7 Reports
Inspection Report — Mar 11, 2026
Renewal
Date: Mar 11, 2026
Visit Reason
The inspection was conducted as a renewal review of the facility license, including follow-up on a submitted plan of correction.
Findings
The inspection identified multiple deficiencies including issues with carbon monoxide alarm battery labeling, resident contract execution timing, quality management plan compliance, staff training hours and topics, resident equipment safety, facility maintenance, emergency supplies, combustible material storage, fire drill documentation, medical evaluation completeness, smoking area safety, and medication management.
Citations (17)
Carbon monoxide alarms had batteries and units without installation date labels, violating the Carbon Monoxide Alarm Standards Act.
Resident #1's resident-residence contract was not signed within 24 hours of admission as required.
The quality management plan failed to hold monthly QAIP meetings as required, with the last meeting held on 11/7/24.
The quality management plan review dated 11/7/24 did not address incident reporting, complaint procedures, or staff training.
On multiple occasions, only one staff member trained in first aid and CPR was present for 59 residents, violating the 1:35 ratio requirement.
Staff Member A received only 12 hours and 10 minutes of required 16 hours annual training during the 2025 training year.
Staff Member A did not receive required training on medication self-administration, infection control, and assisted living service needs during the 2025 training year.
Staff Member A did not receive required training on resident rights, the Older Adult Protective Services Act, and falls and accident prevention during the 2025 training year.
Resident #2’s bedside mobility device cover was improperly installed, creating an entrapment hazard.
The carpet in living unit #111 was stained with multiple brown, dark brown, and gray stains.
The residence did not maintain the required 3-day supply of emergency drinking water, having 174 gallons instead of 177 gallons for 59 residents.
A 5 gallon gasoline container filled with gasoline was unlocked and accessible to residents in the patio area.
Fire drill records for drills on 11/14/24 and 12/17/24 lacked documentation of resident counts and evacuation numbers.
Medical evaluations for Residents #1, #3, and #4 did not include the height of the residents.
The designated smoking area was located along a common walkway, posing a fire safety risk.
Tylenol prescribed for Resident #4 was found in the medication cart without a current order.
A package of magnesium capsules belonging to Resident #5 was not labeled with the resident's name in the medication cart.
Report Facts
Residents served: 59
Staff count: 74
Waking staff: 56
Emergency drinking water required: 177
Emergency drinking water available: 174
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff Member A | Named in findings related to insufficient annual training hours and missing required training topics |
Inspection Report — Jul 31, 2025
Complaint Investigation
Date: Jul 31, 2025
Visit Reason
The inspection was conducted as a complaint investigation with an unannounced partial inspection on 07/31/2025 to review compliance and the submitted plan of correction.
Complaint Details
The inspection was complaint-driven and the submitted plan of correction was fully implemented as of 09/29/2025.
Findings
The facility was found to have a deficiency related to the resident initial assessment form not being completed on the Department’s assessment form and missing multiple required elements. A plan of correction was directed and later implemented to ensure all required assessment content is included in resident service plans.
Citations (1)
Resident initial assessment was not completed on the Department’s assessment form and lacked required information including formal and informal supports, assessment dates, reasons, levels of supervision and mobility, medical, dental, dietary, sensory, mental health, social needs, and assessor details.
Report Facts
Residents Served: 63
Current Residents in Hospice: 9
Residents Age 60 or Older: 63
Residents with Mobility Need: 17
Residents with Physical Disability: 2
Total Daily Staff: 80
Waking Staff: 60
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Area Director of Clinical Services | In-serviced Health and Wellness Director on assessment content requirements as part of plan of correction | |
| Health and Wellness Director | Responsible for ensuring assessment content inclusion and completing quarterly service plan reviews | |
| Executive Director | Responsible for reviewing service plans and auditing new admissions for compliance |
Inspection Report — Apr 1, 2025
Complaint Investigation
Date: Apr 1, 2025
Visit Reason
The inspection was conducted as a complaint investigation at the facility.
Complaint Details
The inspection was complaint-driven, 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: 62
Current Hospice Residents: 7
Residents Age 60 or Older: 62
Residents with Mobility Need: 16
Total Daily Staff: 78
Waking Staff: 59
Notice — Sep 10, 2024
Date: Sep 10, 2024
Visit Reason
The document is a response to a request for a waiver of Pennsylvania Code § 2800.190(b) to allow unlicensed direct care staff to administer subcutaneous injections of GLP-1 agonist medications in an assisted living facility.
Findings
The waiver outlines training requirements for direct care staff administering GLP-1 agonist injections, including successful completion of medication administration courses, in-person training by licensed professionals, and annual training hours. The facility must have policies for administration, monitoring, documentation, and a clinical contact available at all times.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Theresa Hartman | Bureau Director, Human Services Licensing | Signed the waiver approval letter. |
Inspection Report — Aug 27, 2024
Renewal
Date: Aug 27, 2024
Visit Reason
The inspection was a full, unannounced renewal inspection conducted on 08/27/2024 and 08/28/2024, including an incident review and follow-up on plan of correction submissions.
Findings
Multiple deficiencies were identified including failure to post current license inspection summary, expired elevator inspection certification, incomplete medical evaluations, unsigned resident contracts, missing signed resident rights statements, insufficient first aid/CPR trained staff, incomplete staff orientation and training, missing emergency procedures posting, incomplete fire drill evacuation, medication records lacking diagnosis/purpose, and lack of resident education on medication refusal rights. All deficiencies had accepted plans of correction with proposed completion dates mostly by 09/30/2024 or 10/31/2024.
Citations (13)
The residence's most recent license inspection summary dated 8/10/23 was not posted in a conspicuous and public place.
The residence's elevator inspection certification expired on 5/31/24.
Resident #5's initial medical evaluation was completed more than 60 days prior to admission.
Residents #2, #3, #4, and #6 did not sign the facility contract.
Resident #6's record did not contain a signed statement acknowledging receipt of resident rights and complaint procedures.
On 8/14/24 and 8/18/24, only one staff member was certified and trained in first aid and CPR for 62 residents.
Staff person A did not receive required orientation on fire safety and emergency preparedness topics on their first day of work.
Staff person A did not complete required orientation training within the first 40 hours worked on resident rights, emergency medical plan, abuse reporting, and core competencies.
Staff person A provided unsupervised assisted living services without completing 18 hours of required direct care training.
The residence’s emergency procedures were not posted in a conspicuous and public place.
During the fire drill on 5/21/24, only 53 out of 57 residents evacuated the building.
Resident #3's medication administration record did not include a diagnosis or purpose for prescribed medications.
Residents #1, #2, #3, #4, #5, and #6 were not educated on their right to refuse medication if they believe there may be a medication error.
Report Facts
Residents Served: 61
Current Residents in Hospice: 12
Residents 60 Years or Older: 61
Residents with Mobility Need: 20
Residents with Physical Disability: 1
Total Daily Staff: 81
Waking Staff: 61
Staff Certified in First Aid/CPR: 1
Residents Present During CPR Deficiency: 62
Residents Evacuated During Fire Drill: 53
Residents Present During Fire Drill: 57
Inspection Report — Aug 2, 2023
Renewal
Date: Aug 2, 2023
Visit Reason
The inspection was conducted as a renewal inspection of the facility's license, with an unannounced full inspection on 08/02/2023 and an exit conference on 08/03/2023.
Findings
The inspection identified several deficiencies related to criminal background checks, expired medications, improper medication storage, and medication administration record inaccuracies. Plans of correction were submitted and determined to be fully implemented by 09/22/2023.
Citations (4)
Staff Member A did not have a Pennsylvania State Police background check completed within the acceptable timeframe.
Expired narcotic medications (Lorazepam and Tramadol HCL) were found in the medication cart.
Loose pill found in medication cart and insulin vials lacked dates showing when medications were opened.
Glucometer for Resident #4 lacked calibration to the correct date and time, and discrepancies were found in medication administration record (MAR) recordings.
Report Facts
Residents Served: 61
Current Hospice Residents: 9
Residents Diagnosed with Mental Illness: 1
Residents with Mobility Need: 11
Total Daily Staff: 72
Waking Staff: 54
Inspection Report — Jun 8, 2022
Original Licensing
Date: Jun 8, 2022
Visit Reason
The inspection was conducted as a licensing inspection for a newly licensed assisted living facility operated by a new legal entity.
Findings
The facility was found to be in substantial compliance with applicable regulations, but the licensing inspector was unable to complete a full inspection due to the new legal entity status. A re-inspection will be conducted within 3 months of the license effective date.
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