12 Reports
Inspection Report — Nov 3, 2025
Renewal
Date: Nov 3, 2025
Visit Reason
The inspection was conducted as a renewal review of the facility's compliance with licensing requirements on 11/03/2025 and 11/04/2025.
Findings
The facility was found to have multiple deficiencies including missing payment responsibility in resident contracts, delayed criminal background checks, lack of CPR-trained staff on certain shifts, incomplete fire safety training, maintenance issues such as holes in ceilings, hot water temperature violations, missing window screens, unsecured furniture and equipment, lack of approved signaling devices for hearing-impaired residents, and missing fire extinguisher inspection tags. All deficiencies had accepted plans of correction implemented by 12/19/2025.
Citations (10)
25c4 Payment Responsibility: The resident-home contract did not specify the party responsible for payment.
51 Criminal Background Check: A direct care staff member's Pennsylvania State Police criminal background check was not requested until after employment began.
63a First Aid/CPR Training: Approximately 40 residents were present during a night shift with no staff trained in first aid and certified in CPR.
65g Annual Training Content: A direct care staff member did not receive required fire safety training by a fire safety expert during the training year.
88a Surfaces: An 8 inch by 4 inch hole was found in the plaster ceiling above a bathroom stall on the 3rd floor.
89b Hot Water Temperature: Hot water temperatures in multiple resident rooms and common areas exceeded 120°F or were not warm to the touch.
92 Windows: Missing screens were found in operable windows in resident rooms and stairwell areas.
95 Furniture and Equipment: Various issues including unsecured escutcheon plate, broken hot water handle, loose towel bar, and cracked toilet handle were observed.
130e Hearing Impairment: A hearing-impaired resident lacked an approved signaling device to alert them in the event of a fire.
131f Fire Extinguisher Inspection: A fire extinguisher inside the social hall/gym area lacked an inspection tag indicating annual inspection by a fire safety expert.
Report Facts
Residents Served: 41
Staff Count: 52
Waking Staff: 39
Hospice Residents: 12
Residents Present During CPR Deficiency: 40
Inspection Report — Oct 29, 2024
Renewal
Date: Oct 29, 2024
Visit Reason
The inspection was conducted as part of a renewal and complaint investigation process, including multiple licensing inspections on 10/29/24, 11/4/24, 11/13/24, and 3/21/24, to assess compliance with 55 Pa. Code Ch. 2600 relating to Personal Care Homes.
Complaint Details
The inspection included complaint investigation as part of the renewal process. Specific complaint details are not provided, but the report notes corrections made after inspections and no deficiencies found on the 03/21/2025 follow-up partial inspection.
Findings
The facility was found to be in compliance overall, with multiple deficiencies cited related to record confidentiality, privacy, poisonous materials storage, lighting, surfaces, grab bars, fire safety inspections and drills, medication administration, and record keeping. All deficiencies had plans of correction accepted and were implemented by 03/26/2025. A follow-up partial inspection on 03/21/2025 found no deficiencies.
Citations (16)
Resident records binder was unlocked and accessible, violating confidentiality requirements.
No door on common bathroom 307 and bathroom stalls lacked locking devices, violating privacy rights.
Spray bottle with unlabeled disinfectant found outside original container.
Exit sign above patio door unsafe due to no means of egress to public thoroughfare.
Rubber stripping detached at door threshold creating tripping hazard.
No grab bars or handrails in men's and women's bathrooms near main dining room.
Fire safety inspection and drill not completed annually; last done 8/3/22.
Fire drill records lacked indication of a.m. or p.m. times.
Evacuation times exceeded allowable 2 minutes 30 seconds in multiple fire drills.
Fire drills routinely held at end of month dates, not varied days/times.
Resident #4 self-administered medications without proper assessment.
Non-licensed staff administered GLP-1 agonist medication to resident #5.
Prescription medication label for resident #5 inconsistent with physician orders.
Morphine medication for resident #6 not included on medication administration record.
Medication administration record for resident #5 not initialed for multiple medications on 10/7/24 at 8:00 p.m.
Correction fluid used on resident #7's nursing note, violating record entry requirements.
Report Facts
Residents Served: 39
Staffing Hours: 46
Waking Staff: 35
Residents Served: 42
Staffing Hours: 53
Waking Staff: 40
Fire Drill Evacuation Times: 13
Inspection Report — Feb 26, 2024
Complaint Investigation
Date: Feb 26, 2024
Visit Reason
The inspection was conducted as a complaint investigation triggered by an incident involving mistreatment or abuse of a resident, failure to submit and comply with an acceptable plan of correction, and related violations of 55 Pa. Code Chapter 2600 for Personal Care Homes.
Complaint Details
The complaint investigation was substantiated based on findings of resident neglect and abuse, failure to submit and comply with an acceptable plan of correction, and violations of licensing regulations.
Findings
The investigation found that a resident was found deceased outside the facility after wandering away in cold weather, indicating neglect and abuse. Additional violations included failure to properly document medication administration and lack of a current written description of services. A provisional license was issued due to these violations and an acceptable plan of correction.
Citations (3)
Resident #1 was found deceased outside the home after wandering away unattended in cold weather, indicating neglect and abuse.
Failure to document medication administration accurately; resident's morning medications were not administered though documented as given.
The home did not have a current written description of services and activities provided, including criteria for admission and discharge and services not provided but arranged.
Report Facts
Residents Served: 38
Resident Support Staff: 50
Waking Staff: 38
Supplemental Security Income Recipients: 9
Residents 60 Years or Older: 38
Residents with Mobility Need: 12
Residents with Physical Disability: 1
Current Hospice Residents: 4
Inspection Report — Mar 30, 2023
Plan of Correction
Date: Mar 30, 2023
Visit Reason
The inspection was a partial review conducted as a follow-up to verify the submitted plan of correction for the facility.
Findings
The facility had deficiencies related to building renovations and electronic locking systems on secured dementia care unit doors. The facility rescinded its request to open a secured dementia unit and disconnected all locking systems and wander guard devices. Photographic evidence was directed to be submitted to the local code enforcement official to verify corrections.
Citations (4)
The home's most recent occupancy permit indicates 'mixed use' and does not specify use classes; keypad locking devices were added to doors without proper approval.
The home lacks written approval for keypad locking devices on secured dementia care unit doors.
The home does not have a manufacturer statement verifying the locking system will shut down and doors will open immediately upon fire alarm, power failure, or override.
Doors in the secured dementia care unit are only monitored by a wander guard system and lack an electronic locking system.
Report Facts
Residents Served: 51
Staffing: 52
Waking Staff: 39
Secured Dementia Care Unit Residents Served: 0
Hospice Current Residents: 3
Residents Receiving Supplemental Security Income: 9
Residents Age 60 or Older: 51
Residents with Mobility Need: 1
Residents with Physical Disability: 1
Inspection Report — Dec 7, 2022
Renewal
Date: Dec 7, 2022
Visit Reason
The inspection was conducted as a renewal and complaint investigation for the facility Mt. Assisi Place on 12/07/2022, 12/08/2022, and 12/09/2022.
Complaint Details
The inspection included a complaint investigation as part of the renewal process. Specific complaint substantiation status is not stated.
Findings
The inspection identified multiple deficiencies including expired boiler certificates, use of restraints (bedrails) without proper justification, incomplete criminal background checks for staff, incomplete orientation documentation for new staff, inadequate bedside lighting for a resident, and incomplete documentation in a resident's support plan regarding bedrails. Plans of correction were submitted and implemented by January 24, 2023.
Citations (6)
Certificates for multiple boilers within the home expired on 11/2/22.
Bilateral half-length bedrails were present at the top of the beds of residents #1, #2, and #3; residents were unable to independently use the devices.
A Pennsylvania criminal background check was not completed for direct care staff person A.
Orientation documentation was incomplete for direct care staff person C and ancillary staff person B, making it unclear if orientation was completed timely.
Resident #1's bedside lamp was approximately 5 feet from the bed and could not be turned on/off from bedside.
Resident #1's support plan did not address the need for bedrails or a plan to protect the resident from potential dangers of the bedrails.
Report Facts
Inspection dates: 3
Residents served: 48
Staff total daily: 65
Waking staff: 49
Current hospice residents: 4
Residents receiving Supplemental Security Income: 10
Residents age 60 or older: 48
Residents with mobility need: 17
Residents with physical disability: 1
Inspection Report — Feb 28, 2022
Follow-Up
Date: Feb 28, 2022
Visit Reason
The inspection was a partial, unannounced follow-up visit conducted on 02/28/2022 to review the implementation of a plan of correction related to a prior incident.
Complaint Details
The visit was triggered by an incident involving allegations of abuse against staff persons A and B. The allegations were investigated by AAA and DHS. Staff persons A and B were suspended and subsequently terminated. The resident was monitored and did not report lasting distress. The complaint was substantiated.
Findings
The submitted plan of correction was determined to be fully implemented. The facility was found to have addressed the abuse allegations involving two staff members, who were suspended and terminated. Staff training on resident rights was completed and increased monitoring was initiated.
Citations (1)
Resident #1 was subjected to intimidation and verbal abuse by staff persons A and B, violating resident rights and abuse prevention regulations.
Report Facts
Residents Served: 42
Current Hospice Residents: 2
Residents 60 Years or Older: 42
Residents with Mental Illness: 3
Residents with Mobility Need: 12
Residents with Physical Disability: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Janine Wenzig | Signed letters regarding inspection results and plan of correction acceptance |
Inspection Report — Dec 27, 2021
Complaint Investigation
Date: Dec 27, 2021
Visit Reason
The inspection was conducted as a complaint investigation with a provisional exit conference on 12/27/2021 at MT. ASSISI PLACE.
Complaint Details
The visit was complaint-related and provisional, with a follow-up plan of correction submission due on 01/13/2022. The plan of correction was accepted.
Findings
The inspection identified deficiencies related to incomplete resident-home contract signatures, incomplete medical evaluations missing vital signs, and incomplete resident assessments missing prescribed diet information. Plans of correction were accepted with specified completion dates.
Citations (3)
Resident #1's resident-home contract was not signed by the resident or the home's administrator or designee; Resident #2's resident-home contract was not signed by the home's administrator or designee.
Resident #1's medical evaluation did not include blood pressure or temperature; these sections were blank.
Resident #3's most recent assessment did not include the resident's prescribed diet of mechanical soft foods as indicated on the medical evaluation.
Report Facts
Residents Served: 42
Current Hospice Residents: 2
Resident Support Staff: 0
Total Daily Staff: 54
Waking Staff: 41
Residents Receiving Supplemental Security Income: 13
Residents 60 Years or Older: 42
Residents Diagnosed with Mental Illness: 3
Residents with Mobility Need: 12
Inspection Report — Mar 15, 2021
Monitoring
Date: Mar 15, 2021
Visit Reason
The inspection was a partial, unannounced monitoring visit conducted by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing on 03/15/2021.
Findings
The inspection identified three deficiencies: an entrapment hazard due to an unsecured enabler bar on a resident's bed, missing emergency telephone numbers by a kitchen phone, and improperly stored food (an unsealed bag of tater tots) in the walk-in freezer. Plans of correction were accepted and included staff reeducation and ongoing inspections.
Citations (3)
The 9" x 3" opening between the rails of the uncovered, unsecured enabler bar on resident #1's bed posed an entrapment hazard due to insecure attachment allowing movement.
No emergency telephone numbers including nearest hospital and fire department were posted on or by the telephone in the kitchen next to the ice maker.
An unsealed 5 pound bag of tater tots was found in the walk-in freezer, violating food storage requirements.
Report Facts
Residents Served: 50
Staffing Hours - Total Daily Staff: 67
Staffing Hours - Waking Staff: 50
Current Hospice Residents: 4
Residents Receiving Supplemental Security Income: 13
Residents Diagnosed with Mental Illness: 3
Residents with Mobility Need: 17
Residents Age 60 or Older: 50
Residents Diagnosed with Intellectual Disability: 1
Residents with Physical Disability: 1
Inspection Report — Nov 20, 2020
Renewal
Date: Nov 20, 2020
Visit Reason
The inspection was a renewal visit conducted by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing to assess compliance with licensing requirements.
Findings
The inspection identified multiple deficiencies including missing influenza awareness posters, incomplete criminal background checks, unsecured medications, unlabeled and undated food items, uncovered trash receptacles, missing emergency telephone numbers, and issues with medication administration and storage. Plans of correction were accepted and follow-up inspections scheduled.
Citations (21)
The home had not posted the Influenza Awareness poster as required by the Influenza Awareness Act.
Direct care staff lacked timely Pennsylvania State Police criminal background checks as required.
A direct care staff person did not have a high school diploma, GED, or active registry status on the Pennsylvania nurse aide registry.
Unsecured and uncovered enabler bars on residents' beds posed entrapment and fall hazards.
Trash cans in kitchens and bathrooms were uncovered, allowing penetration of insects and rodents.
Trash outside the home was left on top of a cracked dumpster lid instead of in covered receptacles.
Emergency telephone numbers were not posted on or by telephones with outside lines in resident areas.
Resident #5 did not have access to a source of light that can be turned on/off at bedside.
Multiple food items in refrigerators and freezers were unlabeled and undated.
No thermometers were present in the kitchen chest freezer and a second floor kitchenette refrigerator.
Food was stored in unsealed plastic bags in the walk-in freezer.
Emergency procedures and preparedness plans were not posted in a conspicuous and public place in the home.
Fire drill evacuation times exceeded the maximum safe evacuation time determined by a fire safety expert.
Weekly menus were not posted one week in advance as required.
A medication container labeled with resident #5's name contained medication removed from its original container.
Medications and syringes were unsecured and accessible in a resident's private bathroom despite inability to self-administer.
Opened medications lacked dates indicating when they were opened and expiration dates as required.
Prescription medications were not labeled with pharmacy labels including resident name, medication name, date issued, and dosage instructions.
A pink oval tablet was found on the medication room floor, violating safe storage procedures.
Resident #3's medication administration record did not match the prescribed frequency for Systane eye gel.
The home did not follow the directions of the prescriber regarding medication administration changes without written orders within 48 hours.
Report Facts
Residents Served: 52
Staffing Hours: 68
Waking Staff: 51
Hospice Residents: 4
Residents 60 or Older: 52
Residents with Mental Illness: 3
Residents with Mobility Need: 16
Residents with Physical Disability: 1
Inspection Report — Aug 23, 2019
Routine
Date: Aug 23, 2019
Visit Reason
The Department’s Bureau of Human Services Licensing conducted an inspection of Mt. Assisi Place to assess compliance with 55 Pa. Code Ch. 2600 relating to Personal Care Homes.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Inspection Report — Jul 25, 2019
Original Licensing
Date: Jul 25, 2019
Visit Reason
The inspection was conducted as part of the licensing process for a new legal entity operating the personal care home facility.
Findings
The facility was found to be in substantial compliance with the applicable regulations under 55 Pa. Code Chapter 2600 for Personal Care Homes. The licensing inspector was unable to complete a full inspection due to the new legal entity status.
Notice — June 3, 2020
Date: June 3, 2020
Visit Reason
The document serves as a license renewal approval and notification that an annual onsite inspection will be conducted within the next twelve months as required by regulation.
Findings
The Department issued a regular license in response to the renewal application and advised that an inspection will occur within twelve months. Enforcement actions may follow if noncompliance is found during the inspection.
Report Facts
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