Inspection Reports for
Plush Mills
501 Plush Mill Rd, Wallingford, PA 19086, United States, PA, 19086
Back to Facility Profile25 Reports
Inspection Report — Jun 18, 2025
Re-Inspection
Date: Jun 18, 2025
Visit Reason
The inspection was conducted as a licensing inspection of a newly licensed personal care home operated by a new legal entity. A re-inspection is required within 3 months to verify full compliance.
Findings
The facility was found to be in substantial compliance with 55 Pa. Code Chapter 2600 regulations at the time of inspection, but the licensing inspector was unable to complete a full inspection due to the new legal entity status. Citations were found and must be corrected by specified dates.
Inspection Report — Jun 18, 2025
Follow-Up
Date: Jun 18, 2025
Visit Reason
The inspection visit was conducted due to a change in legal entity and to review the submitted plan of correction.
Findings
The submitted plan of correction was determined to be fully implemented. A combustible storage violation was identified and immediately corrected during the inspection.
Citations (1)
A sheet of cardboard, roughly four square-feet in size, was wedged to the boiler-room wall behind the hot water heater safety switch, which is a combustible storage violation.
Report Facts
Residents Served: 63
Current Residents: 6
Total Daily Staff: 101
Waking Staff: 76
Inspection Report — Mar 26, 2025
Follow-Up
Date: Mar 26, 2025
Visit Reason
The inspection was a partial, unannounced follow-up visit triggered by an incident to verify the implementation of a previously submitted plan of correction.
Findings
The facility was found to have fully implemented the plan of correction related to resident dignity and respect. The follow-up confirmed compliance with the corrective actions.
Citations (1)
42c. A resident reported that staff person B grabbed their call pendant aggressively and made them feel uncomfortable by watching them eat despite no care need. The facility provided in-servicing on dignity and respect to staff and implemented ongoing resident interviews to ensure compliance.
Report Facts
Residents Served: 63
Current Residents: 6
Resident Support Staff: 0
Total Daily Staff: 102
Waking Staff: 77
Residents Age 60 or Older: 63
Residents with Mobility Need: 39
Inspection Report — Feb 3, 2025
Renewal
Date: Feb 3, 2025
Visit Reason
The inspection was a renewal visit conducted on 02/03/2025 to review the facility's compliance with licensing requirements.
Findings
The submitted plan of correction was determined to be fully implemented. The facility was found to have one medication storage violation related to improper refrigeration of Latanoprost solution, which was corrected with staff inservice and ongoing audits.
Citations (1)
183e - Storing Medications: An unopened bottle of Latanoprost solution was not refrigerated as required by the manufacturer’s instructions. The facility provided inservice training and implemented weekly and monthly medication cart audits to ensure compliance.
Report Facts
Residents Served: 65
Current Residents in Hospice: 7
Total Daily Staff: 106
Waking Staff: 80
Residents with Mobility Need: 41
Residents 60 Years or Older: 65
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Health and Wellness Director | Provided inservice training regarding proper medication storage |
Inspection Report — Mar 4, 2024
Renewal
Date: Mar 4, 2024
Visit Reason
The inspection was conducted as a renewal visit to assess compliance with licensing requirements for Plush Mills.
Findings
The submitted plan of correction was fully implemented and compliance was maintained. A previous deficiency related to the use of alternate exit routes during fire drills was corrected.
Citations (1)
132f. Alternate exit routes shall be used during fire drills. The fire safe zone was the only exit route used during fire drills held from 2023 to 2024.
Report Facts
Residents Served: 25
Current Hospice Residents: 4
Notice — Dec 13, 2023
Date: Dec 13, 2023
Visit Reason
The document serves to grant a waiver for a direct care staff member at Plush Mills who received their high school education outside the United States, allowing them to serve despite not meeting the usual Pennsylvania nurse aide registry requirements.
Findings
The waiver is granted under specific conditions including documentation of education equivalency and record keeping by the facility. The Department will review this waiver annually during inspections to ensure compliance.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Theresa Hartman | Bureau Director, Human Services Licensing | Signed the waiver approval letter. |
Inspection Report — Nov 28, 2022
Monitoring
Date: Nov 28, 2022
Visit Reason
The inspection was a monitoring visit conducted by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing on 11/28/2022.
Findings
No regulatory citations or deficiencies were identified during this inspection.
Inspection Report — Oct 18, 2022
Monitoring
Date: Oct 18, 2022
Visit Reason
The inspection was a partial, unannounced monitoring visit conducted on 10/18/2022 to review compliance and follow-up on the submitted plan of correction.
Findings
The inspection found multiple deficiencies related to medication administration, glucometer readings, documentation timing, and adherence to prescriber's orders. The submitted plan of correction was accepted and fully implemented by 12/02/2022.
Citations (4)
85.a Sanitary conditions were not maintained as Resident 1 missed a scheduled blood sugar reading at 9pm on 10/2/22, and Resident 2 had an unscheduled reading at the same time.
185.a Procedures for safe storage and use of medications and medical equipment were deficient as Resident 1's glucometer reading on 10/11/22 was 243 but documented as 175.
187.b Medication administration times were not properly recorded; Resident 1's blood sugar reading taken at 3:22PM on 10/11/22 was not documented until 5:09PM.
187.d The home failed to follow prescriber's orders when Resident 1 did not receive insulin units as prescribed on 10/11/22 and Resident 2 missed a dose of Creon medication on 10/10/22.
Report Facts
Residents Served: 59
Hospice Current Residents: 4
Residents with Mobility Need: 27
Inspection Report — Sep 15, 2022
Renewal
Date: Sep 15, 2022
Visit Reason
The inspection was conducted as a renewal inspection of the Plush Mills facility to review compliance with licensing requirements.
Findings
The inspection identified multiple deficiencies including sanitary conditions related to shared glucometers, hot water temperatures exceeding 120°F in resident rooms, medication storage and documentation errors, and failure to follow prescriber's orders for medication administration and blood sugar monitoring. Plans of correction were submitted and determined to be fully implemented.
Citations (5)
Evidence of shared glucometers was observed with glucose readings of resident #2 found on resident #1's glucometer.
Hot water temperature in resident rooms 226 and 229 exceeded 120°F, measured at 122.5°F and 123.6°F respectively.
Discrepancies in glucometer readings and documentation for residents #1 and #2, with multiple glucose readings missing or inaccurately recorded.
Medication administered to resident #1 was not initialed on the MAR on two occasions.
Resident #2 did not have the prescribed number of blood sugar readings completed on two days; resident #3 missed a prescribed medication dose.
Report Facts
Residents Served: 58
Current Hospice Residents: 6
Total Daily Staff: 84
Waking Staff: 63
Residents with Mobility Need: 26
Hot Water Temperature: 122.5
Hot Water Temperature: 123.6
Inspection Report — May 19, 2022
Follow-Up
Date: May 19, 2022
Visit Reason
The inspection visit on 05/19/2022 was conducted as a complaint investigation to review compliance and the submitted plan of correction.
Complaint Details
The visit was complaint-related. The violation involved failure to administer medications to a resident. The plan of correction was accepted and fully implemented.
Findings
The facility was found to have a medication administration violation where a staff member failed to administer medications to a resident as required. The submitted plan of correction was reviewed and determined to be fully implemented.
Citations (1)
Staff person did not administer resident #1's medications and left medication in the resident's apartment without administration.
Report Facts
Residents Served: 61
Staffing Hours - Total Daily Staff: 78
Staffing Hours - Waking Staff: 59
Residents with Mobility Need: 17
Residents Age 60 or Older: 61
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director/Director of Wellness | Named in relation to plan of correction submission and communication | |
| Director of Nursing | Responsible for ensuring compliance with medication administration | |
| Assistant Director of Nursing | Responsible for ensuring compliance with medication administration | |
| Charge Nurses | Responsible for ensuring compliance with medication administration | |
| Med Techs | Responsible for medication administration and training |
Inspection Report — Jun 24, 2021
Renewal
Date: Jun 24, 2021
Visit Reason
The inspection was conducted as a renewal inspection of the Plush Mills facility to assess compliance with licensing requirements.
Findings
The inspection identified deficiencies related to medication storage procedures and documentation of medication administration times. The facility submitted a plan of correction which was determined to be fully implemented.
Citations (2)
A small round white pill was found loose in medication cart 2 in the third drawer on the second floor, indicating failure to implement safe storage procedures for medications.
Resident 1’s Medication Administration Record had omissions and did not include the initials of the staff person administering medications for specified dates and times.
Report Facts
Residents Served: 53
Total Daily Staff: 76
Waking Staff: 57
Current Hospice Residents: 4
Residents with Mobility Need: 23
Notice — Oct 21, 2020
Date: Oct 21, 2020
Visit Reason
The document serves as a license renewal approval and notification that the Department will conduct an annual inspection of the Personal Care Home 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.
Report Facts
Inspection Report — Jun 3, 2020
Complaint Investigation
Date: Jun 3, 2020
Visit Reason
The inspection was conducted as a complaint investigation at Plush Mills facility on June 3, 2020.
Findings
No regulatory citations or deficiencies were identified during this complaint investigation inspection.
Report Facts
Residents Served: 60
Current Hospice Residents: 5
Resident Mobility Need: 23
Inspection Report — May 26, 2020
Date: May 26, 2020
Visit Reason
The inspection was conducted as a partial, unannounced visit due to an incident at the facility.
Findings
No regulatory citations or deficiencies were identified during the inspection conducted over multiple days from May 26 to June 2, 2020.
Inspection Report — Apr 17, 2020
Routine
Date: Apr 17, 2020
Visit Reason
The Department’s Bureau of Human Services Licensing Representatives conducted an inspection of the Plush Mills facility on April 17, 2020.
Findings
No regulatory citations with 55 Pa. Code Ch. 2600 (relating to Personal Care Homes) were identified as a result of this inspection.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mia Johnson | Human Services Licensing Supervisor | Signed the inspection report and conducted the inspection. |
Notice — Aug 20, 2019
Date: Aug 20, 2019
Visit Reason
The document is a renewal approval letter for the Personal Care Home license of Plush Mills, 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 inspection requirements for the upcoming year.
Report Facts
Inspection Report — Jun 10, 2019
Annual Inspection
Date: Jun 10, 2019
Visit Reason
The visit was an annual inspection conducted by the Department’s Bureau of Human Services Licensing to assess compliance with 55 Pa. Code Ch. 2600 relating to Personal Care Homes.
Findings
The facility was found to be in compliance with the applicable regulations during the annual inspection.
Inspection Report — Aug 24, 2018
Renewal
Date: Aug 24, 2018
Visit Reason
The document is a renewal application and license issuance for Plush Mills Personal Care Home. The Department of Human Services notifies that an annual 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 confirmation and notification of upcoming annual inspection requirements.
Inspection Report — Jun 28, 2018
Complaint Investigation
Date: Jun 28, 2018
Visit Reason
The inspection was conducted as a complaint investigation triggered by an incident involving possible verbal abuse and other resident rights violations at Plush Mills Personal Care Home.
Complaint Details
The complaint investigation was substantiated with findings of verbal abuse, disrespectful language, and privacy breaches involving staff and a private companion. Plans of correction included staff training and policy updates.
Findings
Multiple violations of 55 Pa. Code Chapter 2600 were found, including failure to immediately report suspected abuse, disrespectful language by staff, and breach of resident privacy during care. Plans of correction were submitted addressing staff training and policy enforcement.
Citations (3)
55 Pa.Code §2600.16(a) - The home failed to immediately report suspected abuse of a resident as required by the Older Adults Protective Services Act. An act of possible verbal abuse was witnessed but not reported promptly.
55 Pa.Code §2600.42(c) - A resident was not treated with dignity and respect when staff used inappropriate language in the hallway directed at the resident.
55 Pa.Code §2600.42(s) - A resident's right to privacy was violated when staff was observed using a cell phone while providing 1:1 private duty care.
Report Facts
Number of Residents Served: 67
Number of Current Hospice Residents: 5
Number of Hospice Residents in Past Year: 18
Number of Residents 60 Years or Older: 67
Number of Residents with Mobility Need: 31
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christine O'Reilly | Executive Director / DON | Named as legal entity representative and responsible party for plan of correction |
| Natasha Braswell | Department representative conducting the inspection |
Inspection Report — Jun 6, 2018
Routine
Date: Jun 6, 2018
Visit Reason
The Department's Bureau of Human Services Licensing representatives conducted an inspection of the facility Plush Mills on June 6, 2018.
Findings
No regulatory violations with 55 Pa. Code Ch. 2600 (relating to Personal Care Homes) were identified as a result of this inspection.
Inspection Report — Feb 27, 2018
Routine
Date: Feb 27, 2018
Visit Reason
The Department of Human Services licensing representatives conducted an inspection of the facility on February 27, 2018.
Findings
No regulatory violations with 55 Pa. Code Ch. 2600 (relating to Personal Care Homes) were identified as a result of this inspection.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Patricia Adams | Regional Director | Signed the inspection report letter. |
Inspection Report — Sep 11, 2017
Renewal
Date: Sep 11, 2017
Visit Reason
The inspection was a renewal licensing inspection conducted by the Pennsylvania Department of Human Services for the Personal Care Home Plush Mills.
Findings
Multiple violations of 55 Pa.Code Chapter 2600 were found, including failure to post the license inspection summary, sanitation issues, improper food storage, lack of emergency procedure documentation, and medication labeling errors. Plans of correction were submitted and partially or fully implemented.
Citations (11)
55 Pa.Code §2600.3(c) - The home's violation report was not posted in a conspicuous and public place in the home on the date of inspection.
55 Pa.Code §2600.85(e) - Trash outside the home was not kept in covered receptacles; the dumpster weld was broken and recycle containers were uncovered with debris overflowing.
55 Pa.Code §2600.103(b) - Kitchen surfaces were unclean and unsanitary, with dirt, grime, and scuff marks observed on counters and floors.
55 Pa.Code §2600.103(c) - Food was not protected from contamination; uncovered raw food was placed on a transport cart in the refrigerator.
55 Pa.Code §2600.103(d) - Food was stored on the floor; staff poured sauce into containers placed on the floor over an open drain.
55 Pa.Code §2600.107(d) - Written emergency procedures were not documented and submitted annually to the local emergency management agency.
55 Pa.Code §2600.162(c) - Menus were not posted one week in advance in a conspicuous and public place in the home.
55 Pa.Code §2600.162(d) - Past menus of meals served were not documented or provided; only the menu of the day was posted.
55 Pa.Code §2600.163(b) - Staff failed to follow sanitary practices while working in the kitchen; sauce was poured onto the floor from pans.
55 Pa.Code §2600.184(a) - Prescription medication containers did not include the resident's name on the pharmacy label.
55 Pa.Code §2600.187(b) - Medication administration records did not document the administration of medication before it was given to the resident.
Report Facts
Number of Residents Served: 64
Number of Current Hospice Residents: 3
Number of Hospice Residents in past year: 23
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christina O'Reilly | Administrator | Named as legal entity representative and signer of plan of correction documents |
| Sabrina Freeman | Surveyor | Department representative on-site during inspection |
| Natasha Braswell | Surveyor | Department representative on-site during inspection |
Notice — Aug 25, 2017
Date: Aug 25, 2017
Visit Reason
This document serves as a renewal notification for the Personal Care Home license of Plush Mills, confirming receipt of the renewal application and informing that a regular license is being issued.
Findings
No inspection findings are reported in this document. It states that an onsite inspection will be conducted within the next twelve months as required by regulation.
Inspection Report — Sep 12, 2016
Renewal
Date: Sep 12, 2016
Visit Reason
The inspection was conducted as part of the Department of Human Services' annual licensing inspections of the Plush Mills Personal Care Home on September 12 and 13, 2016.
Findings
Multiple violations of 55 Pa.Code Chapter 2600 were found, including failure to report incidents timely, unsigned resident contracts, improper food labeling, lack of fire drills, improper use of fire drill exit routes, medication administration errors, and incomplete documentation of blood sugar monitoring.
Citations (7)
2600.16(c) - The home failed to report an incident to the Department's personal care home complaint hotline within 24 hours as required.
2600.25(b) - The contract for resident #2 was not signed by the resident as required.
2600.103(e) - Food served and returned from an individual's plate was not properly labeled and dated; several unlabeled and undated food items were observed.
2600.132(e) - Fire drills were not held during sleeping hours once every six months as required.
2600.132(f) - Alternate exit routes were not used during fire drills as required.
2600.182(c) - Resident #13's recorded blood glucose readings did not match the data found on the resident's glucometer.
2600.187(d) - The home failed to follow the physician's orders for resident #13's blood sugar monitoring.
Report Facts
Number of Residents Served: 68
Number of Current Hospice Residents: 2
Number of Hospice Residents in past year: 15
Notice — Aug 19, 2016
Date: Aug 19, 2016
Visit Reason
This document serves as a renewal notification and license issuance for Plush Mills Personal Care Home, confirming the facility's authorized capacity 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 issuance of a regular license and outlines the Department's obligation to conduct an annual inspection.
Report Facts
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