Inspection Reports for
Morris-Pace Personal Care Home
416 Reading Avenue, West Reading, PA, 19611
Back to Facility Profile46 Reports
Inspection Report — Jun 25, 2026
Complaint Investigation
Date: Jun 25, 2026
Visit Reason
The inspection was conducted as a complaint investigation by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing on 06/25/2026.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Residents Served: 57
Residents Receiving Supplemental Security Income: 40
Residents Diagnosed with Mental Illness: 40
Residents Age 60 or Older: 28
Residents Diagnosed with Intellectual Disability: 1
Inspection Report — May 13, 2026
Date: May 13, 2026
Visit Reason
The inspection was an unannounced partial licensing inspection conducted as an interim review 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.
Report Facts
Residents Served: 57
Resident Support Staff: 0
Total Daily Staff: 57
Waking Staff: 43
Residents Receiving Supplemental Security Income: 41
Residents Diagnosed with Mental Illness: 43
Residents Age 60 or Older: 50
Residents Diagnosed with Intellectual Disability: 1
Notice — Mar 26, 2026
Date: Mar 26, 2026
Visit Reason
The document serves as a formal notice granting a waiver to Morris-Pace Personal Care Home for a direct care staff qualification requirement under 55 Pa.Code § 2600.54(a)(2).
Findings
The waiver is granted with conditions requiring documentation of education and training to be maintained and reviewed annually during inspections. Noncompliance may result in waiver termination or licensing action.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Theresa Hartman | Bureau Director, Human Services Licensing | Signed the waiver approval letter. |
Inspection Report — Mar 24, 2026
Follow-Up
Date: Mar 24, 2026
Visit Reason
The inspection was conducted as a follow-up to verify correction of previous deficiencies identified during a licensing inspection on March 24, 2026.
Findings
The facility was found to be in compliance with the regulations after the submitted plan of correction was fully implemented. Several deficiencies related to resident funds accounting, criminal background checks, staff training, sanitary conditions, lighting, combustible storage, annual medical evaluations, and medication administration were corrected.
Citations (10)
28f Resident's Funds and 30-day Refund: The home lacked documentation of an itemized written account of resident funds and refunds owed after discharge or death.
51 Criminal Background Check: The home did not request a criminal background check on the day of hire for a staff member, delaying it by two days.
65f Training Topics: Three direct care staff did not receive required training in medication self-administration, dementia care, and safe management techniques during 2025.
85a Sanitary Conditions: Brown fecal-like matter was found on the bathroom floor mat and shower curtain near room F4.
101j7 Lighting/Operable Lamp: Three residents did not have access to a source of light that can be turned on and off at bedside.
125a Combustible Storage: Linens and a black plastic trash bag were found lying against hot water heaters in laundry and utility rooms.
141b1 Annual Medical Evaluation: Some residents were out of compliance with having annual medical evaluations completed by their PCPs on time.
187a Medication Record: A resident's medication dose was incorrectly documented on the Medication Administration Record.
187b Date/Time of Medication Admin.: Medication was documented as administered when it was not available, missing documentation for one dose.
187d Follow Prescriber's Orders: A resident's inhaler was not available and not administered as prescribed.
Report Facts
Residents Served: 58
Number of Residents Receiving Supplemental Security Income: 39
Number of Residents Diagnosed with Mental Illness: 43
Number of Residents Age 60 or Older: 41
Number of Residents Diagnosed with Intellectual Disability: 1
Inspection Report — Feb 24, 2026
Monitoring
Date: Feb 24, 2026
Visit Reason
The visit was an unannounced partial inspection conducted as a monitoring review of Commonwealth Senior Living at Willow Grove.
Findings
The inspection identified multiple deficiencies including failure to timely report incidents, improper handling of resident refunds, breaches in resident dignity and respect, unsecured poisonous materials and medications, unsanitary conditions, and incomplete resident admission documentation. Plans of correction were accepted and implemented with ongoing quality management monitoring.
Citations (13)
16c - The home failed to report a resident death incident to the Department within 24 hours as required.
28e - The home did not issue a refund to the estate within the required timeframe following the death of a resident over 60 years of age.
42c - A former staff member posted a video of residents in the secured dementia care unit on social media without their consent.
82c - Poisonous materials were found unlocked and accessible to residents not assessed as capable of safely using or avoiding them.
85a - A brown substance resembling feces was found on the light switch of a common bathroom in the secured dementia care unit.
85e - Two dumpsters outside the home had open side access doors and were filled with trash, violating sanitary requirements.
88a - Two ceiling tiles near a resident bedroom had water stains and were not in good repair.
95 - Toilet paper holders were missing in the secured dementia care unit common bathroom and two resident bathrooms.
101j3 - A resident's bed lacked linens, pillows, and blankets at the time of inspection.
183b - Prescription medications, OTC medications, CAM, and syringes were found unlocked and accessible in multiple resident rooms without assessments for self-medication.
183e - Expired prescription medication and damaged blister packs were found on the medication cart.
231c - A resident admitted to the secured dementia care unit did not have a written cognitive preadmission screening completed within 72 hours prior to admission.
234a - A resident admitted to the secured dementia care unit did not have an initial support plan developed and documented within 72 hours of admission.
Report Facts
Residents Served: 75
Secured Dementia Care Unit Residents Served: 30
Hospice Current Residents: 7
Residents Age 60 or Older: 75
Residents with Mobility Need: 43
Total Daily Staff: 118
Waking Staff: 89
Inspection Report — Jan 29, 2026
Follow-Up
Date: Jan 29, 2026
Visit Reason
This was a partial, unannounced follow-up inspection to verify the full implementation of a previously submitted plan of correction for the Morris-Pace Personal Care facility.
Findings
The inspection found multiple violations related to snow and ice obstructing emergency exits, unsanitary conditions in resident rooms, improper food storage, lint accumulation in dryers, and soap dispensers missing in bathrooms. All issues had directed plans of correction which were implemented by the time of the report.
Citations (7)
2600.18: Egress paths from exits in multiple sections were covered with snow and ice, creating hazardous conditions as confirmed by a fire official.
2600.85a: Bedsheet for a resident was stained with urine and walls had spit stains; a foul stench was noted in a resident's room indicating unsanitary conditions.
2600.100b: Snow and ice obstructed outside walkways, ramps, steps, and exterior fire escapes, including dense ice on exterior stairs creating an icy slope.
2600.102i: Unlabeled bars of soap were found in multiple bathroom showers and bar soap was left in public restrooms, risking infection control.
2600.103d: Three five-gallon buckets of powdered milk were stored on the floor in the dry storage area, violating food safety rules.
2600.105g: Approximately one inch of lint was accumulated in the lint trap of the right side dryer, posing a fire hazard.
2600.121a: Exit door between Section G and H was obstructed by snow and could not be opened more than six inches.
Report Facts
Residents Served: 56
Staff: 56
Waking Staff: 42
Five gallon buckets of powdered milk: 3
Lint accumulation: 1
Inspection Report — Dec 5, 2025
Complaint Investigation
Date: Dec 5, 2025
Visit Reason
The inspection was conducted as a complaint investigation following a complaint regarding discharge procedures at the facility.
Complaint Details
The complaint investigation found that the facility failed to provide the required 30-day discharge notice due to nonpayment of rent for July, August, and September 2025. The resident was hospitalized since July 2025 and no forwarding address was available. Attempts to contact the resident's representatives were unsuccessful.
Findings
The facility discharged a resident for nonpayment of rent without providing the required 30-day written notice to the resident or their designated person. The resident's record did not include documentation of the discharge notice or reasons for discharge.
Citations (2)
228b: The home discharged a resident for nonpayment of rent without providing a 30-day written notice to the resident or their designated person. The facility lacked an address to send the notice as the resident was hospitalized and no address was provided by family or payees.
228e: The resident's record did not include a 30-day written notice or reasons for the discharge. The date and reason for discharge were not properly recorded.
Report Facts
Residents Served: 60
Staffing Hours - Total Daily Staff: 60
Staffing Hours - Waking Staff: 45
Residents Receiving Supplemental Security Income: 43
Residents Age 60 or Older: 43
Residents Diagnosed with Mental Illness: 41
Residents Diagnosed with Intellectual Disability: 1
Inspection Report — Sep 24, 2025
Date: Sep 24, 2025
Visit Reason
The document is a partial inspection conducted by the Department of Human Services Bureau of Human Service Licensing for MORRIS PACE PERSONAL CARE.
Findings
The document provides privacy coding information for staff and residents but does not include any findings or deficiencies.
Inspection Report — Aug 6, 2025
Renewal
Date: Aug 6, 2025
Visit Reason
The inspection was conducted as a renewal inspection combined with complaint and incident investigations at Morris-Pace Personal Care.
Complaint Details
The inspection included complaint and incident investigations as part of the renewal inspection.
Findings
The inspection identified multiple violations including failure to post current license documents, improper storage of poisonous materials, unsanitary conditions, damaged furniture and equipment, outdated food items, combustible storage issues, fire safety inspection deficiencies, missing exit signs, incomplete medical evaluations, incomplete self-administration assessments, medication storage and documentation errors, incomplete preadmission screening forms, incomplete additional assessments, and failure to document refusal to sign support plans. Plans of correction were submitted and some violations were implemented by the time of follow-up.
Citations (17)
3c - The home's License Inspection Summary report dated 11/13/24 was not posted in a conspicuous and public place in the home.
82a - Poisonous materials were stored in unlabeled water bottles containing laundry detergent in the laundry area.
85a - Sanitary conditions were not maintained; urine odor detected in section F TV room, ceiling damage and soiled bathroom in section E, and a dead mouse found in section D.
88a - Floors, walls, ceilings, and other surfaces were not clean or in good repair; plaster fell into a tub, refrigerator stained with food debris, and a hole in the laundry room wall.
95 - Furniture and equipment were not in good repair; broken dresser drawer, shower chair missing backrest, and broken cabinet door.
103i - Outdated or spoiled food was found; frozen pork tacos expired 7/31/25 and spices with best buy dates over two years old.
125a - Combustible materials were improperly stored near heat sources; lint accumulation behind dryers due to disconnected vent hose.
132b - Fire safety inspection and fire drill were not conducted annually; last fire drill by expert was 7/15/25, prior was 2/23/24.
133.1 - Exit sign was missing over the exit door in resident room H1A.
141a - Resident #1's medical evaluation lacked height and ability to self-administer medications information.
141b1 - Residents #4 and #5 had expired annual medical evaluations.
171b5 - First aid kit in the home's vehicle lacked breathing shield, thermometer, and scissors.
181c - Residents #1 and #2 self-administer medications but lacked physician assessment of ability and need for reminders.
185a - Resident #1's blood glucose readings were inaccurately documented and not recorded at correct times.
224a - Resident #6's preadmission screening form did not include the date the form was completed.
225c - Resident #2's support plan did not include frequent overnight absences; Resident #5's plan lacked pager use for fire alarms.
227h - Resident #2 did not sign their support plan and no notation of refusal was documented.
Report Facts
Residents Served: 57
Staffing Hours: 57
Waking Staff: 43
Outdated frozen pork taco packages: 19
Inspection Report — Mar 18, 2025
Date: Mar 18, 2025
Visit Reason
The inspection was conducted as a licensing inspection by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing, due to an incident.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Resident Support Staff: 0
Total Daily Staff: 57
Waking Staff: 43
Residents Served: 57
Residents Receiving Supplemental Security Income: 40
Residents Diagnosed with Mental Illness: 40
Residents Age 60 or Older: 28
Residents with Physical Disability: 1
Inspection Report — Nov 13, 2024
Renewal
Date: Nov 13, 2024
Visit Reason
The inspection was conducted as a full, unannounced review for renewal and complaint reasons on 11/13/2024 and 11/14/2024.
Findings
The inspection identified multiple deficiencies related to infection control, food storage and labeling, fire safety notifications, medication administration, and emergency preparedness. Plans of correction were accepted and implemented by 12/11/2024 with ongoing compliance measures described.
Citations (10)
A bar of soap was found on the sink of a communal bathroom without labeling, violating infection control requirements.
Unlabeled and undated leftover food was found in the kitchen refrigerator.
An opened package of candy corn was found spilled in the pantry, violating food storage requirements.
The home failed to notify the local fire department in writing about the home address, bedroom locations, and evacuation assistance needed.
The annual fire safety inspection and fire drill by a fire safety expert were not completed within the calendar year.
Exit signs indicating paths of egress were missing on interior doors leading to emergency exits.
The home’s van used for resident transport did not contain a first aid kit.
Medication administration records lacked documentation of resident blood glucose levels as ordered.
Medication administration records did not reflect the correct dose and strength as ordered by the physician.
Residents did not receive prescribed medications on certain dates, and medications were not available onsite.
Report Facts
Residents Served: 55
Staffing Hours: 55
Staffing Hours: 41
Residents Receiving Supplemental Security Income: 40
Residents Age 60 or Older: 28
Residents Diagnosed with Mental Illness: 42
Residents with Physical Disability: 1
Inspection Report — Sep 11, 2024
Date: Sep 11, 2024
Visit Reason
The inspection was a partial, unannounced visit conducted due to an incident.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Total Daily Staff: 57
Waking Staff: 43
Residents Served: 57
Residents Receiving Supplemental Security Income: 38
Residents Aged 60 or Older: 26
Residents Diagnosed with Mental Illness: 40
Residents Diagnosed with Intellectual Disability: 0
Residents with Mobility Need: 0
Residents with Physical Disability: 1
Inspection Report — Jan 18, 2024
Complaint Investigation
Date: Jan 18, 2024
Visit Reason
The inspection was conducted as a complaint and incident investigation at the facility.
Complaint Details
The visit was complaint-related, focusing on medication administration delays. The plan of correction was accepted and fully implemented.
Findings
The inspection found that several residents did not receive their prescribed medications on time due to delays in receiving medications from the pharmacy. A plan of correction was submitted and fully implemented to ensure medication availability prior to new admissions.
Citations (1)
Multiple residents were not administered medications as prescribed due to waiting for the medication from the pharmacy.
Report Facts
Residents Served: 59
Total Daily Staff: 59
Waking Staff: 44
Residents Receiving Supplemental Security Income: 41
Residents 60 Years or Older: 27
Residents Diagnosed with Mental Illness: 40
Residents with Physical Disability: 1
Inspection Report — Dec 19, 2023
Renewal
Date: Dec 19, 2023
Visit Reason
The inspection was conducted as a renewal visit with an incident review, unannounced, on 12/19/2023.
Findings
The inspection identified multiple deficiencies including incomplete staff training documentation, uncovered bed rails, overflowing trash dumpsters, lack of operable bedside lamps, outdated food labeling, obstructed emergency egress, combustible storage hazards, cigarette butt fire hazards, missing medication diagnosis information, and incomplete resident assessments and support plans. All deficiencies had plans of correction accepted and were implemented by 01/26/2024.
Citations (12)
Staff training documentation was not dated, preventing confirmation of timely completion.
Resident bed rails were uncovered, posing a safety hazard.
Dumpster lids were unable to close due to overflowing trash, allowing rodent access.
Residents in rooms B3 and F3 lacked operable lamps or lighting sources at bedside.
Outdated or unlabeled food items found in kitchen refrigerator and freezer.
Emergency exit was obstructed by an ironing board and umbrella, blocking immediate egress.
Combustible sheet found behind dryer near exhaust hose, creating fire hazard.
Cigarette butts scattered in mulch near home, creating fire hazard.
Resident medications lacked diagnosis or purpose on MAR and pharmacy labels.
Resident assessment plan was not dated, preventing determination of timely completion.
Resident support plan was not dated, preventing determination of timely completion.
Resident case record did not include identifiable marks information.
Report Facts
Residents Served: 57
Total Daily Staff: 57
Waking Staff: 43
Residents with Supplemental Security Income: 38
Residents 60 Years or Older: 26
Residents Diagnosed with Mental Illness: 40
Residents with Physical Disability: 1
Inspection Report — Aug 9, 2023
Complaint Investigation
Date: Aug 9, 2023
Visit Reason
The inspection was conducted as a complaint investigation following a review by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing on 08/09/2023.
Complaint Details
The visit was complaint-related as indicated by the inspection reason. The submitted plan of correction was accepted and fully implemented.
Findings
The inspection found a medication administration record violation where a resident's medication was not properly signed out, indicating staff did not follow medication administration policies. The submitted plan of correction was accepted and fully implemented.
Citations (1)
Resident #1 medication administration record did not indicate medication was given as prescribed every 6 hours.
Report Facts
Residents Served: 60
Staffing Hours - Total Daily Staff: 60
Staffing Hours - Waking Staff: 45
Residents Receiving Supplemental Security Income: 43
Residents Diagnosed with Mental Illness: 43
Residents Age 60 or Older: 27
Inspection Report — Feb 8, 2023
Follow-Up
Date: Feb 8, 2023
Visit Reason
The inspection was conducted as a follow-up review to verify that the previously submitted plan of correction was fully implemented following an incident-related partial unannounced inspection.
Findings
The facility was found to have fully implemented the plan of correction related to medication administration documentation and support plan documentation for a resident with behavioral and mental health needs. The report details deficiencies in medication record keeping and support plan documentation that were corrected with staff training and audits.
Citations (2)
Medication record did not accurately reflect administration times; staff documented medications as not given when they were administered.
Resident's support plan did not document behavioral changes, mental health status, or facility plans to meet these needs despite known incidents.
Report Facts
Residents Served: 58
Total Daily Staff: 58
Waking Staff: 44
Residents Receiving Supplemental Security Income: 40
Residents Diagnosed with Mental Illness: 47
Residents Aged 60 or Older: 27
Residents with Physical Disability: 1
Inspection Report — Nov 29, 2022
Routine
Date: Nov 29, 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 — Oct 6, 2022
Complaint Investigation
Date: Oct 6, 2022
Visit Reason
The inspection was conducted as a result of an incident, with an unannounced partial inspection on 10/06/2022 and an off-site inspection on 11/29/2022.
Complaint Details
The inspection was incident-related; no deficiencies or citations were found, indicating no substantiated complaint issues.
Findings
No regulatory citations or deficiencies were identified during the inspection.
Report Facts
Residents Served: 58
Total Daily Staff: 58
Waking Staff: 44
Residents Receiving Supplemental Security Income: 43
Residents Age 60 or Older: 27
Residents Diagnosed with Mental Illness: 40
Inspection Report — Oct 3, 2022
Plan of Correction
Date: Oct 3, 2022
Visit Reason
The inspection was conducted as a partial, unannounced review due to an incident at the facility.
Findings
The submitted plan of correction related to an incomplete medical evaluation for a resident was reviewed and determined to be fully implemented. Continued compliance is required.
Citations (1)
Resident #1's medical evaluation was incomplete as it did not indicate whether the resident can safely use or avoid poisonous materials.
Report Facts
Residents Served: 60
Staffing Hours: 60
Waking Staff: 45
Inspection Report — Sep 13, 2022
Renewal
Date: Sep 13, 2022
Visit Reason
The inspection was conducted as a renewal visit to review compliance with licensing regulations and verify the implementation of the submitted plan of correction.
Findings
Multiple deficiencies were identified including issues with criminal background checks, first aid/CPR training, surfaces, refrigerator/freezer temperatures, unobstructed egress, combustible storage, fire safety inspection, medical evaluation information, medication storage and administration, prescriber's orders, additional assessments, and support plan documentation. All deficiencies had accepted plans of correction that were implemented by January 19, 2023.
Citations (13)
No verification of a criminal background check completed for a staff member hired.
Only one CPR certified staff member was working during night shifts despite census of 60 residents.
A piece of baseboard in the stairwell had fallen off with a nail sticking up, creating a hazard.
No thermometer in the refrigerator or freezer in the kitchenette of section D; repeat violation.
Emergency exit from room C was blocked by a chair and laundry, preventing immediate egress; repeat violation.
Laundry stored directly next to and touching the hot water heater, a combustible storage hazard.
Most recent fire inspection by a fire safety expert was completed on 8/7/2019 and was overdue.
Resident 1’s medical evaluation was incomplete with required fields for body positioning and health status left blank.
Medication for Resident 2 was not available on the medication cart at the time of inspection; repeat violation.
Medication administration was documented as given when it was not; repeat violation.
Medication cream for Resident 2 was not available and thus not administered as prescribed; repeat violation.
Most recent additional assessment for Resident 3 was not completed timely.
Resident 4’s support plan was not updated to document a hearing alert device.
Report Facts
Residents served: 60
Staffing hours - Total Daily Staff: 60
Staffing hours - Waking Staff: 45
Inspection Report — Dec 21, 2021
Routine
Date: Dec 21, 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.
Inspection Report — Dec 3, 2021
Renewal
Date: Dec 3, 2021
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 — Oct 15, 2021
Follow-Up
Date: Oct 15, 2021
Visit Reason
The inspection was a partial, unannounced follow-up visit triggered by an incident to review the submitted plan of correction for previously identified deficiencies.
Findings
The submitted plan of correction related to an incomplete medical evaluation form for a resident was found to be fully implemented. The deficiency involved missing documentation of the resident's mobility needs, which was corrected after staff and physician intervention.
Citations (1)
Resident #1's medical evaluation was incomplete as the mobility needs assessment section was left blank.
Report Facts
Residents Served: 58
Resident Support Staff: 58
Total Daily Staff: 116
Waking Staff: 87
Notice — Aug 25, 2021
Date: Aug 25, 2021
Visit Reason
This document serves as a renewal notification and license issuance for Morris-Pace Personal Care, 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 is an administrative notice confirming license renewal and outlining future inspection requirements.
Report Facts
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary, Office of Long-term Living | Signed the renewal notification letter |
Inspection Report — Aug 11, 2021
Renewal
Date: Aug 11, 2021
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 — Jul 28, 2021
Renewal
Date: Jul 28, 2021
Visit Reason
The inspection was conducted as a renewal and complaint investigation visit to assess compliance with licensing requirements and address complaint issues.
Complaint Details
The inspection included a complaint investigation component as indicated by the inspection reason and findings related to medication administration and storage procedures.
Findings
The inspection identified multiple deficiencies including lack of operable bedside lamps, unlabeled bar soap in bathrooms, refrigerator temperature violations, obstructed emergency egress, combustible storage hazards, and medication administration and documentation errors. Plans of correction were submitted and accepted with follow-up dates scheduled.
Citations (7)
Resident room #C3 did not have a bedside lamp available for the resident to use at their bedside.
Resident Room #F1 had 2 bars of bar soap lying on the bathroom sink that were not in a container with the resident's name.
The Ropper brand refrigerator located in section A kitchenette had a temperature reading of 50°F, exceeding the required 40°F.
The rear fire exit door on the first floor in section J had a chair and a walker in front of the door preventing immediate egress in an emergency.
A pillow case and sock were found lying behind the home's commercial dryer in the main laundry room, posing a combustible storage hazard.
Resident #1's glucometer was not calibrated correctly to the date and blood glucose test readings were off by a day and not documented accurately.
Resident #2 had medications that were not available at the home but were documented as being administered, violating medication administration and documentation requirements.
Report Facts
Residents Served: 58
Staffing Hours: 58
Waking Staff: 44
Temperature Reading: 50
Inspection Dates: 2
Inspection Report — Jul 15, 2021
Routine
Date: Jul 15, 2021
Visit Reason
The inspection was conducted as part of the Pennsylvania Department of Human Services, Bureau of Human Service Licensing routine licensing inspections on 04/16/2021 and 07/15/2021.
Findings
No regulatory citations were identified as a result of this inspection.
Inspection Report — May 27, 2021
Routine
Date: May 27, 2021
Visit Reason
The inspection visits on 02/02/2021 and 05/27/2021 were conducted by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing to assess regulatory compliance of the Morris-Pace Personal Care facility.
Findings
No regulatory citations or deficiencies were identified as a result of these inspections.
Inspection Report — Feb 25, 2021
Routine
Date: Feb 25, 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 were identified as a result of this inspection.
Inspection Report — Oct 20, 2020
Renewal
Date: Oct 20, 2020
Visit Reason
The inspection visits on 10/01/2020, 10/08/2020, 10/15/2020, and 10/20/2020 were conducted as part of the licensing inspections for the facility.
Findings
No regulatory citations were identified as a result of these inspections.
Inspection Report — Aug 5, 2020
Follow-Up
Date: Aug 5, 2020
Visit Reason
The visit was a follow-up inspection to verify that the previously submitted plan of correction was fully implemented after an incident involving resident treatment.
Findings
The plan of correction was determined to be fully implemented. The facility addressed a violation where a staff member hit a resident in the stomach while joking, which was the third such incident reported by the resident. The staff member was terminated and staff were instructed on proper resident treatment.
Citations (1)
42c - Treatment of Residents: A staff member hit Resident #1 in the stomach while joking, violating the requirement that residents be treated with dignity and respect. The resident was not injured but reported this was the third occurrence.
Report Facts
Residents Served: 58
Notice — Aug 3, 2020
Date: Aug 3, 2020
Visit Reason
This document serves as a renewal notification and license issuance for Morris-Pace Personal Care Home. It informs the facility that an annual inspection will be conducted within the next twelve months as required by state regulations.
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 — Jun 30, 2020
Routine
Date: Jun 30, 2020
Visit Reason
The inspection was conducted as a licensing inspection by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing on 06/30/2020 and 07/14/2020.
Findings
No regulatory citations were identified as a result of this inspection.
Inspection Report — Dec 11, 2019
Complaint Investigation
Date: Dec 11, 2019
Visit Reason
The inspection was a partial, unannounced visit conducted due to a complaint or incident.
Complaint Details
The inspection was triggered by a complaint or incident. The plan of correction was fully implemented and approved on January 31, 2020.
Findings
The facility was found to have a violation related to disrepair of steps at the left side entrance. The submitted plan of correction was reviewed and determined to be fully implemented as of January 31, 2020.
Citations (1)
Regulation 2600.88a requires floors, walls, ceilings, windows, doors and other surfaces to be clean, in good repair and free of hazards. The steps on the left side entrance were in disrepair on the 3rd, 6th, and 9th steps.
Report Facts
Residents Served: 45
Total Daily Staff: 45
Waking Staff: 34
Residents Receiving Supplemental Security Income: 45
Residents Diagnosed with Mental Illness: 45
Residents Aged 60 or Older: 27
Residents Diagnosed with Intellectual Disability: 1
Residents with Physical Disability: 1
Inspection Report — Jul 18, 2019
Renewal
Date: Jul 18, 2019
Visit Reason
The inspection was a renewal visit conducted by the Department’s Bureau of Human Services Licensing to assess compliance with 55 Pa. Code Ch. 2600 for Morris-Pace Personal Care.
Findings
The inspection identified multiple violations including deficiencies in quality management, staff training, environmental safety, resident care plans, and fire safety documentation. Several plans of correction were submitted and partially implemented.
Citations (15)
26b - Quality Management Plan Content: The home's quality management meeting minutes did not discuss required topics including staff training and license inspection summary violations.
65g - Annual Training Content: Direct care staff persons did not receive required training in Emergency Preparedness Procedures in 2018.
83b - Air Conditioner/Fans: Bedroom H4 temperature was 81.9°F and no fan or air conditioner was provided to the resident.
85e - Trash Outside Home: Two dumpsters at the rear of the home were observed open, allowing penetration of insects and rodents.
92 - Windows: Exit doors in L and J sections were left wide open without screen doors installed.
93a - Handrails: Entrance door with steps lacked a handrail or handle on the left side to assist with entry.
96a - First Aid Kit: The first aid kit in the medication cart did not contain required scissors.
103e - Left Overs: Food items in the kitchen were stored without proper labeling or dating, including milk, flour, cream of wheat, cereal, and a sandwich.
121a - Unobstructed Egress: Emergency exit doors G and H were difficult to open with multiple attempts.
132b - Safety Inspection/Fire Drill: The home lacked documentation of a fire drill supervised by a fire safety expert and a fire safety inspection in 2018.
132d - Evacuation: The home did not have current documentation of maximum safe evacuation time; fire drill logs showed evacuation times exceeding 2.5 minutes on two occasions.
133.1 - Exit Signs: No exit sign was posted over the dining room exit door.
144c1 - Smoking Area Guidelines: Six cigarette butts were found in the grassy area and under bushes in the staff smoking area.
225c - Additional Assessment: Resident #1 did not have a timely Resident Assessment and Support Plan; the most recent was dated 5/20/2018.
227d - Support Plan Medical/Dental: Resident #2 exhibited paranoia and hallucinations not reflected in the support plan dated 2/17/2019.
Report Facts
Residents Served: 59
Staffing Hours: 59
Waking Staff: 44
Residents Receiving SSI: 45
Residents Diagnosed with Mental Illness: 45
Residents 60 Years or Older: 27
Residents Diagnosed with Intellectual Disability: 1
Inspection Report — May 22, 2019
Renewal
Date: May 22, 2019
Visit Reason
The document is a renewal application and license issuance for Morris-Pace Personal Care Home. The Department of Human Services will conduct an onsite inspection within the next twelve months as required by state code.
Findings
No inspection findings are reported in this document. It primarily communicates the license renewal and the requirement for a future inspection.
Report Facts
Inspection Report — Jan 31, 2019
Complaint Investigation
Date: Jan 31, 2019
Visit Reason
The inspection was conducted due to an incident complaint involving alleged verbal abuse by a staff person toward residents.
Complaint Details
The complaint involved substantiated verbal abuse by staff person A toward residents #1 and #2. Staff person A was suspended for 5 days without pay and required to undergo counseling and monitoring. The home was required to implement corrective actions to prevent recurrence.
Findings
The inspection found that staff person A was verbally abusive to residents #1 and #2, resulting in a 5-day suspension. Additional violations included failure to treat residents with dignity and respect and failure to provide annual training on resident rights and protective services.
Citations (3)
Regulation 55 Pa.Code 2600.15(c) - The home failed to submit a plan of supervision or notice of suspension for the affected staff person after verbal abuse incidents.
Regulation 55 Pa.Code 2600.42(c) - A resident was not treated with dignity and respect when staff verbally abused residents and called one a grouch.
Regulation 55 Pa.Code 2600.65(g) - Staff did not receive annual training in resident rights or the Older Adult Protective Services Act for 2018.
Report Facts
Number of Residents Served: 60
Staff Suspension Duration: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nathaniel D. Pace | Administrator | Named as legal entity representative and administrator responsible for compliance and corrective actions. |
Inspection Report — Jul 19, 2018
Renewal
Date: Jul 19, 2018
Visit Reason
The inspection was a renewal visit conducted by the Pennsylvania Department of Human Services Bureau of Human Services Licensing to assess compliance with 55 Pa. Code Chapter 2600 for Morris-Pace Personal Care.
Findings
Multiple violations of the Personal Care Homes regulations were found, including staff qualification deficiencies, incomplete training, improper trash handling, inoperable lighting, and incomplete resident medical and medication records. Plans of correction were partially implemented with adequate progress noted.
Citations (13)
55 Pa.Code §2600.54(a): Direct care staff person A lacked a high school diploma, GED diploma, or active Pennsylvania nurse registry status.
55 Pa.Code §2600.65(f): Annual training for direct care staff persons B and C did not include required topics 1 through 6.
55 Pa.Code §2600.85(d): A 5-gallon bucket was used as a garbage can in section F's kitchenette; it was overflowing and lacked a lid.
55 Pa.Code §2600.101(7): Resident room #F1 had an inoperable lamp at the bedside.
55 Pa.Code §2600.121(a): Emergency exits in resident rooms A7 and F1 were obstructed by a mattress and a laundry basket filled with clothes.
55 Pa.Code §2600.141(a)(1): Resident #1's initial medical evaluation was completed more than 60 days prior to admission.
55 Pa.Code §2600.141(a)(2): Medical evaluations for residents #1, #2, and #3 lacked allergies, pulse rate, and self-medication ability documentation respectively.
55 Pa.Code §2600.181(c): Resident #4 was found with vitamin B4 gummies and ear wax remover and is unable to self-administer medications.
55 Pa.Code §2600.183(a)(1): Resident #6's medication Renvela 800mg was listed as a duplicate on the medication administration record with initials in both spots.
55 Pa.Code §2600.183(a)(1): Resident #6's prescription naproxen was removed from the blister pack and placed in a cassette system without proper labeling.
55 Pa.Code §2600.225(a): Resident #3 and #1 did not have initial assessments completed within 15 days of admission.
55 Pa.Code §2600.227(a): Residents #3 and #1 did not have initial support plans developed and implemented within 30 days of admission.
55 Pa.Code §2600.252: Resident #5's photograph was taken more than 2 years ago and was outdated.
Report Facts
Number of Residents Served: 62
Total Daily Staff: 62
Waking Staff: 47
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nathaniel D. Pace | Administrator | Named as administrator and legal entity representative signing violation pages. |
| Kimberli Foulkes | Inspector | On-site inspector conducting the inspection on 07/19/2018. |
| Jason Harvey | Inspector | On-site inspector conducting the inspection on 07/19/2018. |
Notice — May 23, 2018
Date: May 23, 2018
Visit Reason
This document is a renewal notification and license issuance for Morris-Pace Personal Care Home to operate pursuant to Title 55, PA Code, Chapter 2600.
Findings
The Department acknowledges receipt of the renewal application and states that an onsite inspection will be conducted within the next twelve months as required by law. No findings or deficiencies are reported in this document.
Inspection Report — Aug 3, 2017
Renewal
Date: Aug 3, 2017
Visit Reason
The inspection was a renewal licensing inspection conducted by the Pennsylvania Department of Human Services on August 3, 2017, to assess compliance with 55 Pa.Code Chapter 2600 for Personal Care Homes.
Findings
Multiple violations were found including privacy breaches, lack of carbon monoxide detector, pest infestation, expired medications, incomplete medical evaluations, medication administration errors, and failure to maintain confidentiality in posted documents. Plans of correction were partially implemented with adequate progress noted.
Citations (12)
55 Pa.Code 2600.17: Privacy/HIPPA violations occurred as resident names were visible on posted violation reports and documents.
55 Pa.Code 2600.18: The home lacked a carbon monoxide detector near the gas stove in the kitchen.
55 Pa.Code 2600.42(c): Resident confidentiality was breached by posting minutes identifying a resident by name in a common area.
55 Pa.Code 2600.85(b): A live bed bug was observed on the wall of bedroom B3, indicating pest infestation.
55 Pa.Code 2600.141(a)(1): A resident's medical evaluation was completed more than 60 days prior to admission, violating timing requirements.
55 Pa.Code 2600.141(b)(1): A resident's initial medical evaluation was completed more than 60 days prior to admission.
55 Pa.Code 2600.183(d): Several residents had expired medications in their possession.
55 Pa.Code 2600.187(a): Medication administration records lacked staff signatures or initials for multiple residents' medications.
55 Pa.Code 2600.187(d): A prescribed medication cream was not available in the home for a resident.
55 Pa.Code 2600.201: Confidentiality was breached by posting a resident's name in community council meeting minutes.
55 Pa.Code 2600.225(c): Resident assessments and support plans were incomplete or not updated in a timely manner.
55 Pa.Code 2600.227(d): Staff failed to document and communicate behavioral issues of a resident in the support plan and communication book.
Report Facts
Number of Residents Served: 62
Total Daily Staff: 62
Waking Staff: 47
Residents Receiving Supplemental Security Income: 45
Residents Age 60 or Older: 26
Residents with Mental Illness: 44
Residents with Intellectual Disability: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nathaniel D. Pace | Administrator | Named as legal entity representative signing plans of correction and responsible for compliance. |
Inspection Report — May 18, 2017
Renewal
Date: May 18, 2017
Visit Reason
The document is a renewal application and license issuance for Morris-Pace 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 notification and confirmation of regulatory compliance requirements.
Report Facts
Inspection Report — Feb 14, 2017
Complaint Investigation
Date: Feb 14, 2017
Visit Reason
The inspection was conducted as a complaint investigation triggered by an incident at Morris-Pace Personal Care Home.
Complaint Details
The visit was complaint-related due to an incident involving a resident's fall and failure to report it timely. The complaint was substantiated with multiple violations found.
Findings
Multiple violations were found related to failure to report incidents timely, incomplete documentation including missing death certificates, inaccurate pre-admission screening, incomplete resident assessments, and use of outdated incident reporting forms.
Citations (5)
55 Pa.Code §2600.16(c): The home did not secure a copy of the death certificate to accompany the discharge record for a deceased resident and failed to report a fall incident timely.
55 Pa.Code §2600.224(a): The pre-admission form for Resident #1 did not indicate that the home could meet the resident's needs.
55 Pa.Code §2600.225(a): Resident #1's initial Resident Assessment and Support Plan did not address special diet and mobility needs as ordered by the physician.
55 Pa.Code §2600.225(c): Resident #4's annual Resident Assessment and Support Plan did not indicate the resident was on a special diet as ordered by the physician.
55 Pa.Code §2600.251(c): The home was not using the current Reportable Incident form as mandated by the Department as of October 1, 2016.
Report Facts
Number of Residents Served: 60
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nathaniel D. Pace | Administrator | Named in relation to responsibility for compliance and plan of correction. |
| Cindy Yellenic | Department representative conducting the inspection. |
Inspection Report — Dec 13, 2016
Complaint Investigation
Date: Dec 13, 2016
Visit Reason
The inspection was conducted as a complaint and incident investigation at Morris Pace Personal Care related to violations of 55 Pa.Code Chapter 2600.
Complaint Details
The inspection was triggered by complaints and incidents regarding resident treatment and compliance with regulations. The violations were substantiated with corrective plans required.
Findings
Multiple violations of 55 Pa.Code Chapter 2600 were found, including issues with resident dignity and respect, improper use of rewards or sanctions, and failure to follow prescriber orders. Plans of correction were submitted and partially implemented with adequate progress.
Citations (3)
55 Pa.Code 2600.42(c) - A resident was required to clean their bedside commode container daily, causing embarrassment and dignity concerns.
55 Pa.Code 2600.43(b) - A resident's rights were violated by using a cigarette as a reward for emptying a portable commode container.
55 Pa.Code 2600.187(d) - The home failed to follow the prescriber's orders for blood glucose monitoring as required.
Report Facts
Number of Residents Served: 62
Total Daily Staff: 62
Waking Staff: 47
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nathaniel D. Pace | Administrator | Named in relation to the plan of correction and signature on violation reports. |
| Jason Harvey | Department representative conducting inspections on multiple dates. | |
| Julienne Rushin | Department representative conducting inspection on 12/20/2016. |
Inspection Report — Sep 15, 2016
Complaint Investigation
Date: Sep 15, 2016
Visit Reason
The inspection was conducted as a complaint-related incident investigation at Morris-Pace Personal Care on September 15, 2016.
Complaint Details
The investigation was triggered by an incident involving frequent emergency room visits by a resident and lack of documentation in the resident's support plan. The complaint was substantiated with findings of noncompliance.
Findings
Two violations of 55 Pa.Code Chapter 2600 were found related to medical evaluation timing and incomplete resident assessment documentation. Plans of correction were submitted and partially implemented as of March 3, 2017.
Citations (2)
Regulation 55 Pa.Code §2600.141(a)(1): A resident's initial medical evaluation was completed more than 60 days prior to admission, violating the required timeframe of within 60 days prior or 30 days after admission.
Regulation 55 Pa.Code §2600.227(d): The resident's support plan was not updated to include causes or solutions to prevent multiple emergency room visits due to chronic pain.
Report Facts
Number of Residents Served: 62
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nathaniel D. Pace | Administrator | Named in relation to the inspection and plan of correction signatures. |
| Gerald Dumas | Department Representative | Inspector conducting the on-site inspection on 09/15/2016. |
Inspection Report — Jul 22, 2016
Renewal
Date: Jul 22, 2016
Visit Reason
The inspection was conducted as an annual licensing renewal inspection of Morris-Pace Personal Care facility to identify violations of 55 Pa.Code Chapter 2600.
Findings
Multiple violations were found including unsanitary conditions, improper trash management, unsafe floor rugs, missing emergency phone numbers, incomplete fire drill documentation, incomplete medical evaluations, and evidence of smoking in non-designated areas. Plans of correction were submitted and partially implemented with adequate progress noted.
Citations (8)
55 Pa.Code §2600.85(a) - Sanitary conditions were not maintained; fecal matter was smeared on bathroom walls and floors, and commodes appeared uncleaned.
55 Pa.Code §2600.85(d) - Trash containers in resident bathrooms were uncovered and overflowing with garbage.
55 Pa.Code §2600.88(a) - Floors, walls, ceilings, and rugs were not clean or safe; rugs lacked non-skid backing creating tripping hazards.
55 Pa.Code §2600.91 - Emergency phone numbers were not posted near the shared resident phone for required emergency services.
55 Pa.Code §2600.132(c) - Fire drill logs were incomplete; AM/PM times were missing on three days and documentation was inadequate.
55 Pa.Code §2600.141(a)(2) - Resident #1's medical evaluation was incomplete; vital signs and immunization history were missing.
55 Pa.Code §2600.141(b)(1) - Resident #2's annual medical evaluation was not completed timely and documentation was missing or expired.
55 Pa.Code §2600.144(c)(1) - Smoking was observed in a non-designated area with cigarette butts and packs found near an emergency exit.
Report Facts
Staff Count: 62
Waking Staff: 47
Residents Receiving Supplemental Security Income: 48
Residents Age 60 or Older: 25
Residents with Mental Illness: 45
Residents with Intellectual Disability: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nathaniel D. Pace | Administrator | Named as administrator and legal entity representative signing plans of correction. |
| Kimberli Foulkes | Inspector | Department representative on-site during inspection. |
| Anne O'Haire | Inspector | Department representative on-site during inspection. |
Notice — May 24, 2016
Date: May 24, 2016
Visit Reason
This document serves as a renewal notice and certificate of compliance for Morris-Pace Personal Care Home, confirming the facility's license to operate 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 only confirms the license issuance and renewal application receipt.
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