41 Reports
Inspection Report — Mar 25, 2026
Date: Mar 25, 2026
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 as a result of this inspection.
Report Facts
Resident Support Staff: 53
Waking Staff: 40
Residents Served: 42
Secured Dementia Care Unit Residents Served: 10
Hospice Current Residents: 1
Residents Age 60 or Older: 45
Residents with Mobility Need: 11
Inspection Report — Feb 3, 2026
Complaint Investigation
Date: Feb 3, 2026
Visit Reason
The inspection was conducted as a complaint investigation with a provisional reason, including a full unannounced inspection and follow-up on a submitted plan of correction.
Complaint Details
The inspection was complaint-related and provisional in nature. The submitted plan of correction was fully implemented and accepted by the licensing authority.
Findings
The inspection identified multiple deficiencies related to resident record confidentiality, medication storage and documentation, and assessment procedures. The facility submitted plans of correction which were accepted and implemented by the dates noted.
Citations (7)
Resident records confidentiality was breached by leaving a binder with previous Licensing Inspection Summaries containing resident names and privacy coding accessible at the main entrance.
Medication storage was compromised as a foil pack for pills 18, 19, and 20 was tampered with and resealed with tape.
Medication storage procedures lacked proper implementation for safe storage, access, security, and distribution by trained staff.
Narcotic logs and medication cards had discrepancies and incomplete documentation, including incorrect remaining tablet counts and missing dates, times, and nurse signatures.
Resident initial assessments did not accurately reflect the resident's ability to self-administer medications, omitting current information.
Resident annual assessment did not include information about ongoing wound care services.
Support plan for a resident admitted to the Secured Dementia Care Unit was not completed within 72 hours of admission as required.
Report Facts
Residents Served: 41
Secured Dementia Care Unit Residents Served: 12
Resident Support Staff: 19
Total Daily Staff: 72
Waking Staff: 54
Inspection Report — Dec 19, 2025
Complaint Investigation
Date: Dec 19, 2025
Visit Reason
The inspection was conducted to investigate complaints regarding failure to implement physicians' orders, inadequate catheter care, and failure to accommodate residents' individualized food and drink preferences.
Complaint Details
The investigation was complaint-driven, focusing on allegations that the facility failed to follow physicians' orders for bowel management, did not provide proper catheter care, and did not accommodate residents' food and drink preferences. Substantiation status is not explicitly stated.
Findings
The facility failed to ensure physicians' orders were followed for one resident regarding bowel management, failed to provide appropriate catheter care for a resident with an indwelling urinary catheter, and failed to accommodate food and drink preferences for two residents.
Citations (3)
Failure to ensure physicians' orders were implemented for bowel management for one resident.
Failure to assess and provide catheter care in accordance with facility policy for one resident with an indwelling urinary catheter.
Failure to provide food and drink that accommodates resident allergies, intolerances, and preferences for two residents.
Report Facts
Residents sampled: 25
Residents affected: 1
Residents affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Confirmed that physicians' orders for Resident 11 should have been followed and that catheter care was not documented as provided. | |
| Administrator | Stated that dietary department was expected to follow residents' meal selections and provide all items listed on meal tickets. |
Inspection Report — Jul 9, 2025
Enforcement
Date: Jul 9, 2025
Visit Reason
The inspection was conducted due to an incident involving abuse and theft allegations, as well as dietary needs compliance issues, resulting in violations found during unannounced inspections on July 9 and July 17, 2025.
Complaint Details
The complaint involved abuse and neglect of Resident 1, including choking and improper emergency response, and fraudulent credit card charges involving Resident 2. The abuse was substantiated with ongoing criminal investigation and court hearing scheduled.
Findings
Violations included abuse and neglect of residents, fraudulent charges on a resident's credit card, and failure to comply with dietary needs requirements. The facility's certificate of compliance was revoked and a third provisional license was issued based on an acceptable plan of correction.
Citations (3)
Resident 1 was neglected and physically abused, including choking incident and improper emergency response.
Resident 2 had fraudulent charges on their credit card, involving theft and exploitation.
Resident 1 was ordered a pureed diet but EMTs were contacted due to choking incident; dietary needs documentation was inadequate.
Report Facts
Residents Served: 51
Residents Served in Secure Dementia Care Unit: 13
Fraudulent Charges: 434.63
Inspection Report — Apr 10, 2025
Enforcement
Date: Apr 10, 2025
Visit Reason
The inspection was conducted as a complaint and interim review to address violations found during previous licensing inspections on December 3, 2024, February 7, 2025, and April 10, 2025, resulting in a second provisional license being issued.
Complaint Details
The inspection was complaint-related, triggered by violations found during prior inspections on December 3, 2024, February 7, 2025, and April 10, 2025. The complaint involved medication administration errors, resident safety issues, and regulatory noncompliance.
Findings
Multiple medication administration deficiencies were identified, including missed doses, improper documentation, medication labeling errors, and failure to report medication errors. Additional deficiencies included unsafe resident equipment, incomplete resident assessments, and fire safety violations related to hospice care residents.
Citations (10)
Medication was not administered as ordered and the medication error was not reported to the Department.
Resident self-administering medication without physician assessment.
Medication administration documentation was not completed properly; staff initialed all medications at once instead of individually.
Medication labels did not match the Medication Administration Record (MAR).
PRN medication was not available at the time of inspection.
Medication record missing required information such as medication name, strength, dosage, route, frequency, and administration times.
Medications were not initialed as administered at the time of administration.
Refusal of medication was not documented or reported to the prescriber.
Prescriber's orders were not followed; medications were missed or administered incorrectly.
Medication errors were not immediately reported to the resident, designated person, and prescriber.
Report Facts
Residents Served: 46
Residents Served in Secured Dementia Care Unit: 11
Total Daily Staff: 58
Waking Staff: 44
Deficiency Counts: 10
Notice — Dec 27, 2024
Date: Dec 27, 2024
Visit Reason
This document is an invoice issued by the Pennsylvania Department of Human Services Bureau of Human Services Licensing for an assessment related to the Personal Care Home license of Mifflin Court.
Findings
The invoice details a total balance due of $3,760.00 related to assessments or fines under 55 PA Code § 2600 for the facility.
Report Facts
Total Balance Due: 3760
Balance From Last Invoice: 5170
Payments Since Last Invoice: 1410
Inspection Report — Nov 15, 2024
Annual Inspection
Date: Nov 15, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to comprehensive care planning, food service quality, and food safety in the nursing home.
Findings
The facility failed to develop and implement comprehensive care plans addressing individual resident needs for three sampled residents, failed to provide food that was palatable and served at a safe temperature, and failed to maintain proper food handling and sanitary conditions in the main kitchen.
Citations (3)
Failed to develop or implement a comprehensive care plan and/or interventions that addressed individual resident needs for three of 27 sampled residents.
Failed to provide food that was palatable and at an appetizing temperature in the main dining room.
Failed to properly serve food and maintain sanitary conditions in the main kitchen, including improper glove use and cross contamination risks.
Report Facts
Resident sample size: 27
Resident affected: 3
Food temperature: 110
Food temperature: 115.1
Food temperature: 124
Required hot food temperature: 135
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Confirmed lack of documented evidence that care areas were addressed in residents' care plans | |
| Dietary Director | Stated that hot food should have achieved a temperature of 135 degrees Fahrenheit or higher | |
| Dietary Employee 1 | Observed improperly handling food and gloves during tray line service |
Inspection Report — Oct 17, 2024
Follow-Up
Date: Oct 17, 2024
Visit Reason
The visit was a partial, unannounced inspection conducted as a follow-up to verify the submitted plan of correction for previous deficiencies.
Findings
The inspection found that the submitted plan of correction was fully implemented, specifically addressing medication administration record (MAR) documentation issues where medications were administered but not initialed. Staff education and weekly audits were implemented to maintain compliance.
Citations (1)
Medications administered at 5pm were not initialed as administered on the Medication Administration Record (MAR).
Report Facts
Residents Served: 44
Secured Dementia Care Unit Residents Served: 12
Current Hospice Residents: 2
Residents Age 60 or Older: 44
Residents with Mobility Need: 13
Residents with Physical Disability: 2
Total Daily Staff: 57
Waking Staff: 43
Inspection Report — Oct 17, 2024
Enforcement
Date: Oct 17, 2024
Visit Reason
The inspection visit on 10/17/2024 was conducted to verify compliance following a prior notification of compliance on 9/11/2024 and to review fines related to regulatory violations at Mifflin Court.
Findings
The inspection verified that the facility had achieved compliance as of 9/11/2024, resulting in the rescission of previously issued fines. An updated invoice reflecting the adjusted fine amount was issued.
Report Facts
Fine amount: 3760
Fine amount: 8225
Total balance due: 5170
Total balance due: 9635
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Theresa Hartman | Director | Signed the letter regarding enforcement and fine invoice |
Notice — Oct 11, 2024
Date: Oct 11, 2024
Visit Reason
This document serves as an invoice for a Class II additional assessment/fine issued under 55 PA Code § 2600 related to the Personal Care Home license for Mifflin Court.
Findings
The invoice details a financial penalty totaling $8,225.00 for the period from 8/27/2024 to 9/30/2024, with a total balance due of $9,635.00 including prior balance.
Report Facts
Fine amount: 8225
Total balance due: 9635
Balance from last invoice: 1410
Notice — Sep 6, 2024
Date: Sep 6, 2024
Visit Reason
This document acknowledges receipt of the facility's request to appeal the Department of Human Services' decision to issue a first provisional license.
Findings
The document does not contain inspection findings but confirms that the appeal request has been forwarded to the Bureau of Hearings and Appeals and that the facility will be contacted regarding the hearing date and time.
Inspection Report — Aug 26, 2024
Follow-Up
Date: Aug 26, 2024
Visit Reason
The visit was a partial, unannounced follow-up inspection conducted due to an incident and fine, to review the submitted plan of correction for the facility.
Findings
The inspection found medication labeling errors, incomplete medication administration records, and missed medication administrations. The facility submitted plans of correction which were accepted and implemented, with ongoing monitoring and staff inservice to ensure compliance.
Citations (4)
Pharmacy labels for medications were incorrect or missing parameters such as dosage times and blood pressure/heart rate hold parameters.
Medications scheduled for administration were not initialed as given on the medication administration record (MAR).
Medications were administered beyond the documented end date on the MAR without proper documentation.
Resident morning medications were not administered on 8/2/24 due to unavailability.
Report Facts
Residents Served: 47
Secured Dementia Care Unit Residents Served: 11
Hospice Current Residents: 1
Residents with Mobility Need: 11
Residents Age 60 or Older: 47
Total Daily Staff: 58
Waking Staff: 44
Inspection Report — Aug 20, 2024
Enforcement
Date: Aug 20, 2024
Visit Reason
The document concerns enforcement action due to a fine assessed on the Personal Care Home for noncompliance, with payment overdue by more than 30 days.
Findings
A fine of $3,760 was assessed on 8/20/2024 related to enforcement violations under Pennsylvania regulations. The letter requests payment and warns of further license action or referral to the Attorney General if unpaid.
Report Facts
Fine amount: 3760
Inspection Report — Aug 20, 2024
Enforcement
Date: Aug 20, 2024
Visit Reason
The Department of Human Services issued a notice of intent to assess a fine for regulatory violations related to 55 Pa.Code Ch. 2600 for the personal care home Mifflin Court.
Findings
The facility was found to have uncorrected violations under 55 Pa.Code Chapter 2600 Section 184a, Class II, resulting in a fine assessment. The total fine for the period 8/21/2024 through 8/26/2024 was $1,410.
Citations (1)
55 Pa.Code Chapter 2600 Section 184a Class II violation was found with 47 residents present during inspection. The violation remained uncorrected, leading to a fine assessment.
Report Facts
Fine amount: 1410
Inspection Report — May 31, 2024
Enforcement
Date: May 31, 2024
Visit Reason
The inspection was conducted as a complaint investigation and interim exit conference to address violations found during prior licensing inspections on March 26, 2024, March 28, 2024, and May 31, 2024, leading to the issuance of a first provisional license and enforcement actions.
Complaint Details
The inspection was complaint-related, triggered by allegations leading to a complaint and interim exit conference on 05/31/2024. The report includes substantiation of multiple violations.
Findings
Multiple violations were found including exterior hazards, fire drill evacuation failures, medication management issues such as outdated prescriptions, improper labeling, failure to follow prescriber's orders, and deficiencies in resident support plans. Enforcement actions include fines and a provisional license with required corrections.
Citations (10)
The grounds surrounding the concrete patio areas of the memory care courtyard were overgrown with grass and weeds approximately one foot tall.
Resident #1 was not evacuated during the fire drill conducted on 5/20/24 at 9pm.
Medication Divalproex Sodium 125mg found in medication cart for resident #4 without a current order.
Novolin and Novolog insulin pens for residents #2 and #3 were not dated and initialed when opened.
Pharmacy labels for insulin medications did not match prescribed dosages for residents #2 and #5.
Resident #3's medication administration record did not list diagnoses or purposes for Magnesium Oxide and Ferrous Sulfate.
Refusal of medication by resident #4 on 5/24/24 and 5/25/24 was not documented on the MAR.
Failure to follow prescriber's orders for insulin administration and medication holds for residents #2, #3, #4, #5, #6, and #7 on multiple dates.
Support plans for residents #6, #7, and #8 did not document use of enabler bars attached to beds or indicate if covers are required.
Magnetic lock keypad code was not posted at the gate in the memory care courtyard.
Report Facts
Residents Served: 49
Residents Served in Secure Dementia Care Unit: 14
Total Daily Staff: 66
Waking Staff: 50
Fine Amount: 245
Inspection Report — Dec 7, 2023
Routine
Date: Dec 7, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, nursing services, care planning, medication administration, catheter care, food safety, and environmental safety at the Mifflin Center nursing home.
Findings
The facility was found deficient in multiple areas including failure to maintain resident dignity during dining assistance, incomplete and inaccurate Minimum Data Set (MDS) assessments, lack of comprehensive care plans, inadequate personal hygiene assistance, failure to follow physician medication orders, improper catheter care, unsanitary food storage and preparation, and unsafe, unsanitary, and uncomfortable living environment conditions on the 400 unit.
Citations (8)
Failed to provide assistance with dining in a manner that promoted and maintained dignity for three residents.
Failed to ensure that the Minimum Data Set (MDS) assessment was complete to accurately reflect the resident's status for four residents.
Failed to develop a comprehensive care plan to meet each resident's needs identified in the comprehensive assessment for five residents.
Failed to provide services to maintain adequate grooming and personal hygiene for four residents unable to carry out activities of daily living.
Failed to ensure physician's orders were implemented for two residents, including medication administration outside established parameters and lack of documentation of vital signs prior to medication.
Failed to provide proper catheter care to prevent the risk of infection for two residents with indwelling urinary catheters.
Failed to store food in a sanitary manner in the dietary department and on one nursing unit, including presence of dried food debris, hair, unlabeled opened food containers, and damaged microwave.
Failed to provide a safe, sanitary, and comfortable environment on the 400 unit, including peeling paint, dirty and marred surfaces, missing toilet paper holders, torn curtains, debris, and damaged furniture.
Report Facts
Medication administrations outside parameters: 23
Medication administrations without documented vital signs: 22
Number of sampled residents with incomplete MDS assessments: 4
Number of sampled residents without comprehensive care plans: 5
Number of sampled residents with inadequate grooming assistance: 4
Number of residents observed with catheter care issues: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Confirmed diagnoses and care plan deficiencies, medication administration issues, and stated nails were to be done on resident shower days. | |
| Licensed Practical Nurse 1 | LPN | Observed assisting Resident 3 with lunch while standing. |
| Nurse Aide 1 | NA | Observed assisting Resident 20 with lunch while standing. |
| Licensed Practical Nurse 2 | LPN | Observed catheter tubing issues and did not secure tubing or spigot. |
| Nurse Aide 2 | NA | Observed catheter tubing issues and did not secure tubing or spigot. |
| Administrator | Confirmed microwave and refrigerator were used for residents. |
Inspection Report — May 24, 2023
Renewal
Date: May 24, 2023
Visit Reason
The inspection was conducted as a renewal and incident review of the facility to ensure compliance with licensing requirements.
Findings
The inspection identified multiple deficiencies related to annual medical evaluations, self-administration assessments, medication labeling, medication records, support plan documentation, cognitive preadmission screening, and secured dementia unit assessments. Plans of correction were directed and later implemented to address these issues.
Citations (11)
Resident 1's most recent annual medical evaluation was outdated, last dated 3/31/2022.
Resident 1 self-administers medications but had not been assessed in the last year for this ability.
Expired medication found on the medication cart with expiration date 7/2022.
Resident 2's prescribed medication had a pharmacy label that was faded and illegible for dosage, administration instructions, and prescriber information.
Medication Administration Record (MAR) for Resident 3 was incomplete; staff failed to identify the amount of insulin given.
Resident 4's Resident Assessment Support Plan (RASP) was not updated to reflect current diet of soft and ground foods.
Resident 5's RASP was not signed by the assessor.
Resident 6 admitted to the secured dementia unit (SDU) without a completed cognitive preadmission screening.
Resident 7 in the secured dementia unit had not been assessed annually for continuing need since an unspecified date.
Resident 6 admitted to SDU without an assessment completed within 72 hours of admission.
Resident 7's most recent RASP was not current as required.
Report Facts
Residents Served: 50
Secured Dementia Unit Residents Served: 12
Current Hospice Residents: 1
Residents Age 60 or Older: 50
Residents with Mobility Need: 15
Total Daily Staff: 65
Waking Staff: 49
Inspection Report — May 9, 2023
Follow-Up
Date: May 9, 2023
Visit Reason
The visit was a follow-up review conducted on 05/09/2023 and 05/10/2023 to verify the implementation of the submitted plan of correction related to a prior incident.
Findings
The submitted plan of correction was determined to be fully implemented as of the follow-up visit. The report notes that continued compliance must be maintained.
Citations (2)
Failure to immediately report suspected resident abuse; incident involving Resident #2 striking Resident #1 was not reported timely to the Area Agency on Aging or the Department.
Failure to report the incident or condition to the Department’s personal care home regional office or complaint hotline within 24 hours as required by law.
Report Facts
Residents Served: 55
Secured Dementia Care Unit Residents Served: 14
Current Hospice Residents: 2
Residents Age 60 or Older: 55
Residents with Mobility Need: 18
Notice — Apr 12, 2023
Date: Apr 12, 2023
Visit Reason
This letter responds to a request from the facility to use the Safely You Falls Management Program to support fall detection and management for individuals with cognitive impairment.
Findings
The Department reviewed the submitted information and determined that the informed consent process includes voluntary participation, the right to discontinue use of cameras, and notification of residents' rights, satisfying regulatory privacy requirements.
Inspection Report — Mar 7, 2023
Complaint Investigation
Date: Mar 7, 2023
Visit Reason
The inspection was conducted as a complaint and incident investigation at the facility.
Complaint Details
The inspection was triggered by a complaint and incident, but no deficiencies or citations were found, indicating no substantiated issues.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Residents Served: 45
Current Hospice Residents: 1
Residents Age 60 or Older: 45
Residents with Mobility Need: 11
Inspection Report — Apr 21, 2022
Routine
Date: Apr 21, 2022
Visit Reason
The inspection was conducted as a routine licensing inspection by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Inspection Report — Mar 22, 2022
Renewal
Date: Mar 22, 2022
Visit Reason
The inspection was conducted as a renewal visit to review compliance with licensing requirements at Mifflin Court.
Findings
The inspection identified several deficiencies including incomplete medical evaluations, unlabeled resident medications, missed medication administrations, and missing preadmission screening forms. Plans of correction were submitted and implemented with ongoing monitoring established.
Citations (5)
Resident #1 and #2 had incomplete annual medical evaluations missing dates and medication lists.
Resident #3 had over-the-counter medications not labeled with the resident's name.
Resident #2 did not receive certain 9:00 AM medications on 3/9/22 and 3/17/22.
Resident #4 did not have a preadmission screening form completed.
Resident #4 did not have a cognitive screening completed prior to entering the secured dementia care unit.
Report Facts
Residents Served: 55
Residents Served in Secured Unit: 14
Total Daily Staff: 69
Waking Staff: 52
Missed Medication Administrations: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kelly Grainger | Resident Care Director | Named in relation to re-education and monitoring of medication administration and admission paperwork compliance. |
| Casey Hoffman | LPN | Responsible for auditing medication carts weekly to ensure compliance with medication labeling. |
Inspection Report — Jan 27, 2022
Follow-Up
Date: Jan 27, 2022
Visit Reason
The inspection visit on 01/27/2022 was a follow-up to verify the implementation of a previously submitted plan of correction related to complaint and incident reports.
Complaint Details
The visit was complaint-related due to allegations of delayed reporting of resident abuse. The complaint was substantiated as the facility did not report the abuse allegation from 8/20/21 until 11/12/21.
Findings
The facility was found to have fully implemented the plan of correction regarding delayed reporting of a resident abuse allegation. Continued compliance is required. The plan of correction was accepted and verified through subsequent document submissions.
Citations (2)
Failure to immediately report suspected abuse of a resident; the incident was reported late to the Department of Aging.
Failure to report the incident or condition to the Department’s personal care home regional office or complaint hotline within 24 hours as required.
Report Facts
Residents Served: 55
Secured Dementia Care Unit Residents Served: 13
Hospice Residents: 1
Total Daily Staff: 68
Waking Staff: 51
Residents with Mobility Need: 13
Residents 60 Years or Older: 55
Inspection Report — Jun 30, 2021
Routine
Date: Jun 30, 2021
Visit Reason
The inspection was conducted as a routine licensing inspection by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Notice — Apr 16, 2021
Date: Apr 16, 2021
Visit Reason
The document serves as a renewal license approval for the Personal Care Home 'Mifflin Court' and notifies that an annual onsite inspection will be conducted within the next twelve months as required by regulation.
Findings
No inspection findings are reported in this document; it confirms issuance of a regular license following the renewal application and outlines the requirement for a future annual inspection.
Report Facts
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary, Office of Long-term Living | Signed the renewal license approval letter. |
Inspection Report — Mar 10, 2021
Renewal
Date: Mar 10, 2021
Visit Reason
The inspection was conducted as a renewal review of the facility's compliance with licensing requirements on 03/10/2021 and 03/11/2021.
Findings
The facility was found to have multiple deficiencies related to record confidentiality, medication management, medication error reporting, and annual resident assessments. The submitted plan of correction was determined to be fully implemented.
Citations (6)
Resident records confidentiality was breached by posting a Licensing Inspection Summary with attached resident privacy coding sheet at the front desk.
Medication for a discharged resident was found in the medication cart.
Medication Administration Records (MAR) were not properly maintained due to incorrect transcription of blood glucose test results for residents.
Medication administration record did not indicate a prescribed medication was given on the correct date for a resident.
Medication error was not reported to the department, resident, designated person, and prescriber as required.
Residents did not receive annual assessments within the required timeframe.
Report Facts
Residents Served: 48
Medication Cart Error: 1
Medication Transcription Errors: 2
Medication Administration Error: 1
Residents Missing Annual Assessment: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Michele Moskalczyk | Human Services Licensing Supervisor | Signed the letter confirming plan of correction implementation |
Inspection Report — Jan 21, 2021
Renewal
Date: Jan 21, 2021
Visit Reason
The inspection was conducted as part of the Pennsylvania Department of Human Services, Bureau of Human Service Licensing licensing inspections on 01/21/2021, 01/22/2021, and 01/25/2021 for the facility Mifflin Court.
Findings
No regulatory citations were identified as a result of this inspection.
Inspection Report — Jan 12, 2021
Follow-Up
Date: Jan 12, 2021
Visit Reason
The inspection was a partial, unannounced follow-up visit to review the submitted plan of correction related to medication administration errors.
Findings
The facility was found to have previously committed medication administration errors involving failure to administer medications to 10 residents and falsification of medication administration records. The submitted plan of correction was determined to be fully implemented, including staff termination, re-education, and monitoring to prevent recurrence.
Citations (4)
Failure to keep prescription medications in original labeled containers and removal of medications more than 2 hours in advance, resulting in medications being left undistributed overnight.
Failure to record the date/time of medication administration accurately, with staff initialing records without administering medications.
Failure to administer prescribed medications to 10 residents at the scheduled time.
Failure to immediately report medication errors to residents, designated persons, and prescribers.
Report Facts
Residents affected: 10
Staff total daily: 59
Waking staff: 44
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maria Salgado | Med Tech | Staff Member A who failed to administer medications and falsified medication administration records |
Inspection Report — Jul 13, 2020
Routine
Date: Jul 13, 2020
Visit Reason
The inspection was a licensing inspection conducted 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 — Apr 2, 2020
Routine
Date: Apr 2, 2020
Visit Reason
The inspection was conducted as a routine 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 — Feb 12, 2020
Renewal
Date: Feb 12, 2020
Visit Reason
The inspection was conducted as a renewal visit to review compliance and licensing status of Mifflin Court.
Findings
The facility was found to have multiple violations including an expired boiler inspection certificate, lack of documentation for direct care staff qualifications, obstructed egress routes, incorrect medication labeling, and missing documentation for resident admission to the secured dementia care unit. The submitted plan of correction was fully implemented as of the follow-up date.
Citations (5)
The home's boiler inspection certificate expired on 1/17/20 and the boiler had not yet been inspected.
Staff person A hired on 8/6/19 lacked documentation of a high school diploma, GED, or CNA license.
The exit door in the first floor activity room was blocked by a row of chairs during morning activities.
The medication Omeprazole for resident #1 had a pharmacy label with incorrect dosage instructions.
Resident #2's admission to the secured dementia unit lacked documentation that the resident or designated person did not object to placement.
Report Facts
Residents Served: 55
Secured Dementia Care Unit Residents Served: 13
Current Hospice Residents: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Derek Groff | Executive Director | Named in multiple plans of correction and as facility administrator |
| Jaime Zapf | RN | Named in medication labeling violation plan of correction |
Notice — Dec 11, 2019
Date: Dec 11, 2019
Visit Reason
The document is a renewal approval letter for the Personal Care Home license of Mifflin Court, 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 serves as a notification of license renewal and outlines the Department's obligation to conduct an annual inspection.
Report Facts
Inspection Report — Jan 8, 2019
Renewal
Date: Jan 8, 2019
Visit Reason
The inspection was a renewal inspection conducted by the Department's Bureau of Human Services Licensing to assess compliance with 55 Pa. Code Chapter 2600 for the Personal Care Home Mifflin Court.
Findings
The inspection identified violations related to emergency exit lighting, medication management including insulin inhaler documentation, and proper transcription of blood glucose test results on diabetic flow sheets. Plans of correction were partially implemented with ongoing audits planned to ensure compliance.
Citations (3)
55 Pa.Code §2600.87 - The home lacks exterior lighting at the rear exit to the east end exit for emergency evacuation.
55 Pa.Code §2600.183(d) - Resident #1's prescribed inhaler lacked documentation of the open date within the required 6 weeks of opening.
55 Pa.Code §2600.185(a) - The home failed to maintain diabetic flow sheets accurately; blood glucose readings for Residents #2 and #3 were incorrectly transcribed.
Report Facts
Number of Residents Served: 52
Total Daily Staff: 67
Waking Staff: 50
Number of Hospice Residents in past year: 5
Number of Residents Served in Secured Dementia Care Unit: 12
Number of Residents with Mobility Need: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Holly Moylan | Senior Executive Director | Named in relation to plan of correction signatures and oversight |
Notice — Dec 18, 2018
Date: Dec 18, 2018
Visit Reason
This document serves as a renewal notice for the Personal Care Home license of Mifflin Court and informs about the requirement for an annual onsite inspection within the next twelve months.
Findings
No inspection findings are reported in this document. It confirms issuance of a regular license following the renewal application.
Report Facts
Notice — Nov 28, 2018
Date: Nov 28, 2018
Visit Reason
The document serves as a notice of approval for a revised license capacity for Mifflin Court, including the addition of a Secured Dementia Care Unit.
Findings
The Department of Human Services approved a revised license capacity adding a Secured Dementia Care Unit with 14 beds, maintaining the total license capacity at 67 beds.
Report Facts
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jacqueline L. Rowe | Director | Signed the approval letter for the revised license. |
Inspection Report — Apr 2, 2018
Renewal
Date: Apr 2, 2018
Visit Reason
The document is a renewal license issued for Mifflin Court Personal Care Home, indicating the facility's renewal application was received and a regular license is being issued. The Department advises 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 serves as a license renewal notification and certificate of compliance for the facility.
Inspection Report — Feb 15, 2018
Complaint Investigation
Date: Feb 15, 2018
Visit Reason
The inspection was conducted as a complaint investigation triggered by an incident at the facility.
Complaint Details
The visit was complaint-related due to an incident. The complaint was substantiated as violations were found regarding medical care and support plan updates for a resident.
Findings
Violations of 55 Pa.Code Chapter 2600 related to Personal Care Homes were found, specifically concerning the failure to assist a resident in securing medical care and failure to update the resident's support plan for psychiatric services. A plan of correction was submitted addressing these issues.
Citations (2)
55 Pa.Code §2600.142(a) - The home failed to assist a resident in securing medical care when the resident's health status declined and did not document the need for medical care or update the resident's assessment and support plan.
55 Pa.Code §2600.227(d) - The home did not update the resident's support plan with the frequency of psychiatric visits or assign a responsible party to ensure these needs were met.
Report Facts
Number of Residents Served: 51
Total Daily Staff: 55
Waking Staff: 41
Number of Hospice Residents in past year: 6
Number of Residents 60 Years or Older: 51
Number of Residents with Mobility Need: 4
Number of Residents with Physical Disability: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Holly Moylan | Executive Director | Named in plan of correction and signature on violation report |
| Kimberli Foulkes | Department representative on-site during inspection |
Inspection Report — Jan 24, 2018
Renewal
Date: Jan 24, 2018
Visit Reason
The inspection was conducted as an annual licensing renewal inspection of the facility.
Findings
Violations related to compliance with 55 Pa.Code Ch. 2600 were found during the inspection. The facility submitted plans of correction addressing issues such as installation of a CO2 detector, first aid kit replacements, propane tank storage, expired medication removal, and medication administration record updates.
Citations (5)
A CO2 detector was not installed; the facility plans to have it installed by 2018-03-31 and will monitor its proper installation and function.
First aid kits on the 2nd and 3rd floors were replaced with a portable kit on the first floor; monthly checks and audits will ensure compliance.
Propane tanks were improperly stored in the smoking area and were moved to an OSHA-approved cabinet; ongoing compliance will be monitored by the administrator.
Expired bacitracin packets were removed and replaced; monthly checks and audits will ensure all first aid kit items are present and not expired.
Medication Administration Record was updated to match medication labels; staff were instructed to verify labels and weekly audits will be conducted.
Report Facts
Number of Residents Served: 49
Total Daily Staff: 53
Waking Staff: 40
Number of Hospice Residents in past year: 6
Number of Residents who are 60 Years of Age or Older: 49
Number of Residents who Have a Mobility Need: 4
Number of Residents who Have a Physical Disability: 1
Inspection Report — Feb 1, 2017
Renewal
Date: Feb 1, 2017
Visit Reason
The inspection was a renewal licensing inspection conducted by the Pennsylvania Department of Human Services on February 1, 2017, to assess compliance with 55 Pa.Code Chapter 2600 for Personal Care Homes.
Findings
Multiple violations of 55 Pa.Code Chapter 2600 were identified, including resident privacy breaches, fire safety hazards, and medication labeling errors. Plans of correction were submitted and partially implemented as of March 22, 2017.
Citations (5)
55 Pa.Code 2600.17 - Resident records were not kept confidential as a resident privacy coding document was posted in the lobby and visible to others.
55 Pa.Code 2600.84 - Heat sources such as baseboard heaters lacked protective guards, exposing residents to potential contact with heaters measuring 129.5 degrees Fahrenheit.
55 Pa.Code 2600.125(a) - Combustible materials were found near heat sources, including a cotton sock behind a dryer vent creating a fire hazard.
55 Pa.Code 2600.132(f) - A resident failed to evacuate to a designated safe area during a fire drill conducted on 4/25/16.
55 Pa.Code 2600.178(a) - Prescription medication labels for Warfarin Sodium were incorrect, showing wrong dosage instructions.
Report Facts
Number of Residents Served: 45
Total Daily Staff: 47
Waking Staff: 35
Number of Hospice Residents in Past Year: 7
Number of Residents Age 60 or Older: 45
Number of Residents with Mobility Need: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Holly Moylan | Executive Director | Named in multiple findings and signed plans of correction. |
Notice — Dec 9, 2016
Date: Dec 9, 2016
Visit Reason
This document serves as a renewal notification and license issuance for the Personal Care Home 'Mifflin Court' following receipt of the renewal application dated December 9, 2016.
Findings
The Department confirms issuance of a regular license for Mifflin Court and advises that an onsite annual inspection will be conducted within the next twelve months to ensure compliance with applicable laws and regulations.
Report Facts
Inspection Report — Feb 11, 2016
Renewal
Date: Feb 11, 2016
Visit Reason
The inspection was conducted as an annual licensing renewal inspection of the personal care home facility.
Findings
The inspection identified violations related to fire safety, medication administration records, adherence to prescriber directions, and documentation practices. Plans of correction were submitted to address these issues with ongoing monitoring.
Citations (4)
55 Pa.Code §2600.105(g)(1) - Lint was found in the lint trap of the GE dryer on the third floor at 2:05 p.m., posing a fire hazard.
55 Pa.Code §2600.187(a) - Medication administration records for resident #1 showed discrepancies in blood glucose check recordings on 1/8/16 and 1/22/16, with checks not conducted as documented.
55 Pa.Code §2600.187(d) - Resident #1's glucometer checks were not conducted as prescribed on specified dates and times, including Fridays at 6:30 a.m.
55 Pa.Code §2600.251(b) - Whiteout was used in the upper signature portion of staff person A's annual practicum records.
Report Facts
Number of Residents Served: 57
Number of Current Hospice Residents: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lee Dwinna | Executive Director | Signed plan of correction documents related to violations. |
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