile39 Reports
Inspection Report — Aug 5, 2026
Complaint Investigation
Date: Aug 5, 2026
Visit Reason
The inspection was conducted as a complaint investigation during an unannounced partial licensing inspection of the facility.
Findings
No regulatory citations or deficiencies were identified during the inspection. The facility was found to be in compliance with licensing requirements.
Report Facts
Residents Served: 73
Secured Dementia Care Unit Residents Served: 17
Hospice Current Residents: 9
Inspection Report — Dec 17, 2025
Follow-Up
Date: Dec 17, 2025
Visit Reason
The inspection was a partial, unannounced follow-up visit triggered by an incident at the facility to verify correction of previous deficiencies.
Findings
The facility was found to have fully implemented the submitted plan of correction. Two deficiencies were noted: a delayed incident report of an unwitnessed resident fall and snow obstructing an exit, both of which were corrected with re-education and ongoing compliance measures.
Citations (2)
16c - The home failed to report an unwitnessed resident fall to the Department within 24 hours as required, reporting it approximately 11 hours late.
100b - The home had approximately 1.5 inches of snow obstructing the exit from the North Woods lobby, violating requirements to remove snow and obstructions from exits.
Report Facts
Residents Served: 67
Secured Dementia Care Unit Residents Served: 14
Hospice Current Residents: 7
Inspection Report — Nov 5, 2025
Renewal
Date: Nov 5, 2025
Visit Reason
The inspection was an unannounced full renewal inspection with an incident review conducted on 11/05/2025.
Findings
The inspection found multiple deficiencies including breaches in resident record confidentiality, outdated food storage, incomplete fire drill documentation, improper smoking area furniture, medication storage errors, failure to follow prescriber's orders, and delayed admission support plans. All deficiencies had accepted plans of correction with implementation dates by 12/23/2025.
Citations (7)
2600.17 Resident records were not kept confidential as a binder with personal hospice resident information was accessible in the secure memory care unit common room.
2600.103i The kitchen stored dented cans of Campbell's Cream of Celery Soup and Dark Red Kidney Beans in the dried storage area.
2600.132g Fire drill records lacked documentation of the exact start time, only noting the hour for multiple drills in 2025.
2600.144c The outdoor smoking area contained wicker chairs without fire resistant tags, violating fire safety policy.
2600.185a Multiple residents' medications were improperly stored with opened pills taped in place and discrepancies in pill counts.
2600.187d Resident #1 was administered Metoprolol despite heart rate being below the prescribed threshold on two occasions.
2600.234a Resident #2's initial support plan for the Secure Dementia Care Unit was not completed within 72 hours of admission.
Report Facts
Residents Served: 57
SDCU Residents Served: 17
Hospice Current Residents: 9
Residents Age 60 or Older: 74
Residents with Mobility Need: 57
Inspection Report — Sep 24, 2025
Complaint Investigation
Date: Sep 24, 2025
Visit Reason
The inspection was conducted as a complaint investigation at Maple Shade Meadows Senior Living on 09/24/2025.
Complaint Details
The inspection was triggered by a complaint. The submitted plan of correction was determined to be fully implemented.
Findings
The facility was found to have medication administration record deficiencies related to incomplete documentation of blood glucose readings, insulin units administered, and vital sign parameters. A plan of correction was submitted and fully implemented by 12/16/2025.
Citations (2)
2600.185a requires safe storage and use procedures for medications and medical equipment. A resident's blood glucose reading was not properly recorded on the medication record at 11:00 a.m.
2600.187a requires medication records to include details for each administered medication. The medication administration record did not indicate the number of insulin units given at 5:00 p.m. and lacked heart rate readings required for medication administration decisions.
Report Facts
Residents Served: 72
Secured Dementia Care Unit Residents Served: 16
Hospice Current Residents: 6
Inspection Report — Jan 28, 2025
Date: Jan 28, 2025
Visit Reason
The inspection was an unannounced partial licensing inspection conducted as an interim review of the facility.
Findings
No regulatory citations or deficiencies were identified during the inspection.
Report Facts
Total Daily Staff: 108
Waking Staff: 81
Residents Served: 65
Secured Dementia Care Unit Residents Served: 14
Hospice Current Residents: 7
Residents Age 60 or Older: 65
Residents with Mobility Need: 43
Inspection Report — Nov 7, 2024
Renewal
Date: Nov 7, 2024
Visit Reason
The inspection was conducted as a renewal inspection of Maple Shade Meadows Senior Living to assess compliance with licensing requirements and regulations.
Findings
The inspection identified multiple deficiencies related to staff training, medication administration, sanitary conditions, emergency preparedness, food storage, fire safety, resident assessments, and documentation. Plans of correction were accepted and implemented with proposed completion dates mostly by December 2024 and follow-up monitoring ongoing.
Citations (17)
Staff persons A and B did not receive required annual training topics for 2023 including medication self-administration and care for residents with dementia.
Staff persons A, B, and C did not receive required annual training topics for 2023 including fire safety and emergency preparedness.
Unlocked poisonous materials (hand sanitizer and moisturizer) found accessible to residents in memory care unit.
Glucometer belonging to resident #1 was not sanitized after use and had dried red substance on it.
Emergency telephone numbers were not posted by the telephone in A hall.
Unlabeled and undated frozen food items found in memory care unit freezer.
Food stored in refrigerator not properly sealed or covered in memory care unit.
Insufficient drinking water supply on site for emergency (189 gallons vs required 195 gallons).
Door to enclosed patio in memory care unit lacked signage indicating it is not an exit.
Fire extinguisher in outdoor courtyard had expired inspection sticker.
Fire drill logs indicated resident #2 was not evacuated to a fire safe area during fire drill.
Resident #3 medication was not held as per prescriber’s orders based on blood pressure readings.
Resident #4 initial assessment was not completed within 15 days of admission.
Resident #5 and #6 support plans did not reflect dietary requirements and device use information.
Resident #7 cognitive preadmission screening was not completed prior to or on admission to secured dementia care unit.
Resident #8 lacked documentation of no objection to admission to secured dementia care unit.
Staff persons A and B did not receive required six hours of dementia training for 2023.
Report Facts
Residents Served: 65
Secured Dementia Care Unit Residents Served: 12
Hospice Residents: 10
Total Daily Staff: 109
Waking Staff: 82
Mobility Need Residents: 44
Required Drinking Water: 195
Actual Drinking Water: 189
Fire Drill Residents Present: 66
Fire Drill Residents Evacuated: 66
Inspection Report — Aug 20, 2024
Follow-Up
Date: Aug 20, 2024
Visit Reason
The inspection visit on 08/20/2024 was a partial, unannounced follow-up to verify the implementation of a previously submitted plan of correction related to an incident.
Findings
The submitted plan of correction was determined to be fully implemented, with continued compliance required. The deficiency involved a resident's initial assessment not being completed within the required 15 days of admission, which was corrected through staff re-education and monitoring.
Citations (1)
Resident's initial assessment was not finalized within the required 15 days of admission.
Report Facts
Residents Served: 70
Secured Dementia Care Unit Residents Served: 17
Total Daily Staff: 118
Waking Staff: 89
Residents with Mobility Need: 48
License Expiration Date: Nov 20, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Responsible for fixing the initial assessment deficiency and monitoring compliance |
| Administrator | Administrator | Responsible for monitoring compliance and conducting random chart audits |
Inspection Report — Nov 14, 2023
Date: Nov 14, 2023
Visit Reason
The inspection was a partial, unannounced visit conducted due to an incident at the facility.
Findings
No regulatory citations or deficiencies were identified during this inspection.
Report Facts
Total Daily Staff: 146
Waking Staff: 110
Resident Support Staff: 0
Residents Served: 93
Secured Dementia Care Unit Residents Served: 22
Hospice Current Residents: 6
Residents Age 60 or Older: 93
Residents with Mobility Need: 53
Inspection Report — Oct 11, 2023
Renewal
Date: Oct 11, 2023
Visit Reason
The inspection was conducted as a renewal and complaint investigation of Maple Shade Meadows Senior Living on 10/11/2023 and 10/12/2023.
Findings
The facility was found to have multiple deficiencies including unsigned resident contracts, lack of documentation for staff qualifications, incomplete staff training, unsafe resident equipment, inadequate trash receptacle lids, missing bedside lighting, incomplete fire drill compliance, missing posted menus, unlabeled medications, unavailable PRN medication, incomplete preadmission screening forms, incomplete support plans, and missing documentation for resident admission objections. All deficiencies had plans of correction accepted and were implemented by 11/03/2023.
Citations (14)
Resident-home contract for Resident #1 was not signed by the resident.
Direct care staff person A lacked documentation of GED or high school diploma.
Direct care staff person B did not receive training in medication self-administration and DME/RASP during training year 2022.
Resident #2’s bed enabler was not securely fastened and had an uncovered opening posing entrapment risk.
Three trash cans in the kitchen had broken or missing lids that could not completely cover trash.
Residents #3 and #4 did not have operable lamps or other bedside lighting.
The home did not conduct a fire drill during sleeping hours every six months as required.
The memory care unit did not have posted menus for the current and upcoming week in a public and conspicuous area.
OTC medication bottles belonging to Resident #6 were not labeled with the resident’s name.
Resident #7’s PRN medication was not available at the time of inspection.
Resident #8’s preadmission screening form was incomplete; Part III determination was left blank.
Resident #2’s support plan did not document the enabler bar device, its intended use, risks, or resident’s ability to use it safely.
Resident #1 did not have a completed written cognitive preadmission screening prior to admission to the secured dementia unit.
Resident #1 and designee did not have documentation of no objection to admission or transfer to the secured dementia care unit.
Report Facts
Residents Served: 73
Residents Served in Dementia Unit: 20
Current Hospice Residents: 5
Residents with Mobility Need: 44
Residents with Physical Disability: 1
Staff Total Daily: 117
Staff Waking: 88
Trash Cans with Broken Lids: 3
Inspection Report — Aug 22, 2023
Date: Aug 22, 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 during the inspection.
Report Facts
Total Daily Staff: 117
Waking Staff: 88
Residents Served: 73
Secured Dementia Care Unit Residents Served: 22
Hospice Current Residents: 7
Residents Age 60 or Older: 73
Residents with Mobility Need: 44
Inspection Report — Apr 18, 2023
Date: Apr 18, 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
Residents Served: 78
Secured Dementia Care Unit Residents Served: 21
Hospice Current Residents: 3
Residents Age 60 or Older: 78
Residents with Mobility Need: 41
Inspection Report — Jan 19, 2023
Complaint Investigation
Date: Jan 19, 2023
Visit Reason
The inspection was conducted as a complaint investigation with an unannounced partial inspection on 01/19/2023.
Complaint Details
The inspection was complaint-driven and unannounced. The plan of correction was accepted and fully implemented as of 01/31/2023.
Findings
The facility was found to have deficiencies related to medical evaluations and support plan documentation for Resident #1, including failure to complete a medical evaluation within 30 days of admission and failure to update the support plan to reflect changes in the resident's condition. The submitted plan of correction was accepted and fully implemented by 01/31/2023.
Citations (2)
Resident #1 did not have a medical evaluation completed and documented within 30 days of admission; the evaluation was completed by a physician who did not evaluate the resident in person.
Resident #1's support plan was not updated to reflect changes in the resident's condition as required.
Report Facts
Residents Served: 73
Secured Dementia Care Unit Residents Served: 17
Resident Mobility Need: 17
Total Daily Staff: 90
Waking Staff: 68
Inspection Report — Nov 29, 2022
Renewal
Date: Nov 29, 2022
Visit Reason
The inspection was conducted as a renewal visit to review compliance with licensing requirements and verify the implementation of a previously submitted plan of correction.
Findings
The inspection identified multiple deficiencies including failure to post current license inspection summaries, breaches of resident record confidentiality, outdated carbon monoxide monitor batteries, unsigned resident contracts, incomplete criminal background checks, inadequate staffing during certain shifts, lack of required First Aid/CPR trained staff, improper storage of poisonous materials and food, locked exit doors preventing immediate egress, incomplete medical evaluations and support plans, medication storage and documentation issues, and deficiencies in fire safety drills and inspections. All deficiencies had plans of correction accepted and were reported as implemented by January 24, 2023.
Citations (26)
License Inspection Summary reports dated 06/09/2022 and 11/14/21 were not posted in the home as required.
Resident hospital visit paperwork and medication blister packs were left unattended in a private dining room, exposing confidential resident information.
Carbon monoxide monitor batteries throughout the home had not been changed within the past 12 months.
Resident contracts for three residents were not signed.
Criminal background check was not conducted on a staff person hired in 2022.
Inadequate staffing during certain shifts on unspecified dates, with only 3 staff persons present when more were needed for emergencies.
The home did not have at least two staff persons with First Aid and CPR training on specified dates and times.
Two bottles of Dawn dish liquid were found in an unlocked cabinet in the memory care unit’s dining area.
Frozen chicken cutlets and pancakes were stored in the freezer without proper sealing.
Exit doors outside the secure dementia unit were locked with mag locks preventing immediate egress.
Residents #4 and #5 with hearing impairments did not have signaling devices to alert them during fire emergencies.
The home did not conduct a supervised fire drill or fire safety inspection by a fire safety expert by 12/31/2021.
Fire drills were conducted during sleeping hours with additional staff present, not during minimal staffing times.
Medical evaluations for residents #1 and #3 were completed more than 60 days prior to admission.
Medical evaluation forms for residents #5, #2, and #6 did not include a list of medications or resident weight.
Medication pen for resident #7 was not dated when opened, contrary to disposal instructions.
PRN medications for residents #8 and #9 were not available in the medication cart; documentation errors for resident #10's medication administration.
Medication record for resident #9 lacked diagnosis or purpose for a medication; pharmacy label discrepancy noted.
Resident #10's blood glucose reading was not documented in the resident’s record; resident #6 did not receive medication due to unavailability.
Resident #1's support plan was not updated after significant change in condition requiring additional support and evacuation assistance.
Resident #5's support plan did not document hearing impairment and fire alarm response needs.
Medical evaluations for residents #3 and #6 did not properly document need for secured dementia care unit.
Cognitive preadmission screenings for residents #2 and #6 were completed more than 72 hours prior to admission to secured dementia care unit.
Resident records for residents #2 and #6 lacked signed no objection statements for admission to secured dementia care unit.
Support plans for residents #2 and #6 were completed late, past the required 72-hour timeframe after admission.
Correction fluid tape was used on resident #6’s cognitive screening form, violating documentation policy.
Report Facts
Residents served: 70
Memory care residents served: 17
Current hospice residents: 5
Residents with mobility needs: 25
Residents age 60 or older: 70
Residents with physical disability: 1
Total daily staff: 95
Waking staff: 71
Staff present during low staffing times: 3
Fire drills conducted during sleeping hours: 3
Inspection Report — Jun 9, 2022
Follow-Up
Date: Jun 9, 2022
Visit Reason
The inspection was a partial, unannounced follow-up visit conducted due to an incident, with the purpose of reviewing the submitted plan of correction and verifying compliance.
Findings
The facility was found to have multiple deficiencies related to resident abuse, preadmission screening, no objection statements, and admission support plans, all of which had plans of correction submitted and were determined to be fully implemented by the date of this follow-up inspection.
Citations (5)
Failure to immediately report suspected abuse of a resident as required by the Older Adult Protective Services Act.
Resident abuse involving inappropriate sexual touching between residents.
Failure to complete a written cognitive preadmission screening within 72 hours prior to admission to a secured dementia care unit.
Lack of documentation that the resident and/or designated person did not object to admission or transfer to the secured dementia care unit.
Failure to develop, implement, and document a support plan within 72 hours of admission or transfer to the secured dementia care unit.
Report Facts
Residents Served: 64
Secured Dementia Care Unit Residents Served: 17
Hospice Residents: 5
Residents with Mobility Need: 23
Total Daily Staff: 87
Waking Staff: 65
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Michele Moskalczyk | Human Services Licensing Supervisor | Signed the letter confirming the plan of correction was fully implemented. |
| Director of Memory Care | Named as responsible for fixing abuse and compliance issues, including monitoring ongoing compliance. | |
| Administrator | Responsible for ensuring compliance with abuse reporting, preadmission screening, no objection statements, and support plans. | |
| DON | Director of Nursing | Responsible for monitoring ongoing compliance related to abuse and admission requirements. |
Inspection Report — Apr 7, 2022
Routine
Date: Apr 7, 2022
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.
Inspection Report — Nov 2, 2021
Renewal
Date: Nov 2, 2021
Visit Reason
The inspection was conducted as a renewal visit to assess compliance with licensing requirements at Maple Shade Meadows Senior Living.
Findings
The inspection identified multiple deficiencies including failure to report suspected abuse, confidentiality breaches, incomplete medical evaluations, medication administration errors, incomplete staff qualifications and training, missing resident documentation, and failure to post emergency phone numbers. Plans of correction were accepted and implemented with follow-up submissions.
Citations (20)
Failure to complete and submit Act 13 report for suspected resident abuse.
Failure to notify the Department of an alleged abuse incident within 24 hours.
Medication Administration records and narcotic count book left unsecured and accessible.
Failure to change and date batteries in CO2 monitors annually and lack of gas boiler inspection documentation.
Quality management plan review did not include names of staff involved.
Background checks for staff were outdated or not completed within 12 months of hire.
Direct care staff lacked required high school diploma, GED, or active nurse aide registry status.
Medical evaluations for residents were incomplete or unsigned by a physician.
Over-the-counter medications and CAM were not labeled with resident names.
Medication Administration Records were not signed or initialed by staff administering medications.
Failure to follow prescriber's orders due to medication unavailability and missed doses.
Resident's preadmission screening form was not completed within required timeframe.
Resident initial assessment was completed more than 15 days after admission.
Resident support plans lacked documentation of diet and missing resident signatures.
Resident records missing race, hair color, eye color, and dated photographs.
Direct care staff did not receive required orientation on fire safety and emergency preparedness on first day.
Direct care staff did not complete required training within first 40 hours of work.
Direct care staff provided unsupervised ADL services without completing required training and competency test.
Emergency telephone numbers were not posted by phones in resident room NW12 as required.
Medication storage procedures were not properly followed; medication not administered due to unavailability and MAR transcription errors.
Report Facts
Residents Served: 52
Residents in Secured Dementia Care Unit: 13
Hospice Residents: 5
Total Daily Staff: 65
Waking Staff: 49
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Mentioned in relation to background check violation and orientation/training deficiencies. | |
| Staff B | Mentioned for lacking required qualifications, incomplete training, and direct care training violations. | |
| Staff C | Mentioned for lacking required qualifications. | |
| Staff D | Mentioned for not completing direct care training and competency test. |
Inspection Report — Sep 7, 2021
Renewal
Date: Sep 7, 2021
Visit Reason
The document is a renewal application and license issuance for Maple Shade Meadows Senior Living, a Personal Care Home, confirming the facility's authorization to operate and advising that an annual inspection will be conducted within the next twelve months.
Findings
The Department has issued a regular license in response to the renewal application and advises that an onsite inspection will be conducted within the next twelve months to ensure compliance with applicable regulations.
Report Facts
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary, Office of Long-term Living | Signed renewal license letter |
Notice — Sep 3, 2021
Date: Sep 3, 2021
Visit Reason
The document serves to notify Maple Shade Meadows Senior Living that their request to waive the administrator training requirement under 55 Pa.Code § 64(a)(1) has been granted temporarily to allow time to complete training.
Findings
The waiver is granted with conditions including attendance at a Department-approved orientation course and documentation of training to be maintained. The waiver is effective from September 2, 2021 to October 6, 2021, after which full compliance is expected.
Report Facts
Waiver effective dates: From September 2, 2021 to October 6, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jeanne Parisi | Bureau Director, Human Services Licensing | Signed the waiver approval letter |
Inspection Report — May 6, 2021
Complaint Investigation
Date: May 6, 2021
Visit Reason
The inspection was conducted as a complaint investigation to review compliance with regulatory requirements and to verify the submitted plan of correction.
Complaint Details
The visit was complaint-related as indicated by the inspection reason. The complaint involved failure to report an incident and staffing concerns. The submitted plan of correction was accepted and fully implemented.
Findings
The facility had repeat violations including failure to report a resident incident, inadequate staffing to safely evacuate residents, and incomplete medication administration documentation. The submitted plan of correction was accepted and determined to be fully implemented.
Citations (3)
Failure to report a resident incident involving a closed head injury within 24 hours as required.
Inadequate staffing during night shifts to safely evacuate all residents in the event of an emergency.
Medication administration was not documented on the medication administration record for multiple residents on various dates.
Report Facts
Residents Served: 80
Secured Dementia Care Unit Residents Served: 10
Residents Age 60 or Older: 80
Residents with Mobility Need: 21
Staffing: 2
Medication Documentation Violations: 5
Inspection Report — Feb 26, 2021
Renewal
Date: Feb 26, 2021
Visit Reason
The inspection was conducted as part of licensing inspections by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing on 02/26/2021, 03/08/2021, and 03/11/2021.
Findings
No regulatory citations were identified as a result of this inspection.
Report Facts
Inspection dates: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Michele Moskalczyk | Human Services Licensing Supervisor | Signed the inspection report |
Inspection Report — Feb 4, 2021
Renewal
Date: Feb 4, 2021
Visit Reason
The inspection visits on 01/06/2021 and 02/04/2021 were conducted as licensing inspections by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing.
Findings
No regulatory citations or deficiencies were identified as a result of these inspections.
Notice — Jan 12, 2021
Date: Jan 12, 2021
Visit Reason
The document serves as a renewal notification and issuance of a regular license for Maple Shade Meadows Senior Living, a Personal Care Home, pursuant to Title 55, PA Code, Chapter 2600.
Findings
The Department has approved the renewal application and issued a regular license. It advises that an onsite annual inspection will be conducted within the next twelve months to ensure compliance with applicable regulations.
Report Facts
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary, Office of Long-Term Living | Signed the renewal notification letter |
Inspection Report — Dec 15, 2020
Renewal
Date: Dec 15, 2020
Visit Reason
The inspection was conducted as part of the Pennsylvania Department of Human Services, Bureau of Human Service Licensing's licensing inspections on multiple dates including 12/15/2020 through 12/18/2020 and 07/01/2021.
Findings
No regulatory citations were identified as a result of these inspections.
Inspection Report — Aug 25, 2020
Follow-Up
Date: Aug 25, 2020
Visit Reason
The visit was a partial, unannounced follow-up inspection to verify the implementation of a previously submitted plan of correction.
Findings
The facility was found to have implemented the plan of correction fully. Deficiencies related to incident reporting, staffing hours, staff support plans, additional assessments, and support plan documentation were addressed with staff training and scheduling improvements.
Citations (5)
Regulation 2600.16c: The home failed to report incidents involving resident falls to the Department within 24 hours as required.
Regulation 2600.57c: On 8/8/20, direct care staffing hours were insufficient to meet the minimum 2 hours per day per resident with mobility needs.
Regulation 2600.60a: On 8/21/20, staffing was inadequate during the 11pm-7am shift to safely evacuate all secured dementia care unit residents.
Regulation 2600.225c: Resident assessments were incomplete or outdated, lacking dental details and timely updates after significant events.
Regulation 2600.227d: Resident support plans did not document how medical and care needs related to falls would be met by the home.
Report Facts
Residents served: 58
Residents with mobility needs: 23
Direct care staffing hours required: 81
Direct care staffing hours provided: 67.5
Secured Dementia Care Unit residents: 11
Hospice residents: 1
Inspection Report — Dec 5, 2019
Complaint Investigation
Date: Dec 5, 2019
Visit Reason
The inspection was conducted as a complaint investigation with unannounced visits on December 5, 10, and 11, 2019 to review compliance at Maple Shade Meadows Senior Living.
Complaint Details
The inspection was triggered by a complaint and was unannounced. The violations were substantiated and addressed with plans of correction.
Findings
The inspection found violations related to failure to post the current license inspection summary in a public area, conducting a mock fire drill instead of an unannounced drill, and failure to evacuate residents to the designated meeting place during a fire drill. Plans of correction were submitted and fully implemented by March 2, 2020.
Citations (3)
Regulation 2600 3.c requires posting the current license inspection summary in a public place. The summary was found in a locked cabinet and not publicly posted in the home's lobby.
Regulation 2600 132.a requires an unannounced fire drill at least monthly. A fire drill on 8/8/19 was announced to staff and was a mock drill, not a true unannounced drill.
Regulation 2600 132.h requires residents to evacuate to a designated meeting place during fire drills. Residents were kept in the main lobby during the fire drill on 10/31/19 due to heavy rain and wind.
Report Facts
Residents Served: 65
Residents Served in Dementia Unit: 14
Current Hospice Residents: 9
Total Daily Staff: 82
Waking Staff: 62
Employees mentioned
| Name | Title | Context |
|---|---|---|
| John Perry | Executive Director | Signed plans of correction and named as administrator |
Inspection Report — Oct 10, 2019
Complaint Investigation
Date: Oct 10, 2019
Visit Reason
The inspection was conducted as a complaint and provisional licensing inspection of Maple Shade Meadows Senior Living on October 10, 2019.
Complaint Details
The inspection was complaint-related and provisional, as indicated by the inspection reason and type on page 3.
Findings
Multiple violations of 55 Pa. Code Chapter 2600 related to Personal Care Homes were found, including missing criminal background checks, inadequate staffing for emergency evacuation, incomplete staff orientation and training, unsafe resident equipment, insufficient lighting, missing emergency phone numbers, incomplete notification to fire department, medication storage issues, and incomplete medication records.
Citations (11)
51. Criminal History Checks - The home lacked documentation of criminal background checks for several staff persons, including agency CNAs working regularly on the 3rd shift.
60a. Staff/Support Plan - The home did not schedule adequate staff on the 3rd shift to safely evacuate all residents in an emergency, despite multiple residents requiring one or two person assists.
65a. FS Orientation 1st Day - Several agency staff persons did not receive required orientation training topics on their first day of work.
65b. Rights/Abuse 40 Hours - Several agency staff persons did not receive required training within 40 hours of their first day of work.
65d. Initial Direct Care Training - The home lacked documentation that staff person E passed the department's direct care training competency test.
81b. Resident Personal Equipment - An enabler bar attached to a resident's bed was not covered, posing a potential entrapment risk.
87. Lighting - Insufficient lighting was found along the dementia emergency exit egress path to the exterior emergency meeting location.
91. Emergency Telephone Numbers - Emergency numbers were not posted near the phone in resident bedroom A21.
124. Notice to Fire Department - The home's letter to the fire department did not include the capacity of the home.
185a. Implement Storage Procedures - PRN cough syrup Robafen was not on hand for resident #1 as prescribed.
187a. Medication Record - Metoclopramide for resident #2 did not include a diagnosis or purpose for the medication.
Report Facts
Residents Served: 68
Residents in Secure Dementia Unit: 16
Staff on 3rd Shift: 4
Residents Requiring 2 Person Assist: 4
Residents Requiring 1 Person Assist: 29
Inspection Report — Jul 25, 2019
Monitoring
Date: Jul 25, 2019
Visit Reason
The inspection was an interim monitoring visit conducted by the Department’s Bureau of Human Services Licensing to assess compliance with 55 Pa. Code Chapter 2600 for Personal Care Homes.
Findings
Multiple violations were found related to medication administration, documentation of blood glucose levels, resident support plans, and resident record content. Plans of correction were partially implemented with ongoing monitoring planned.
Citations (4)
185a - Implement Storage Procedures: Resident #1 and #2 blood glucose levels were not documented correctly on specified dates and times.
187a - Medication Record: Several residents' medication administration records were not initialed to confirm medications were given as prescribed on multiple dates.
227d - Support Plan Medical/Dental: Resident #1 and #6 support plans did not adequately document medical needs, services, or medication descriptions.
252 - Record Content: Resident #7's record lacked documentation of identifiable marks on the face sheet.
Report Facts
Residents Served: 83
Secured Dementia Care Unit Residents Served: 17
Hospice Current Residents: 10
Residents Age 60 or Older: 66
Residents with Mobility Need: 24
Residents with Physical Disability: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Melanie Goodman | Administrator | Named in plans of correction and correspondence |
| Sandy Insalaco Jr. | President | Named in plans of correction and correspondence |
Notice — Jun 27, 2019
Date: Jun 27, 2019
Visit Reason
This document serves as a renewal notification and license issuance for Maple Shade Meadows Senior Living, confirming receipt of the renewal application and advising of the requirement for an annual onsite inspection within twelve months.
Findings
No inspection findings are reported in this document. It is an administrative notice confirming license renewal and outlining inspection requirements.
Report Facts
Inspection Report — Jun 5, 2019
Complaint Investigation
Date: Jun 5, 2019
Visit Reason
The inspection was conducted as a complaint investigation with unannounced visits on March 26, 2019, April 10, 2019, and June 5, 2019, to assess compliance with Personal Care Homes regulations.
Complaint Details
The inspection was complaint-driven, with unannounced visits on March 26, 2019, April 10, 2019, and June 5, 2019. The complaint triggered a partial inspection focused on verifying compliance with Personal Care Homes regulations.
Findings
Multiple violations were found including unsecured medication administration records, inadequate staffing on the 11-7 shift, failure to conduct fire drills and safety training properly, improper food storage, blocked emergency exits, and incomplete resident medical evaluations. Plans of correction were submitted but several were only partially implemented or not implemented as of the last update.
Citations (9)
Regulation 55 Pa.Code §2600: Medication Administration Records were left unlocked and unattended, exposing confidential resident information.
Regulation 55 Pa.Code §2600.60(a): The 11-7 shift was inadequately staffed to meet resident needs, with only 3 staff scheduled for 74 residents requiring assistance.
Regulation 55 Pa.Code §2600.65(a): Newly hired staff did not receive first day orientation on fire safety and emergency procedures.
Regulation 55 Pa.Code §2600.103(g): Food was stored on the floor in the dry food storage area, violating safe food storage requirements.
Regulation 55 Pa.Code §2600.121(a): The exit door in the dining room was blocked by furniture, preventing immediate egress in an emergency.
Regulation 55 Pa.Code §2500.132(a): Fire drills were not conducted monthly as required, and some drills were falsified or not documented properly.
Regulation 55 Pa.Code §2500.132(d): Residents were not evacuated to a safe area within the required time during fire drills.
Regulation 55 Pa.Code §2600.141(a)(2): Resident medical evaluation documentation was incomplete and did not reflect current needs.
Regulation 55 Pa.Code §2600.237(d): Staff in the secured dementia care unit did not receive the required 6 hours of annual training in dementia care.
Report Facts
Residents Served in Dementia Unit: 18
Current Hospice Residents: 11
Staffing Hours: 98
Waking Staff: 74
Residents Served: 68
Total Daily Staff: 95
Waking Staff: 71
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Melanie Goodman | Administrator | Named as administrator responsible for monitoring training and compliance. |
| Sandy Insalaco Jr. | President | Signed plans of correction and referenced in violation reports. |
| Martin J. Joyce | Fire Inspector | Conducted fire safety training and inspections referenced in fire drill violations. |
Inspection Report — Jul 27, 2018
Renewal
Date: Jul 27, 2018
Visit Reason
The inspection was an annual licensing renewal inspection combined with a complaint investigation at Maple Shade Meadows Senior Living.
Complaint Details
The inspection included a complaint investigation triggered by concerns related to licensing violations and resident care.
Findings
Multiple violations of 55 Pa.Code Chapter 2600 related to personal care homes were found, including issues with posting inspection summaries, resident privacy, storage of poisonous materials, sanitary conditions, and medication labeling. Plans of correction were submitted and partially implemented.
Citations (8)
The licensing inspection summary dated 2/4/18 was not posted in a public conspicuous place in the home.
Resident privacy coding document was attached to the inspection summary posted on the home's bulletin board exposing confidential resident information.
Two spray bottles labeled bleach and cleaner were located in the laundry room without the original manufacturer's label attached.
A bag of chips was stored in the activities closet of the memory care unit next to cleaning products including spic and span cleaner and hand foam sanitizer.
Poisonous materials were not kept locked and inaccessible to residents in the activities closet of the memory care unit.
Resident #1's and Resident #2's glucometers were used to test blood glucose without proper sanitary conditions.
Resident #5's insulin had expired on 7/16/18 and Resident #1's insulin expired on 7/14/18.
Resident #3 and #4 glucometers were not calibrated to the correct date and time.
Report Facts
Number of Residents Served: 77
Number of Current Hospice Residents: 5
Number of Hospice Residents in past year: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Melanie Goodman | Administrator | Named in facility header and plan of correction approvals |
| Sandy Insalaco Jr. | President | Signed plans of correction as legal entity representative |
| Melanie Goodnow | Executive Director | Signed plans of correction and mentioned in monitoring compliance |
Notice — Jun 21, 2018
Date: Jun 21, 2018
Visit Reason
This document serves as a renewal notification and license issuance for Maple Shade Meadows Senior Living to operate as a Personal Care Home.
Findings
No inspection findings are reported in this document. It confirms the renewal application receipt and license issuance with a reminder of the annual inspection requirement.
Report Facts
Inspection Report — Feb 14, 2018
Complaint Investigation
Date: Feb 14, 2018
Visit Reason
The inspection was conducted due to an incident reported at the facility, triggering a complaint investigation.
Complaint Details
The complaint was substantiated as staff were found to have argued loudly with a resident and failed to timely report the incident to the appropriate agencies.
Findings
A violation was found involving suspected abuse of a resident, where staff argued loudly with the resident and failed to report the incident to the local area agency on aging until several days later. The facility submitted a plan of correction including staff re-education and timely reporting procedures.
Citations (2)
55 Pa.Code §2600 2600.15(a) requires immediate reporting of suspected abuse of a resident. Staff argued loudly with a resident and failed to report the incident to the local area agency on aging until 2/8/2018.
55 Pa.Code §2600 2600.16(c) requires reporting incidents to the Department's complaint hotline within 24 hours. The incident was not reported to the Department's regional office until 2/8/2018.
Report Facts
Number of Residents Served: 64
Number of Residents Served in Secured Dementia Care Unit: 10
Number of Current Hospice Residents: 1
Number of Hospice Residents in past year: 7
Number of Residents 60 Years or Older: 64
Number of Residents with Mobility Need: 20
Number of Residents with Physical Disability: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Melanie Goodman | Administrator | Named in plan of correction and violation report |
| Amy Deluca | Department representative on-site during inspection | |
| Sandy Insalaco Jr. | President | Signed plan of correction as legal entity representative |
Inspection Report — Nov 22, 2017
Original Licensing
Date: Nov 22, 2017
Visit Reason
The inspection was an initial, announced visit conducted as part of the original licensing process for Maple Shade Meadows Senior Living, including review of compliance with Personal Care Homes regulations.
Findings
Several violations were identified including improper placement of carbon monoxide monitors, failure to notify the fire department about the secured dementia care unit, discrepancies in fire drill resident counts, and lack of access codes on secured dementia care unit exit doors. Plans of correction were submitted and partially or fully implemented.
Citations (4)
55 Pa.Code §2600 - Carbon monoxide monitors were placed less than 15 feet from a heat source in resident rooms, violating the Care Facility Carbon Monoxide Alarms Standards.
55 Pa.Code §2600.124 - The facility failed to notify the local fire department in writing about the addition of a secured dementia care unit and residents with mobility needs.
55 Pa.Code §2600.132(c) - The fire drill log showed mismatched numbers of residents present and evacuated during a drill, indicating inaccurate documentation.
55 Pa.Code §2600.233(c) - The exit door near the Bistro in the secured dementia care unit lacked a posted access code for the magnetic locking system.
Report Facts
Number of Residents Served: 61
Number of Current Hospice Residents: 2
Number of Hospice Residents in past year: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Melanie Goodman | Administrator | Named in violation report as facility administrator |
| Sandy Insalaco Jr. | President | Signed plans of correction and legal entity representative |
| Jesse Hummel | Department representative conducting inspection |
Inspection Report — Jul 7, 2017
Renewal
Date: Jul 7, 2017
Visit Reason
The inspection was conducted as part of the Department of Human Services' annual licensing renewal inspections on July 7 and July 14, 2017, for Maple Shade Meadows Senior Living.
Findings
Multiple violations of 55 Pa.Code Chapter 2600 were found, including improper placement of carbon monoxide alarms, insufficient certified CPR staff, missing emergency phone labels, inadequate fire drill frequency, and medication administration documentation errors. Plans of correction were submitted and partially implemented as of August 8, 2017.
Citations (6)
Regulation 55 Pa.Code 2600.18 - The home did not have carbon monoxide alarms placed properly according to standards; alarms were incorrectly located in the dining room and laundry area.
Regulation 55 Pa.Code 2600.63(a) - The home lacked the required number of direct care staff certified in CPR and first aid during the night shift on June 18, 2017.
Regulation 55 Pa.Code 2600.91 - Required emergency phone numbers were not posted near resident phones, including police, fire, ambulance, hospital, poison control, and complaint hotline.
Regulation 55 Pa.Code 2600.132(e) - The home failed to conduct two sleep hour fire drills every six months; drills were conducted only every eight months.
Regulation 55 Pa.Code 2600.187(a) - Medication records lacked initials for administration or declination for several residents' medications on specified dates.
Regulation 55 Pa.Code 2600.187(d) - The home did not follow prescriber directions for insulin vial expiration dates; insulin was used beyond the 28-day period.
Report Facts
Number of Hospice Residents: 1
Number of Hospice Residents in past year: 8
Total Daily Staff: 60
Waking Staff: 45
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Melanie Goodman | Executive Director | Named in relation to the inspection and plan of correction signatures. |
| Sandy Insalaco Jr. | President | Named in relation to the inspection and plan of correction signatures. |
Inspection Report — Jun 14, 2017
Renewal
Date: Jun 14, 2017
Visit Reason
The document is a renewal application and license issuance for Maple Shade Meadows Senior Living, a Personal Care Home, indicating the Department's intent to conduct an annual onsite inspection within the next twelve months as required by regulation.
Findings
No inspection findings are reported in this document. It serves as a license renewal confirmation and notification of future inspection requirements.
Report Facts
Inspection Report — Jul 14, 2016
Renewal
Date: Jul 14, 2016
Visit Reason
The inspection was conducted as an annual licensing renewal inspection of Maple Shade Meadows Senior Living.
Findings
Multiple violations of 55 Pa.Code Chapter 2600 were found, including deficiencies in emergency preparedness training, fire drill evacuation procedures, medication storage and administration, medication record keeping, and documentation of medication refusals.
Citations (5)
55 Pa.Code 2600.856(b)(1) - Direct care staff did not receive annual emergency preparedness training in 2015 as required.
55 Pa.Code 2600.132(h) - Residents were not evacuated to a designated safe area during a fire drill as required.
55 Pa.Code 2600.185(a) - Medication MAPAP 325mg PRN was not available at the time of inspection for resident #1.
55 Pa.Code 2600.187(a) - Medication MAPAP 325mg PRN every 6 hours was not listed on the MAR for resident #1.
55 Pa.Code 2600.187(a) - Medication refusals were not properly documented or reported for resident #2.
Report Facts
Number of Residents Served: 64
Total Daily Staff: 69
Waking Staff: 52
Number of Hospice Residents in Past Year: 12
Number of Residents Age 60 or Older: 64
Number of Residents with Mobility Need: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sandy Insalaco Jr. | President | Signed plan of correction on multiple pages. |
| Melanie Goodman | Executive Director | Named in plan of correction and monitoring compliance for deficiencies. |
Inspection Report — Jun 22, 2016
Renewal
Date: Jun 22, 2016
Visit Reason
The document is a renewal license issued in response to the June 21, 2016 renewal application to operate Maple Shade Meadows Senior Living as a Personal Care Home. It 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 serves as a license renewal certificate and notification letter.
Report Facts
Notice — Mar 3, 2016
Date: Mar 3, 2016
Visit Reason
Response to a waiver request for qualifications of direct care staff persons under 55 Pa.Code § 2600.54(a).
Findings
The waiver request was reviewed and determined not to be needed as the submitted documentation confirmed the education exceeds the criteria for a high school diploma. The facility must keep a copy of the educational documentation.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tara Pride | Director of Regulatory Implementation | Signed the waiver response letter. |
Notice — Jan 21, 2016
Date: Jan 21, 2016
Visit Reason
Response to a waiver request for staff education qualifications under 55 Pa.Code § 2600.54(a) relating to personal care homes.
Findings
The waiver request was returned for additional information because the submitted documentation did not include a transcript showing three years of education. Alternatives for substantiating education were provided.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tara Pride | Director of Regulatory Implementation | Signed the letter responding to the waiver request. |
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