Inspection Reports for
Maris Grove
500 MARIS GROVE WAY,, GLEN MILLS, PA, 19342
Back to Facility Profile34 Reports
Inspection Report — Oct 20, 2025
Follow-Up
Date: Oct 20, 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 reporting and other cited deficiencies. Several deficiencies were cited including failure to report suspected abuse, missing resident signatures on contracts, lack of signed statements acknowledging receipt of resident rights, incidents of resident-to-resident abuse, failure to educate residents on their right to refuse medication, and incomplete support plan revisions.
Citations (6)
2600.15a The home failed to immediately report suspected abuse of a resident involving grabbing and scratches to the chest to the local area agency on aging.
2600.25b Resident home contracts were not signed by the residents, with Power of Attorney signing instead due to resident incompetency.
2600.41e Resident records lacked signed statements acknowledging receipt of resident rights and complaint procedures.
2600.42b Resident-to-resident abuse occurred including grabbing causing scratches, verbal aggression, and physical altercations with multiple documented incidents.
2600.191 Residents were not educated on their right to question or refuse medication if they believed there was a medication error.
2600.227c The support plan was not revised to reflect aggressive actions and expressions including hitting and grabbing of another resident.
Report Facts
Residents Served: 50
Residents Served in Dementia Care Unit: 44
Current Hospice Residents: 2
Total Daily Staff: 94
Waking Staff: 71
Resident Support Staff: 0
Number of documented aggressive incidents: 11
Inspection Report — May 20, 2025
Follow-Up
Date: May 20, 2025
Visit Reason
The inspection was conducted as a follow-up to verify that the submitted plan of correction was fully implemented after an incident.
Findings
The facility was found to have implemented corrective actions for multiple deficiencies including record confidentiality, locking poisonous materials, surface repairs, annual medical evaluations, medication storage security, and following prescriber's orders. Ongoing quality assurance monitoring programs were established to ensure continued compliance.
Citations (6)
Several resident records were unlocked, unattended, and accessible in the first floor nurse's station.
Poisonous materials were unlocked, unattended, and accessible to residents in the 3rd floor activity room bathroom.
The handle to the 3rd floor linen closet door was broken and could not be closed securely.
A resident's most recent annual medical evaluation was not completed within the required timeframe.
Two bins of resident medications were unlocked, unattended, and accessible in the first floor nurse's station.
A resident was administered medication at incorrect times, not following the prescriber's orders.
Report Facts
Residents Served: 50
Secured Dementia Care Unit Residents Served: 43
Current Hospice Residents: 1
Residents with Mobility Need: 50
Residents Age 60 or Older: 43
Total Daily Staff: 100
Waking Staff: 75
Inspection Report — Dec 4, 2024
Date: Dec 4, 2024
Visit Reason
The inspection was conducted as a licensing inspection by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing, with the reason noted as 'Incident'.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Resident Support Staff: 84
Waking Staff: 63
Residents Served: 42
Current Residents: 3
Residents Age 60 or Older: 42
Residents with Mobility Need: 42
Inspection Report — May 2, 2024
Follow-Up
Date: May 2, 2024
Visit Reason
The visit was a partial, unannounced follow-up inspection triggered by an incident to review the facility's plan of correction and compliance with licensing requirements.
Complaint Details
The inspection was incident-related, triggered by a complaint or incident involving sexually aggressive behavior by Resident #1. The report does not explicitly state substantiation status.
Findings
The inspection found repeated violations related to resident abuse and inadequate assessment and support plans, specifically concerning sexually aggressive behaviors of Resident #1. The facility implemented a plan of correction including 1:1 supervision, psychiatric evaluation, and updates to resident assessments and support plans.
Citations (3)
Resident #1 exhibited sexually aggressive behaviors not addressed in the support plan, including inappropriate touching and wandering into other residents' rooms.
Resident #1's initial assessment did not include the need for re-orientation or address wandering and inappropriate behaviors.
Resident #1's support plan did not include how the need for 'actions and expressions' would be met by the home.
Report Facts
Residents Served: 40
Staffing Hours: 80
Staffing Hours: 60
Current Residents in Hospice: 2
Residents Age 60 or Older: 40
Residents with Mobility Need: 40
Inspection Report — Dec 19, 2023
Follow-Up
Date: Dec 19, 2023
Visit Reason
The inspection visit on 12/19/2023 was a partial, unannounced follow-up to review the submitted plan of correction related to an incident involving medication administration discrepancies.
Findings
The submitted plan of correction was determined to be fully implemented as of the review date. The main deficiency involved medication record discrepancies related to narcotic administration, which led to staff suspensions and corrective actions including audits and staff education.
Citations (1)
Medication record discrepancies involving narcotic counts and misplacement of dosage logs for a resident receiving memory care and hospice services.
Report Facts
Residents Served: 44
Staffing Hours: 88
Waking Staff: 66
Current Residents Receiving Hospice: 2
Inspection Report — Jul 24, 2023
Follow-Up
Date: Jul 24, 2023
Visit Reason
The inspection visit on 07/24/2023 was conducted as a follow-up to verify the implementation of a previously submitted plan of correction related to a renewal and incident.
Findings
The facility was found to have fully implemented the submitted plan of correction. Two deficiencies were cited: one involving neglect and failure to provide first aid to a resident, and another related to staffing documentation errors during a fire drill. Corrective actions included suspension and separation of the responsible staff member and improvements in documentation and monitoring procedures.
Citations (2)
Staff person neglected to report and provide first aid to resident #1 who had skin tears and dried blood on the hand after a fall.
Staffing documentation during a fire drill showed only 1 staff for 44 residents, which was a documentation error not reflecting actual staffing.
Report Facts
Residents Served: 44
Staffing during fire drill: 1
Residents during fire drill: 44
Inspection Report — May 9, 2023
Follow-Up
Date: May 9, 2023
Visit Reason
The inspection was an unannounced partial review conducted due to an incident at the facility.
Findings
The inspection found repeated deficiencies related to failure to provide assistance with activities of daily living, neglect/abuse in care practices, incomplete medical evaluations, and missing signatures on support plans. The facility submitted a plan of correction which was accepted and fully implemented.
Citations (4)
Failure to provide required assistance with toileting, bladder, and bowel management to three residents as indicated in their assessment and support plans.
Neglect and abuse: residents found soaking wet with inadequate incontinence care and failure to follow procedures including timely bathroom assistance.
Medical evaluations for four residents lacked required information including dietary needs, special health considerations, allergies, body positioning, movement stimulation, and health status.
Support plan for one resident was not signed by the resident's Power of Attorney as required.
Report Facts
Residents Served: 42
Secured Dementia Care Unit Residents Served: 42
Current Hospice Residents: 2
Total Daily Staff: 84
Waking Staff: 63
Inspection Report — Dec 22, 2022
Date: Dec 22, 2022
Visit Reason
The inspection was a partial, unannounced licensing inspection conducted due to an incident.
Findings
No regulatory citations or deficiencies were identified during this inspection.
Report Facts
Total Daily Staff: 82
Waking Staff: 62
Residents Served: 41
Residents 60 Years of Age or Older: 41
Residents with Mobility Need: 41
Inspection Report — Dec 7, 2022
Follow-Up
Date: Dec 7, 2022
Visit Reason
The inspection was a partial, unannounced follow-up visit triggered by an incident to verify the implementation of a previously submitted plan of correction.
Findings
The facility was found to have fully implemented the submitted plan of correction related to deficiencies in activities of daily living assistance, treatment of residents, and resident-home contract services. The deficiencies involved failure to provide required assistance and dignity to a resident, with corrective actions including staff re-education and suspension of an employee who subsequently resigned.
Citations (3)
Failure to provide assistance with toileting, bladder management, and bowel management to resident 1 as required by the resident's assessment and support plan.
Resident 1 was treated without dignity and respect when staff person B yanked off the resident's protective undergarment and laughed as it fell to the ground.
Failure to provide total incontinence care to resident 1 as contracted in the resident-home contract.
Report Facts
Residents Served: 43
Total Daily Staff: 86
Waking Staff: 65
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff Person B | Named in deficiencies related to failure to assist resident and disrespectful treatment; placed on suspension and subsequently resigned. | |
| Staff Person C | Interviewed regarding the deficiencies. | |
| Staff Person A | Interviewed regarding the deficiencies. |
Inspection Report — Nov 9, 2022
Follow-Up
Date: Nov 9, 2022
Visit Reason
The inspection visit was conducted as a follow-up to verify the implementation of a previously submitted plan of correction related to an incident at the facility.
Findings
The submitted plan of correction was found to be fully implemented. Deficiencies related to assistance with activities of daily living, abuse, and support plan signatures were addressed with corrective actions including supervision plans, staff training, and audits of support plans.
Citations (3)
Failure to provide assistance with activities of daily living as required in the resident's assessment and support plan.
Resident abuse including neglect and improper care as described in staff interviews and observations.
Resident participated in development of support plan but did not sign the support plan.
Report Facts
Residents Served: 40
Staffing Hours: 80
Waking Staff: 60
Residents Age 60 or Older: 40
Residents with Mobility Need: 40
Inspection Report — Oct 6, 2022
Follow-Up
Date: Oct 6, 2022
Visit Reason
The visit was a partial, unannounced follow-up inspection conducted due to an incident involving resident abuse reporting and treatment concerns.
Complaint Details
The visit was triggered by an incident involving alleged resident abuse. The allegations were substantiated by incident reports and staff interviews. Staff persons A and D were suspended and subsequently separated from employment due to the deficient practices.
Findings
The facility was found to have delayed reporting suspected resident abuse to the appropriate agency and had incidents of staff mistreatment of residents. Corrective actions included staff suspensions and separations, education on abuse reporting, and implementation of quality assurance monitoring.
Citations (3)
Failure to immediately report suspected abuse of a resident as required by law.
Failure to report an incident or condition to the Department’s personal care home regional office within 24 hours.
Residents were not treated with dignity and respect; incidents of staff grabbing, swinging, pushing, and forcibly handling residents were documented.
Report Facts
Residents Served: 44
Current Hospice Residents: 2
Total Daily Staff: 88
Waking Staff: 66
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff Person A | Named in multiple abuse allegations involving grabbing and swinging resident's legs. | |
| Staff Person B | Witnessed abuse incidents and provided statements during investigation. | |
| Staff Person C | Reported the abuse incident to management. | |
| Staff Person D | Involved in multiple incidents of aggressive handling of residents; suspended and separated from employment. | |
| Nursing Home Administrator | Administrator | Responsible for education on abuse reporting and oversight of corrective actions. |
| Director of Nursing | Director of Nursing (DON) | Part of interdisciplinary team reviewing abuse reports and ensuring compliance. |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Part of interdisciplinary team reviewing abuse reports and ensuring compliance. |
Inspection Report — Jul 18, 2022
Renewal
Date: Jul 18, 2022
Visit Reason
The inspection was a renewal visit to assess compliance with licensing regulations for the facility.
Findings
The inspection identified multiple deficiencies including unsecured poisonous materials, improper refrigerator/freezer temperatures, outdated food, lint accumulation in dryer vents, incomplete fire drill records, missing annual medical evaluations, medication storage and labeling issues, medication administration documentation errors, incomplete resident records, and glucometer calibration errors. Corrective actions were implemented and plans for ongoing monitoring were established.
Citations (14)
Poisonous materials were found unlocked and accessible to residents in the secure dementia care unit.
The temperature in the walk-in freezer was 8 degrees Fahrenheit, above the required 0°F.
Outdated milk with use by date of 7/17/22 was found in the 3rd floor fridge.
Approximately 1/4 inch accumulation of lint in the lint trap of the dryer.
Fire drill records did not include evacuation routes used for drills conducted on multiple dates.
Resident did not evacuate to a designated meeting place during fire drill on 2/18/22.
Resident #2 and #3 had missing or incomplete annual medical evaluations.
Resident #1 had an insulin pen not dated for opening, contrary to manufacturer instructions.
Medication administration record for Resident #4 did not match medication label instructions.
Resident #4's medication administration was not documented on the electronic MAR as required.
Resident #1's glucometer reading was not properly documented and calibrated.
Resident #1 was not administered prescribed medication as ordered.
Resident #1's support plan did not indicate if resident participated or refused to sign.
Resident #2's record did not include eye color.
Report Facts
Residents Served: 33
Staffing Hours: 66
Waking Staff: 50
Deficiency Completion Date: Sep 16, 2022
Inspection Report — May 3, 2022
Plan of Correction
Date: May 3, 2022
Visit Reason
The inspection was conducted as a follow-up to verify the implementation of the submitted plan of correction for previous deficiencies at the facility.
Findings
The submitted plan of correction was determined to be fully implemented, with continued compliance required. Two specific deficiencies were addressed: failure to submit a new fire safety approval after building renovations, and lack of toilet paper in a resident bathroom.
Citations (2)
The building was structurally altered with a completion date of 4/30/22. The home did not submit a new fire safety approval from the appropriate fire safety authority.
On 3/5/22, there was no toilet paper in the bathroom of bedroom 322.
Report Facts
Residents Served: 29
Residents Served in Secured Dementia Care Unit: 29
Total Daily Staff: 29
Waking Staff: 22
Inspection Report — Apr 11, 2022
Follow-Up
Date: Apr 11, 2022
Visit Reason
The inspection was a partial, unannounced follow-up visit triggered by an incident to verify the implementation of a previously submitted plan of correction.
Findings
The facility was found to have deficiencies related to failure to provide required assistance with medication administration and incontinence care during the 11pm-7am shift on 3/26/22. Staff abandonment and neglect were noted, including missed medication administration and soaked incontinence products for residents. The facility implemented corrective actions including clearer staff assignments, weekly audits, and staff in-service training. The submitted plan of correction was determined to be fully implemented.
Citations (4)
Failure to provide assistance with medication administration and incontinence care to residents during the 11pm-7am shift on 3/26/22.
Staff abandonment during the 11pm-7am shift on 3/26/22, resulting in residents' call bell ringing unanswered for over 15 minutes and missed medication administration.
Failure to provide contracted services including medication administration and incontinence care to residents during the 11pm-7am shift on 3/26/22.
Failure to follow prescriber's orders by not administering prescribed medications to resident 1 on 3/27/22 at 06:30 AM.
Report Facts
Residents Served: 29
Staffing: 58
Waking Staff: 44
Completion Date: May 31, 2022
Inspection Report — Feb 9, 2022
Date: Feb 9, 2022
Visit Reason
The inspection was a partial announced visit conducted as a new inspection to review compliance with licensing regulations and to verify the facility's capacity and physical space use adjustments.
Findings
Two deficiencies were found: the facility lacked a working television and radio in a common area, and directions for operating key-locking devices were not conspicuously posted near Secure Dementia Care Unit exits. Both issues were corrected prior to the exit survey.
Citations (2)
2600.98.c: The home did not have a working television and radio available to residents in a living room or lounge area on 2/9/22 at 10:15 AM.
2600.233.c: Directions for operating key-locking devices were not conspicuously posted near the Secure Dementia Care Unit exits on 2/9/22 at 9:45 AM and 10:15 AM.
Report Facts
Residents Served: 29
SDCU Residents Served: 19
Total Daily Staff: 53
Waking Staff: 40
Residents with Mobility Need: 24
Residents 60 Years or Older: 29
Inspection Report — Feb 9, 2022
Follow-Up
Date: Feb 9, 2022
Visit Reason
The inspection was a partial, announced follow-up visit conducted on 02/09/2022 to review the plan of correction and verify compliance with licensing requirements.
Findings
Two deficiencies were identified: the absence of a working television and radio in a resident lounge area, and missing conspicuous posting of directions for operating key-locking devices at Secure Dementia Care Unit exits. Both deficiencies were corrected immediately prior to the exit survey.
Citations (2)
No working television and radio available to residents in a living room or lounge area.
Directions for operating key-locking devices were not conspicuously posted near the Secure Dementia Care Unit exits.
Report Facts
Residents Served: 29
Staffing Hours: 53
Waking Staff: 40
SDCU Residents Served: 19
Residents with Mobility Need: 24
Residents 60 Years or Older: 29
Inspection Report — Sep 24, 2021
Follow-Up
Date: Sep 24, 2021
Visit Reason
The inspection was a partial, unannounced follow-up visit conducted due to an incident, to verify the implementation of a previously submitted plan of correction.
Findings
The facility was found to have implemented the submitted plan of correction fully. Several deficiencies were cited related to criminal background checks for contractors, emergency telephone numbers posting, resident assessments, support plans, and confidentiality of resident records, but the facility contested these citations and provided corrective actions. The plan of correction was accepted and marked as implemented.
Citations (5)
Criminal background checks for contractors were not on file in the home during renovations.
No emergency telephone numbers, including nearest hospital and fire department, were posted on or by the telephone in room #318.
Resident #1's annual assessments for 2020 and 2021 were not in the chart on the inspection date.
Resident #1's support plan did not document how the need for assistance with Dementia with behavioral disturbance would be met, and the resident had not been reassessed for a higher level of care.
Records for resident #1 were unlocked, unattended, and accessible in the basement conference room with an unsupervised contractor present.
Report Facts
Residents Served: 61
Residents Served in Dementia Unit: 22
Total Daily Staff: 96
Waking Staff: 72
Residents 60 Years or Older: 39
Residents with Mental Illness: 1
Residents with Mobility Need: 35
Inspection Report — Aug 6, 2021
Follow-Up
Date: Aug 6, 2021
Visit Reason
The inspection was a partial follow-up visit conducted on 08/06/2021 to verify the implementation of a previously submitted plan of correction related to an incident.
Findings
The facility was found to have implemented the plan of correction fully. Deficiencies related to staff orientation, medication storage and administration, medication error reporting, and support plan signatures were addressed with corrective actions and monitoring plans in place.
Citations (7)
Staff persons did not receive first day orientation on fire safety and emergency preparedness topics as required.
Staff persons did not complete orientation training on resident rights, emergency medical plan, and mandatory reporting within 40 scheduled working hours.
Medications for Resident #2 were not available in the home, and blister packs were partially punched causing medication integrity issues.
Resident #2 refused scheduled doses of oxycodone but refusals were not reported to the prescriber within 24 hours.
The home did not follow prescriber's orders correctly, including incorrect dosages and failure to administer medications due to unavailability.
Medication errors were not immediately reported to the resident, designated person, and prescriber as required.
Resident #1's support plan was not signed by the resident despite participation by the power of attorney.
Report Facts
Residents Served: 53
Residents Served in Secured Dementia Care Unit: 22
Current Hospice Residents: 1
Total Daily Staff: 89
Waking Staff: 67
Inspection Report — Jul 12, 2021
Follow-Up
Date: Jul 12, 2021
Visit Reason
The inspection was a partial, unannounced incident investigation conducted on 07/12/2021 to review compliance and follow up on a plan of correction submission.
Findings
The facility failed to follow prescriber's orders by not administering prescribed medications to Resident #1 on multiple occasions due to medication unavailability. The submitted plan of correction was accepted and later determined to be fully implemented.
Citations (1)
Failure to administer prescribed medications (Metformin, Omeprazole, Aspercreme patch) to Resident #1 on specified dates due to medication unavailability.
Report Facts
Residents Served: 63
Current Residents in Hospice: 3
Residents Age 60 or Older: 63
Residents with Mental Illness: 3
Residents with Mobility Need: 58
Residents in Secured Dementia Care Unit: 21
Inspection Report — Jun 17, 2021
Plan of Correction
Date: Jun 17, 2021
Visit Reason
The inspection was conducted as a follow-up to review the submitted plan of correction for previously cited deficiencies related to medication administration and compliance.
Findings
The facility was found to have deficiencies in medication administration documentation and following prescriber's orders, specifically related to missing medications and inaccurate medication administration records. The submitted plan of correction was accepted and fully implemented with corrective actions including staff re-education, medication audits, and competency assessments.
Citations (2)
Failure to record the time of medication administration accurately; medication was marked as administered when it was not available in the home.
Failure to follow the directions of the prescriber; medications were missing and not available at the time of administration.
Report Facts
Residents Served: 64
Staff Total Daily: 121
Waking Staff: 91
Inspection Report — Apr 22, 2021
Renewal
Date: Apr 22, 2021
Visit Reason
The inspection was a full, unannounced renewal inspection conducted on 04/22/2021 and 04/23/2021 to assess compliance with regulatory requirements.
Findings
The inspection identified multiple deficiencies including delayed incident reporting, failure to timely refund resident charges after death, sanitary condition issues, environmental maintenance concerns, and medication documentation errors. Plans of correction were accepted for all deficiencies with corrective actions and monitoring measures outlined.
Citations (6)
Failure to report incidents or conditions to the Department within 24 hours as required, including medication errors and resident altercations.
Failure to refund resident charges within required timeframes following death of residents under and over 60 years of age.
Sanitary conditions not maintained; bathroom curtains in resident bedrooms had brown stains.
Trash outside the home was not properly contained; presence of a broken wood pallet outside trash containers.
Bedrooms had walls in disrepair including holes and cracks near residents' beds and in dementia care unit.
Medication documentation errors observed for resident #20, including discrepancies between glucometer readings and medication administration records.
Report Facts
Residents Served: 61
Staffing: 118
Waking Staff: 89
Medication Errors: 6
Resident Altercations: 3
Residents with Mental Illness: 3
Residents with Mobility Need: 57
Residents Age 60 or Older: 61
Inspection Report — Aug 19, 2020
Follow-Up
Date: Aug 19, 2020
Visit Reason
The inspection was a partial, unannounced follow-up visit triggered by an incident to verify the implementation of a submitted plan of correction.
Findings
The submitted plan of correction was determined to be fully implemented, with continued compliance required. The deficiency involved inaccurate incident reporting regarding a resident incident.
Citations (1)
2600.16(c) The home failed to accurately report an incident involving two residents; the incident report did not reflect that residents were engaged in sexual intercourse as witnessed by staff.
Report Facts
Residents Served: 43
Memory Care Residents Served: 13
Total Daily Staff: 65
Waking Staff: 49
Residents Age 60 or Older: 43
Residents Diagnosed with Mental Illness: 4
Residents with Mobility Need: 22
Inspection Report — Jun 1, 2020
Complaint Investigation
Date: Jun 1, 2020
Visit Reason
The inspection was a partial, unannounced complaint investigation triggered by an incident at the facility.
Complaint Details
The inspection was complaint-related, triggered by an incident involving mistreatment of residents and medication errors. The plan of correction was accepted and fully implemented.
Findings
The investigation found multiple deficiencies including mistreatment of residents by staff, inadequate substitute staff training and orientation, medication administration errors, incomplete narcotic record keeping, and illegible record entries. The facility submitted and implemented a plan of correction addressing all cited deficiencies.
Citations (8)
2600.42(c) A resident shall be treated with dignity and respect. Staff member A was verbally disrespectful and intimidating to residents, causing embarrassment and discomfort.
2600.61 Substitute Personnel - Substitute staff person B worked without passing the required Direct Care Certificate Competency Test.
2600.65(a) Substitute staff person B did not receive required orientation on fire safety and emergency preparedness topics on the first day of work.
2600.65(b) Substitute staff person B did not complete required orientation on resident rights, emergency medical plan, abuse reporting, and incident reporting within 40 scheduled work hours.
2600.182(c) Medication administration deficiencies included missing documentation, inaccurate narcotics log entries, and administration of medications by unqualified staff.
2600.185(a) The facility failed to maintain proper procedures for safe storage, access, security, and distribution of medications, evidenced by missing narcotic count signatures on multiple dates.
2600.190(a) Staff person B administered medications without successfully completing the Department-approved medication administration course and competency test within the past 2 years.
2600.251(b) Resident record entries were not permanent or legible; a narcotics log entry date was overwritten, compromising record integrity.
Report Facts
Residents Served: 43
Memory Care Residents Served: 13
Hospice Residents: 3
Staff Total Daily: 56
Staff Waking: 42
Notice — Nov 27, 2019
Date: Nov 27, 2019
Visit Reason
The document serves as a renewal approval notice for the Personal Care Home license of Maris Grove, confirming receipt of the renewal application and advising of the requirement for an annual onsite inspection within the next twelve months.
Findings
No inspection findings are reported in this document. It confirms the issuance of a regular license following the renewal application.
Report Facts
Inspection Report — Nov 18, 2019
Renewal
Date: Nov 18, 2019
Visit Reason
The inspection was conducted as a renewal and incident review of the Maris Grove facility on November 18 and 19, 2019.
Findings
The facility was found to have deficiencies related to medication storage, administration, and documentation, as well as medical evaluations for residents in the secured dementia care unit. The submitted plan of correction was fully implemented as of April 9, 2020.
Citations (4)
2600.185(a) The home failed to have prescribed PRN medications available for Resident #1 on 11/19/19.
2600.187(b) The medication administration record for Resident #1 lacked documentation of medication administration times on 11/17/19 and 11/19/19.
2600.187(d) The home did not administer prescribed eye drops to Resident #1 on 11/17/19 at 5:00 pm and 11/19/19 at 9:00 am due to medication unavailability.
2600.231(b) Resident #2 and Resident #3's most recent medical evaluations did not indicate the need for secured dementia care unit placement.
Report Facts
Residents Served: 65
Secured Dementia Care Unit Residents Served: 21
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nicole Zdunowski | PC Administrator | Named in multiple deficiency findings and plan of correction approvals |
Inspection Report — Sep 12, 2019
Routine
Date: Sep 12, 2019
Visit Reason
The Department’s Bureau of Human Services Licensing conducted a routine inspection of the Maris Grove facility on September 12, 2019.
Findings
No regulatory citations with 55 Pa. Code Ch. 2600 relating to Personal Care Homes were identified as a result of this inspection.
Inspection Report — Jul 30, 2019
Routine
Date: Jul 30, 2019
Visit Reason
The Department’s Bureau of Human Services Licensing conducted an inspection of the Maris Grove facility on July 30, 2019.
Findings
No regulatory citations with 55 Pa. Code Ch. 2600 relating to Personal Care Homes were identified as a result of this inspection.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shawn Parker | Human Services Licensing Supervisor | Signed the inspection report letter. |
Inspection Report — Dec 4, 2018
Annual Inspection
Date: Dec 4, 2018
Visit Reason
The annual licensing inspection was conducted to assess compliance with 55 Pa. Code Chapter 2600 relating to Personal Care Homes.
Findings
The facility was found to be in compliance with applicable regulations. A revised license was issued reducing the personal care capacity to 44 and adding 22 Secure Dementia Care Unit beds, with the license expiration date unchanged.
Report Facts
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jacqueline L. Rowe | Director | Signed the letter reporting inspection results |
Inspection Report — Nov 26, 2018
Renewal
Date: Nov 26, 2018
Visit Reason
This document is a renewal application and license issuance for Maris Grove Personal Care Home. The Department of Human Services will conduct an onsite inspection within the next twelve months as required by regulation.
Findings
No inspection findings are reported in this document. It confirms the issuance of a regular license following the renewal application.
Inspection Report — Aug 29, 2018
Complaint Investigation
Date: Aug 29, 2018
Visit Reason
The inspection was conducted as an incident investigation following an allegation of abuse involving a resident and staff at the facility.
Complaint Details
The visit was complaint-related due to an allegation of abuse against staff person A regarding resident #1. The allegation was found to be unsubstantiated.
Findings
The investigation found that the home did not implement a plan of supervision or suspend the staff person involved in the alleged abuse. The allegation was ultimately unsubstantiated, and the staff person was allowed to return to work without a Department-approved supervision plan.
Citations (3)
55 Pa.Code §2600.15(b) - The home failed to immediately develop and implement a plan of supervision or suspend the staff person involved in an alleged abuse incident. The staff person was allowed to return to work without Department approval.
55 Pa.Code §2600.15(c) - The home did not submit a plan of supervision or notice of suspension to the Department's personal care home regional office as required.
55 Pa.Code §2600.16(d) - The home failed to submit a final report to the Department following the conclusion of the abuse investigation.
Report Facts
Number of Residents Served: 62
Number of Current Hospice Residents: 3
Number of Hospice Residents in Past Year: 8
Number of Residents 60 Years or Older: 61
Number of Residents with Mental Illness: 1
Number of Residents with Mobility Need: 30
Notice — Nov 29, 2017
Date: Nov 29, 2017
Visit Reason
This document serves as a renewal notification for the Personal Care Home license and informs the facility of the requirement for an annual onsite inspection within the next twelve months.
Findings
No inspection findings are reported in this document. It confirms issuance of a regular license following the renewal application.
Report Facts
Inspection Report — Dec 12, 2016
Renewal
Date: Dec 12, 2016
Visit Reason
The inspection was conducted as part of the annual licensing renewal of the Maris Grove Personal Care Home facility on December 12 and 13, 2016.
Findings
Multiple violations of 55 Pa.Code Chapter 2600 were found related to contract signatures, payment responsibility, resident rights acknowledgements, staff training, environmental safety, food storage temperatures, medication management, resident education on medication refusal rights, and support plan signatures. Plans of correction were developed and partially implemented with ongoing monitoring.
Citations (10)
55 Pa.Code 2600.25(b): Contracts for residents #1, #2, and #4 were not signed by the resident or responsible parties.
55 Pa.Code 2600.25(c)(4): Contracts for residents #1 and #4 did not specify the party responsible for payment.
55 Pa.Code 2600.41(e): Residents #1, #2, and #4 records lacked signed statements acknowledging receipt of resident rights and complaint procedures.
55 Pa.Code 2600.65(g): Staff member A did not receive required annual training on new population groups during 2015.
55 Pa.Code 2600.85(d): Trash can on 3rd floor pantry was observed without a lid, risking pest intrusion.
55 Pa.Code 2600.103(f): Pantry freezers on 1st and 3rd floors had thermometers exceeding 0 degrees Fahrenheit, violating food storage temperature requirements.
55 Pa.Code 2600.183(f): Resident #3 had expired medications including Milk of Magnesia, Lidocaine ointment, and Naturale Tears in the medicine cabinet.
55 Pa.Code 2600.184(a): Medication labels for residents #3 and #5 were missing required information including medication name, dosage, and prescriber details.
55 Pa.Code 2600.191: Residents #1, #2, and #4 were not educated on their right to refuse medication if they believed there was a medication error.
55 Pa.Code 2600.227(g): Residents #1 and #3 did not sign and date their support plans as required.
Report Facts
Number of Residents Served: 63
Number of Current Hospice Residents: 6
Number of Hospice Residents in Past Year: 13
Staffing Hours - Resident Support: 63
Staffing Hours - Total Daily Staff: 157
Staffing Hours - Waking Staff: 118
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Beverly Duffy | Administrator | Named as legal entity representative signing plans of correction and involved in findings |
| Sabrina Freeman | Surveyor | Conducted the inspection on December 12 and 13, 2016 |
| Tahesia Thomas | Surveyor | Conducted the inspection on December 12 and 13, 2016 |
Notice — Nov 21, 2016
Date: Nov 21, 2016
Visit Reason
The document is a renewal application approval and license issuance for the Personal Care Home facility, Maris Grove. It also 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 is an administrative notice confirming license renewal and outlining inspection requirements.
Notice — Jul 21, 2016
Date: Jul 21, 2016
Visit Reason
Response to a waiver request submitted by Maris Grove for certain Pennsylvania Code Chapter 2600 regulations related to personal care homes.
Findings
The Department determined that the waiver for doors, locks, and alarms is not applicable as Maris Grove is not licensed to operate a secured dementia care unit. A waiver for unobstructed egress may be required. Additional documentation is requested for further review.
Report Facts
Waiver request: 55
License number: 134660
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tara Pride | Director of Regulatory Implementation | Signed letter regarding waiver request |
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