32 Reports
Notice — Jun 12, 2026
Date: Jun 12, 2026
Visit Reason
The document serves as a formal notice granting a waiver to Rose Tree Place for direct care staff qualifications under 55 Pa.Code § 2600.54(a)(2), allowing staff with education from outside the United States to serve as direct care staff.
Findings
The waiver is granted with specific conditions including documentation of equivalency to a high school diploma and maintenance of records by the facility. The Department will review the 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 — Jun 11, 2026
Follow-Up
Date: Jun 11, 2026
Visit Reason
The inspection was a partial, unannounced follow-up visit to review the submitted plan of correction for the facility.
Findings
The facility was found to have violations related to resident record confidentiality, unsecured poisonous materials accessible to residents, and unlocked medications and syringes. All identified issues were corrected with plans for ongoing audits and staff training.
Citations (3)
Resident records including code status, care needs, dietary needs, and hospice status were unlocked and accessible in the Director of Memory Care's Office.
Multiple poisonous materials with manufacturer warnings were unlocked and accessible to residents in Resident Bedroom and the Director of Memory Care's office, without all residents assessed as capable of safe use.
Prescription and over-the-counter medications and syringes were unlocked and accessible in a resident's bedroom; the resident was not assessed to self-medicate.
Report Facts
Residents Served: 125
Secured Dementia Care Unit Residents Served: 23
Hospice Current Residents: 12
Inspection Report — May 22, 2026
Enforcement
Date: May 22, 2026
Visit Reason
The Department of Human Services issued a notice of intent to assess a fine for regulatory violations related to 55 Pa. Code Chapter 2600 for the Personal Care Home Rose Tree Place.
Findings
The facility was found to have uncorrected violations under 55 Pa. Code Chapter 2600, Section 82c, Class II, resulting in a fine assessment based on a census of 110 residents. The total fine assessed from 5/23/26 to 6/11/26 equals $11,000.
Citations (1)
55 Pa. Code Chapter 2600 Section 82c Class II violation was found uncorrected at the time of inspection. The fine was calculated at $5 per resident per day based on a census of 110 residents.
Report Facts
Fine amount: 11000
Fine per resident per day: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Amy Duncan | Enforcement Manager, Human Services Licensing | Contact person for questions regarding the invoice |
| Theresa Hartman | Director | Signed the enforcement letter |
Notice — Apr 7, 2026
Date: Apr 7, 2026
Visit Reason
The document serves to notify Rose Tree Place that their request to waive the high school diploma or equivalent requirement for a direct care staff member educated outside the United States has been granted under Pennsylvania regulations.
Findings
The waiver is granted with conditions requiring documentation of education and training to be maintained and made available upon request. 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 — Mar 30, 2026
Monitoring
Date: Mar 30, 2026
Visit Reason
The visit was a partial, unannounced monitoring inspection conducted by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing on 03/30/2026 and 03/31/2026 to review compliance and verify the submitted plan of correction.
Findings
Multiple deficiencies were identified including insufficient CPR/first aid certified staff during night shift, unlocked poisonous materials accessible to residents, hot water temperatures exceeding 120°F in resident bathrooms, incomplete medical evaluations and assessments, medication administration and storage issues, and documentation errors. Plans of correction were accepted and implemented by 08/05/2026.
Citations (17)
63a - At least one staff person per 50 residents trained in first aid and certified in CPR was not present from 11 PM to 7 AM when 110 residents were in the home.
82c - Poisonous materials including personal hygiene items and cleaning chemicals were unlocked and accessible to residents, some not assessed as capable of safe use.
89b - Hot water temperature in resident bathroom sinks exceeded 120°F, with measurements up to 127.7°F.
141b2 - Medical evaluations for residents with status changes were not checked to ensure needs could be met safely at the home.
181f - Resident medication records did not include current lists of prescription, CAM, and OTC medications for self-administering residents.
183e - Expired and damaged medications were found in medication carts on the 2nd floor and secured dementia care unit.
185a - Medications prescribed as needed were not available in the home when required.
187b - Medication administration records lacked initials of staff administering medications at the time of administration.
187d - Prescriber's orders were not followed; required vital signs were not checked before medication administration and some medications were unavailable.
191 - Residents were not educated on their right to question or refuse medications if they believed there was a medication error.
224a - Preadmission screenings were completed after resident admission dates.
225a - Initial resident assessments were not completed within 15 days of admission.
225c - Additional assessments were not completed when required, including after transfer to secured dementia care unit.
227a - Written support plans were not developed and implemented within 30 days of admission.
231c - Written cognitive preadmission screenings for secured dementia care unit residents were not completed within 72 hours prior to admission.
234a - Support plans for secured dementia care unit residents were not developed or updated within 72 hours of admission or transfer.
251c - Resident medical evaluations were not completed on the Department’s current standardized forms.
Report Facts
Residents served: 110
Secured Dementia Care Unit residents served: 20
Hospice current residents: 8
Residents age 60 or older: 108
Residents with mobility need: 73
Residents diagnosed with mental illness: 3
Residents diagnosed with intellectual disability: 2
Notice — Mar 12, 2026
Date: Mar 12, 2026
Visit Reason
This document serves as a waiver approval for a direct care staff member at Rose Tree Place who does not meet the standard Pennsylvania nurse aide registry qualifications due to education obtained outside the United States.
Findings
The waiver is granted under conditions that the staff member's education is equivalent to a U.S. accredited high school diploma as determined by a professional credential evaluator, and documentation must be maintained and available upon request. The Department will review this waiver annually during inspections to ensure compliance.
Inspection Report — Nov 13, 2025
Complaint Investigation
Date: Nov 13, 2025
Visit Reason
The inspection was conducted due to a renewal and incident investigation at Rose Tree Place, a personal care home, including complaint-related issues.
Complaint Details
The complaint investigation included allegations of abuse, neglect, medication errors, and failure to follow care plans. The family provided video evidence of rough handling of a resident during transfer. Multiple incidents of choking and falls were documented with inadequate staff response. Several training deficiencies and policy violations were identified.
Findings
Multiple violations were found including failure to post required notices, inadequate staff training, medication errors, abuse incidents, unsafe storage of medications and food, and incomplete resident assessments and support plans. The facility was issued a first provisional license with mandated corrections and fines pending.
Citations (33)
82c - Poisonous materials were unlocked, unattended, and accessible to residents in memory care, including items not safely used by all residents.
191 - Resident was not educated on the right to refuse medication despite believing a medication error occurred.
42b - Resident was roughly handled during transfer causing a fall; staff failed to respond to choking and fall incidents appropriately.
41c - Resident rights poster was not posted in a conspicuous and public place in the home's memory care area.
44g - Required telephone numbers were not posted in a conspicuous and public place in the home's memory care area.
51 - Staff member did not have a criminal background check on file at time of hire.
63a - Insufficient staff certified in first aid and CPR were present during night shifts for the number of residents.
65f - Direct care staff did not receive required medication self-administration training during the training year.
65g - Direct care staff did not receive required emergency preparedness training during the training year.
85d - Trash receptacles in kitchens and bathrooms were uncovered and unattended, allowing insect and rodent penetration.
86b - Bathroom lacked operable window or ventilation fan; exhaust fan was inoperable.
89b - Hot water temperature in resident bathrooms exceeded 120°F, measuring up to 126.3°F.
91 - Emergency telephone numbers including nearest hospital and fire department were not posted by telephones.
103g - Food was stored in opened and unsealed containers in the ice cream freezer.
103i - Unlabeled and undated frozen meats were found in the walk-in freezer.
131f - Fire extinguishers in vehicle and near resident rooms had not been inspected since October 2024.
162c - Weekly menus were not posted in a conspicuous and public place in the home's memory care area.
181f - Resident medication records did not include current lists of prescription, CAM, and OTC medications.
183b - Overstock medication cart was unlocked, unattended, and accessible in an alcove.
183d - Medications in the medication cart were not current; some were discontinued or not on current orders.
183e - Medication blister packs were punctured and taped, compromising medication integrity.
185a - Medications prescribed to residents were not available in the home as needed.
186b - Medication with a note indicating it was being used improperly was found included with resident's medications.
187d - Medications were not administered as prescribed due to unavailability and incorrect timing.
225a - Initial resident assessment was not completed within 15 days of admission.
227g - Residents participated in support plan development but did not sign the support plans.
231c - Written cognitive preadmission screening was not completed within 72 hours prior to admission to secured dementia care unit.
231e - Documentation that resident and designated person did not object to admission to secured dementia care unit was missing.
234a - Initial support plan was not completed within 72 hours of admission to secured dementia care unit.
234e - Resident or designated person was not involved in development or revision of support plan.
252 - Resident records did not include copies of death certificates when applicable.
121a - Snow blocked egress from the secured dementia care unit through the courtyard.
23a - Resident requiring two-person assistance for transfer received assistance from only one staff member.
Report Facts
Fine amount: 550
Fine amount: 330
Residents served: 102
Residents served: 114
Total daily staff: 189
Waking staff: 142
Residents served in secured dementia care unit: 21
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff Person A | Named in abuse incident involving rough handling of resident during transfer | |
| Staff Person B | Named in failure to respond to resident fall and choking incidents | |
| Staff Person C | Named for lacking criminal background check at time of hire | |
| Staff Person D | Named for missing medication self-administration and emergency preparedness training | |
| Staff Person E | Named for missing emergency preparedness training | |
| Director of Nursing | Director of Nursing | Responsible for staff training, medication management, and investigation of abuse incidents |
| Administrator | Administrator | Responsible for overall facility compliance, staff training, and monitoring |
| Dining Director | Dining Director | Responsible for food storage and sanitation compliance |
| Memory Care Director | Memory Care Director | Responsible for secured dementia care unit compliance and resident care plans |
| Program Coordinator | Responsible for resident support plan audits and documentation | |
| HR Director | HR Director | Responsible for staff training record reviews |
| Move In Coordinator | Responsible for verifying non-objection documentation for secured dementia care unit admissions | |
| DON/LPN Supervisors | Responsible for medication administration monitoring |
Notice — Nov 7, 2025
Date: Nov 7, 2025
Visit Reason
The document serves to notify the facility that a waiver request to waive the high school diploma or GED requirement for a direct care staff person has been granted under Pennsylvania Code 55 Pa.Code § 2600.19.
Findings
The waiver is granted with conditions that the staff member's education is equivalent to a U.S. high school diploma as determined by a professional credential evaluator, and documentation must be maintained and made available upon request. 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. |
Notice — Sep 15, 2025
Date: Sep 15, 2025
Visit Reason
This document serves to notify the approval of a waiver request for a direct care staff person at Rose Tree Place who received their education outside the United States, exempting them from the high school diploma or GED requirement under 55 Pa.Code § 2600.54(a)(2).
Findings
The waiver is granted with conditions requiring documentation of education equivalency to be maintained and made available upon request. 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 — Dec 3, 2024
Renewal
Date: Dec 3, 2024
Visit Reason
The inspection was an unannounced full renewal inspection conducted on 12/03/2024 and 12/04/2024 to review compliance with licensing requirements.
Findings
The facility was found to have multiple deficiencies including failure to post current license documents, unsigned resident-home contracts, delayed refunds after resident deaths, missing signed resident rights statements, incomplete staff training, unlocked poisonous materials accessible to residents, inoperable bedside lamps, incomplete medication records, lack of resident education on medication refusal rights, incomplete resident-home contract disclosures, and insufficient dementia care training hours for staff.
Citations (11)
The home's current violation report was not posted in a conspicuous and public place.
Resident-home contracts for residents #1, #2, and #3 were not signed by the residents.
Refunds to estates for deceased residents #4 and #5 were not processed within required timeframes.
Residents #1, #2, and #3's records lacked signed statements acknowledging receipt of resident rights and complaint procedures.
Direct care staff persons A, C, and D did not receive required training in meeting resident needs, medication self-administration, emergency preparedness, and dementia care during 2023.
Poisonous materials were unlocked and accessible to residents in the memory care unit.
Bedside lamps in rooms 109 and 209 were missing or not working, leaving residents without operable lighting at bedside.
Resident #6 and #7 medication records did not include all current medications present in their rooms.
Residents #1, #2, and #3 were not educated on their right to refuse medication if they believed there was a medication error.
Resident-home contracts for residents #2 and #3 lacked disclosure of services offered in the secured dementia care unit.
Direct care staff persons A and D working in the secured dementia care unit had less than the required 6 hours of dementia care training during 2023.
Report Facts
Residents Served: 94
Residents in Secured Dementia Care Unit: 21
Current Hospice Residents: 2
Direct Care Staff Training Hours Deficiency: 5
Total Daily Staff: 162
Waking Staff: 122
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Resident #1 | Resident | Named in findings related to unsigned contracts, missing signed resident rights statements, and lack of medication refusal education. |
| Resident #2 | Resident | Named in findings related to unsigned contracts, missing signed resident rights statements, lack of medication refusal education, and incomplete resident-home contract disclosures. |
| Resident #3 | Resident | Named in findings related to unsigned contracts, missing signed resident rights statements, lack of medication refusal education, and incomplete resident-home contract disclosures. |
| Resident #4 | Resident | Named in findings related to delayed refund processing after death. |
| Resident #5 | Resident | Named in findings related to delayed refund processing after death. |
| Resident #6 | Resident | Named in findings related to incomplete medication records. |
| Resident #7 | Resident | Named in findings related to incomplete medication records. |
| Direct Care Staff Person A | Direct Care Staff | Named in findings related to incomplete training in resident needs and dementia care. |
| Direct Care Staff Person C | Direct Care Staff | Named in findings related to incomplete training in medication self-administration and emergency preparedness. |
| Direct Care Staff Person D | Direct Care Staff | Named in findings related to incomplete training in resident needs, emergency preparedness, and dementia care. |
Inspection Report — Jun 21, 2023
Follow-Up
Date: Jun 21, 2023
Visit Reason
The inspection visit on 06/21/2023 was a partial, unannounced review conducted due to an incident, with a follow-up type of Plan of Correction (POC) submission.
Findings
The inspection found deficiencies in resident record content, specifically missing race, color of hair, color of eyes, and incident reports for individual residents. The submitted plan of correction was determined to be fully implemented as of the review date.
Citations (2)
Resident 1's record does not include race, color of hair, color of eyes and a record of incident reports for the individual resident.
Resident 2's record does not include race and a record of incident reports for the individual resident.
Report Facts
Residents Served: 91
Secured Dementia Care Unit Residents Served: 23
Hospice Current Residents: 3
Residents Age 60 or Older: 90
Residents Diagnosed with Mental Illness: 2
Residents with Mobility Need: 64
Residents with Physical Disability: 1
Inspection Report — Jul 20, 2022
Renewal
Date: Jul 20, 2022
Visit Reason
The inspection was an unannounced full renewal inspection conducted on 07/20/2022 and 07/21/2022 to review compliance with licensing requirements.
Findings
The inspection identified multiple deficiencies including lack of carbon monoxide detectors near gas appliances, unlocked poisonous materials accessible to residents, improper refrigerator/freezer temperatures, uncovered food items, outdated or unlabeled food, missing emergency procedure submissions, missed fire drills, medication labeling errors, inaccurate glucometer readings, incomplete preadmission screening and support plans, and incomplete resident record content. All deficiencies had plans of correction submitted and were implemented by 01/13/2023.
Citations (15)
No carbon monoxide detectors located in the area of the kitchen near gas operated stove.
Toothpaste and disinfectant wipes with poison label were unlocked and accessible in resident room of secure dementia care unit.
Temperature in ice cream freezer was above required temperature (10°F and 8°F).
Uncovered ice cream tub in ice cream freezer.
Unlabeled and undated food item (20oz Wawa cup) in pathways fridge.
Written emergency procedures not submitted to local emergency management agency in 2021 and 2022.
Unannounced fire drills not held during months of January 2022 and May 2022.
Medication labels did not match prescribed orders for Resident #1.
Glucometer reading for Resident #1 was inaccurate (139 documented as 135).
Resident #2 admitted without completed preadmission screening form.
Resident #3 support plan was not signed by resident and assessor.
Resident #2 admitted to secured dementia care unit without completed cognitive preadmission screening.
Resident #2 and designated person did not have documentation of no objection to admission to secured dementia care unit.
Resident #2's initial support plan was not completed within required timeframe.
Resident records missing eye color and hair color information.
Report Facts
Residents Served: 81
Secured Dementia Care Unit Residents Served: 18
Hospice Residents: 7
Total Daily Staff: 134
Waking Staff: 101
Mobility Need Residents: 53
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Maintenance | Named in corrective action for carbon monoxide alarms. | |
| Dining Director | Responsible for refrigerator/freezer temperature compliance and food storage. | |
| Program Directors (Memory Care) | Responsible for securing poisonous materials and resident room inspections. | |
| LPN | Responsible for verifying prescription orders with pharmacy. | |
| DON | Director of Nursing | Responsible for auditing glucometers and reviewing preadmission screenings. |
| Program Coordinator | Responsible for medication compliance, support plans, and resident record content. | |
| Executive Director | Responsible for emergency procedure submission and review of support plans. | |
| Maintenance Coordinator | Responsible for scheduling monthly fire drills. |
Inspection Report — Feb 18, 2022
Follow-Up
Date: Feb 18, 2022
Visit Reason
The inspection was an unannounced partial review conducted due to an incident at the facility.
Findings
The inspection found multiple violations related to supervision, abuse, restraints, and positive interventions involving a staff person forcibly moving a resident and pulling their hair. The facility submitted plans of correction and investigations found no violations, with the staff member returning to work. Training and resident interviews were directed to ensure compliance.
Citations (5)
Staff person A restrained and pulled resident 1's hair while attempting to force them to get up off the sofa to go to sleep.
Resident 1 was physically and verbally abused by staff person A who forced the resident to move and pulled their hair causing pain.
Resident 1 was held in a hugging position restraining their arms and forcibly moved off the sofa by staff person A.
Failure to implement positive interventions to modify or eliminate resident 1's behavior; staff person A used force instead.
Use of prohibited restraints including manual restraint and mechanical restraint techniques by staff person A on resident 1.
Report Facts
Residents Served: 69
Secured Dementia Care Unit Residents Served: 17
Current Hospice Residents: 7
Residents Age 60 or Older: 69
Residents with Mental Illness: 3
Residents with Physical Disability: 1
Residents with Mobility Need: 47
Notice — Sep 14, 2021
Date: Sep 14, 2021
Visit Reason
This document serves as a renewal notification and license issuance for the Personal Care Home 'Rose Tree Place' following receipt of the renewal application on September 9, 2021.
Findings
The Department issued a regular license in response to the renewal application and advised that an annual onsite inspection will be conducted within the next twelve months to ensure compliance with applicable regulations.
Report Facts
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary, Office of Long-term Living | Signed the renewal notification letter. |
Inspection Report — Apr 5, 2021
Renewal
Date: Apr 5, 2021
Visit Reason
The inspection was conducted as a renewal review of the facility's compliance with licensing requirements on 04/05/2021 and 04/06/2021.
Findings
The inspection identified several deficiencies including failure of direct care staff to complete required training, exit door egress issues, improper calibration of glucometers, and a medical evaluation timing discrepancy for a resident in the secured dementia care unit. Plans of correction were accepted and implemented to address these issues.
Citations (4)
Direct care staff persons A and B provided unsupervised ADL services without completing the Department-approved direct care training course and competency test after CNA registration expired or since hire.
The exit door at the Southeast Stairwell #1 had a magnetic lock with keypad code not posted in a conspicuous location for easy egress.
Glucometers for residents #1 and #2 were not calibrated to the correct date and time due to daylight saving time adjustment not made.
Resident #3 was admitted to the Secure Dementia Care Unit one day before the medical evaluation was completed, which was outside the required 60 days prior to admission.
Report Facts
Residents Served: 72
Current Hospice Residents: 16
Residents Age 60 or Older: 66
Residents with Mobility Need: 54
Residents Diagnosed with Mental Illness: 3
Residents with Physical Disability: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shawn Parker | Signed the letter confirming plan of correction implementation |
Inspection Report — Feb 4, 2021
Complaint Investigation
Date: Feb 4, 2021
Visit Reason
The inspection was conducted as a complaint investigation triggered by a complaint received from the family of Resident #1.
Complaint Details
The complaint investigation was initiated based on a family complaint regarding Resident #1. The Department interviewed Resident #1 and requested a new assessment. The investigation found issues with documentation and assessments related to Resident #1's falls and ambulation.
Findings
The inspection found deficiencies related to incomplete preadmission screening documentation and inadequate additional assessments for Resident #1, who had a history of falls. The facility submitted a plan of correction including new assessments and support plans, which were implemented and accepted. The violation related to the support plan was later withdrawn.
Citations (3)
Resident #1's preadmission screening form was not dated.
Resident #1's additional assessment was outdated and did not reflect the resident's frequent falls and use of a walker.
Resident #1's support plan did not address the use of a walker under the ambulating section.
Report Facts
Residents Served: 68
Residents in Secured Dementia Care Unit: 14
Current Hospice Residents: 15
Residents Age 60 or Older: 67
Residents Diagnosed with Mental Illness: 3
Residents with Mobility Need: 43
Residents with Physical Disability: 1
Falls by Resident #1: 5
Mini-Mental State Exam Score: 29
Inspection Report — Sep 17, 2020
Complaint Investigation
Date: Sep 17, 2020
Visit Reason
The inspection was conducted as a complaint investigation with unannounced partial inspections on 09/17/2020, 09/18/2020, 09/22/2020, and 09/23/2020.
Complaint Details
The inspection was complaint-driven and unannounced. 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: 73
Secured Dementia Care Unit Residents Served: 16
Hospice Current Residents: 0
Resident Support Staff Hours: 50
Total Daily Staff: 175
Waking Staff: 131
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Susan Smith | Lead Inspector | Lead inspector for the complaint investigation |
Inspection Report — May 13, 2020
Complaint Investigation
Date: May 13, 2020
Visit Reason
The inspection was conducted as a complaint investigation with multiple off-site review dates to assess compliance and plan of correction implementation.
Complaint Details
The inspection was complaint-driven and included multiple off-site reviews and follow-ups. The plan of correction was accepted and fully implemented.
Findings
The facility was found to have medication administration record deficiencies related to Resident #1, including missing diagnosis/purpose for medication and delayed administration of prescribed medication. The submitted plan of correction was accepted and fully implemented.
Citations (2)
187a - Medication Record: Resident #1's medication administration record did not indicate the diagnosis or purpose for Zithromax 500 mg.
187d - Follow Prescriber's Orders: Resident #1 was prescribed Zithromax 500 mg once daily starting 4/3/2020 but was not administered the medication until 4/7/2020.
Report Facts
Residents Served: 87
Residents Served in Secured Dementia Care Unit: 20
Current Hospice Residents: 8
Residents Age 60 or Older: 87
Residents with Mobility Need: 60
Residents with Physical Disability: 2
Residents Diagnosed with Mental Illness: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cynthia Evans | Administrator | Named as facility administrator |
| Denise Gillespie | Lead Inspector | Lead inspector for the complaint investigation |
| Claire Mendez | Human Services Licensing Supervisor | Reviewer and supervisor involved in plan of correction acceptance and follow-up |
Notice — Apr 28, 2020
Date: Apr 28, 2020
Visit Reason
This document serves as a renewal approval notice for the Personal Care Home license of Rose Tree Place, confirming the facility's compliance and outlining the requirement for an annual onsite inspection within the next twelve months.
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 — Jan 2, 2020
Routine
Date: Jan 2, 2020
Visit Reason
The Department’s Bureau of Human Services Licensing Representatives conducted an inspection of the facility on January 2, 2020.
Findings
No regulatory citations with 55 Pa. Code Ch. 2600 relating to Personal Care Homes were identified as a result of this inspection.
Inspection Report — Sep 4, 2019
Renewal
Date: Sep 4, 2019
Visit Reason
The inspection was an annual renewal inspection conducted by the Department’s Bureau of Human Services Licensing on September 4, 5, 18, and December 5, 2019, to assess compliance with 55 Pa. Code Ch. 2600 relating to Personal Care Homes.
Findings
Multiple violations of the Pennsylvania Personal Care Homes regulations were found, including denial of access to Department agents, failure to report suspected resident abuse, inadequate oxygen tank management, lack of criminal background checks for contractors, insufficient direct care staffing hours, untimely dining service, incomplete staff training plans, medication management issues, and incomplete resident assessments and support plans.
Citations (14)
2600.5.a. Staff person denied immediate access to an agent of the Department to the home's wellness center where resident's medical equipment is kept.
2600.42.b. Resident #1 was brought to dining room without oxygen tank, causing distress; resident has mobility needs and dementia requiring bed sheet changes.
2600.52. The home had contractors working without criminal background checks as required by regulations.
2600.57.c. On August 28, 2019, only 197 hours of direct care staffing were provided instead of the required 201 hours for 129 residents with mobility needs.
2600.60.c. Dining service was not timely on September 18, 2019; food was served cold and some residents left without eating due to long wait.
2600.66.b. Staff training plan lacked names of courses, job titles of staff taking training, and training locations.
2600.85.a. Medication residue and spillage were found on the medication cart on September 5, 2019.
2600.187.a. Resident #4's over-the-counter medications were not on the medication administration record.
2600.187.b. OTC medication of resident #4 was on a Microsoft Word document and not signed on the MAR at administration times.
2600.187.d. Resident #3 self-administered melatonin 5mg nightly but was prescribed 3mg; medication administration was reassessed and corrected.
2600.225.c. Resident #1's assessment did not include care for oxygen therapy; resident #3's assessment did not reflect medication assistance needs.
2600.227.d. Resident #3's support plan did not document how medication assistance needs would be met.
2600.183.e. On December 5, 2019, a small white round tablet was found loose in the 3rd floor medication cart.
2600.185.b. On November 11, 2019, resident #1 was administered Lorazepam at 10pm; medication was not logged on the declining inventory narcotics log as required.
Report Facts
Residents Served: 129
Residents Served: 130
Residents Served: 26
Direct Care Staffing Hours Required: 201
Direct Care Staffing Hours Provided: 197
Residents with Mobility Needs: 72
Residents Age 60 or Older: 129
Residents Diagnosed with Mental Illness: 3
Residents Diagnosed with Intellectual Disability: 0
Residents with Physical Disability: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cynthia Evans | Executive Director | Signed multiple violation reports and plans of correction |
| Michele Swisher | On-site Department representative for December 5, 2019 inspection |
Inspection Report — Mar 12, 2019
Renewal
Date: Mar 12, 2019
Visit Reason
The document is a renewal application and license issuance for Rose Tree Place Personal Care Home. The Department received the renewal application and will conduct an onsite inspection 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 for the facility following the renewal application.
Report Facts
Inspection Report — Sep 5, 2018
Renewal
Date: Sep 5, 2018
Visit Reason
The inspection was a renewal licensing inspection conducted by the Pennsylvania Department of Human Services Bureau of Human Services Licensing on September 5 and 6, 2018.
Findings
The inspection found violations related to criminal background checks and emergency telephone number postings. Plans of correction were submitted to address these issues and prevent recurrence.
Citations (2)
Regulation 2600.51 requires criminal history checks and hiring policies in accordance with the Older Adult Protective Services Act. Staff person A was hired on 11/6/2017 without a timely criminal background check.
Regulation 2600.91 requires emergency telephone numbers to be posted by each telephone. The telephone in resident #1's bedroom did not have emergency numbers posted nearby.
Report Facts
Number of Residents Served: 126
Number of Current Hospice Residents: 10
Number of Hospice Residents in past year: 31
Number of Residents Age 60 or Older: 124
Number of Residents with Mental Illness: 2
Number of Residents with Mobility Needs: 88
Number of Residents with Physical Disability: 1
Number of Residents Served in Secured Dementia Care Unit: 23
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cynthia L. Evans | Executive Director | Named as legal entity representative and responsible for monitoring and compliance in plans of correction. |
| Sabrina Freeman | Department representative present on-site during inspection. | |
| Tahesla Thomas | Department representative present on-site during inspection. |
Notice — Apr 6, 2018
Date: Apr 6, 2018
Visit Reason
The document serves as a renewal notice and license issuance for the Personal Care Home 'Rose Tree Place' following a renewal application submitted on March 6, 2018. It also informs the facility 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 letter confirming license renewal and outlining inspection requirements.
Report Facts
Inspection Report — Mar 14, 2018
Routine
Date: Mar 14, 2018
Visit Reason
The Department's Bureau of Human Services Licensing representatives conducted an inspection of the facility on March 14, 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 — Sep 28, 2017
Routine
Date: Sep 28, 2017
Visit Reason
The Department of Human Services licensing representative conducted an inspection of the facility on 9/28/2017.
Findings
No regulatory violations were identified as a result of this inspection.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sandra Wooters | Regional Licensing Director | Signed the inspection report letter. |
Notice — Mar 10, 2017
Date: Mar 10, 2017
Visit Reason
The document serves as a renewal notification and license issuance for the Personal Care Home 'Rose Tree Place' following receipt of a renewal application.
Findings
The Department will conduct an onsite annual inspection within the next twelve months to ensure compliance with Title 55, PA Code, Chapter 2600. No findings or deficiencies are reported in this document.
Report Facts
Inspection Report — Mar 1, 2017
Renewal
Date: Mar 1, 2017
Visit Reason
The inspection was conducted as a renewal licensing inspection of the Personal Care Home Rose Tree Place on March 1 and 2, 2017.
Findings
The inspection identified violations related to medication labeling and medication administration records. The facility submitted plans of correction and was in the process of implementing corrective actions.
Citations (3)
2600.184(a) - The original container for prescription medications must be labeled with the resident's name, medication name, prescription date, dosage instructions, and prescriber information. The label for resident #1's Xtandi medication did not include the resident's name, dosage, or administration instructions.
2600.187(a) - Medication records must include resident name, drug allergies, medication name, strength, dosage form, dose, route, frequency, administration times, duration, special precautions, diagnosis, date/time of administration, and staff initials. Medication administration records for residents #1, #2, and #3 contained discrepancies and missing information.
2600.187(d) - The home must follow the directions of the prescriber. Resident #1's Gabapentin medication label did not match the MAR, and resident #3's Acetaminophen medication was discontinued but not removed from the medication cart.
Report Facts
Number of Residents Served: 128
Number of Current Hospice Residents: 13
Number of Hospice Residents in Past Year: 17
Number of Residents Age 60 or Older: 127
Number of Residents with Mental Illness: 3
Number of Residents with Mobility Need: 83
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cynthia Evans | Executive Director | Named in signature on violation report and plan of correction |
Inspection Report — Jun 29, 2016
Renewal
Date: Jun 29, 2016
Visit Reason
The inspection was a licensing inspection conducted by the Pennsylvania Department of Human Services on June 29, 2016, to assess compliance with 55 Pa.Code Chapter 2600 for Personal Care Homes.
Findings
Multiple violations were found related to resident dignity, freedom from restraints, medication self-administration, and medication administration services. Residents were confined to their rooms due to bed bug infestation and were temporarily relocated. Medication administration policies and procedures were not properly followed during the temporary relocation.
Citations (5)
55 Pa.Code §2600.42(c) - Residents #1 and #2 were confined to their room from 6/25/16 to 6/29/16 due to bed bugs and were treated as contagious without inclusion in decision making.
55 Pa.Code §2600.42(p) - Residents #1 and #2 were confined to their room due to bed bugs, and staff contact with residents was limited during this period.
55 Pa.Code §2600.181(c)(1) - Residents #1 and #2 were temporarily lodged at a local motel during bed bug treatment and self-administered medications; neither could self-administer properly.
55 Pa.Code §2600.182(a) - The home did not provide medication administration services for residents unable or choosing not to self-administer medications during temporary lodging.
55 Pa.Code §2600.183(a)(1) - Residents #1 and #2's medications were repackaged and placed in daily pill boxes during temporary lodging, contrary to regulation.
Report Facts
Number of Residents Served: 131
Number of Residents Age 60 or Older: 130
Number of Residents with Mental Illness: 3
Number of Residents with Mobility Need: 84
Number of Residents with Physical Disability: 1
Number of Residents Served in Secured Dementia Care Unit: 20
Number of Current Hospice Residents: 9
Number of Hospice Residents in Past Year: 19
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cynthia Evans | Administrator | Named as facility administrator on page 2. |
| Patricia Adams | Human Services Licensing Supervisor | Department representative conducting inspection on pages 1 and 2. |
| Lindsey Evans | Executive Director | Signed multiple violation reports and plans of correction on pages 2-12. |
Inspection Report — May 6, 2016
Renewal
Date: May 6, 2016
Visit Reason
This document is a renewal license issued to Watermark Operator, LLC for Rose Tree Place Personal Care Home. The Department received a renewal application on March 11, 2016, and advises that an annual onsite inspection will be conducted within the next twelve months.
Findings
No inspection findings are reported in this document. It serves as a license renewal notification and outlines the requirement for an annual inspection within the next year.
Report Facts
Inspection Report — Mar 23, 2016
Annual Inspection
Date: Mar 23, 2016
Visit Reason
The inspection was conducted as an annual licensing inspection for Rose Tree Place on March 23 and 24, 2016, to assess compliance with 55 Pa.Code Chapter 2600 regulations for Personal Care Homes.
Findings
Multiple violations were found related to expired boiler certification, safety hazards such as lack of non-skid surfaces and grab bars, improper labeling of shower equipment, and medication administration documentation errors. Plans of correction were submitted and partially implemented as of April 2016.
Citations (6)
The home's Certificate of Boiler or Pressure Vessel Operation expired on 11/14/2015 and was not reinspected until 03/16/2016.
The rug in the front bathroom of room #338 did not have a non-skid surface, posing a slipping/tripping hazard.
There were no grab bars or assist bars at the toilets in the two bathrooms located in room #338.
There was an unlabeled mesh shower pouf located in the shared shower of room #111.
Blood glucose levels documented in residents' MARs did not match the readings in the glucometer for multiple dates and residents.
Resident #1, #3, and #4 did not receive ordered accuchecks or medications as prescribed, with missing accuchecks and missed doses documented.
Report Facts
Number of Residents Served: 127
Number of Current Hospice Residents: 10
Number of Residents 60 Years or Older: 128
Number of Residents with Mental Illness: 3
Number of Residents with Mobility Need: 82
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cindy Evans | Executive Director | Named as responsible party for multiple plans of correction and signed the POCs. |
Document — July 7, 2026
Date: July 7, 2026
Visit Reason
This document is an invoice for a Class II fine assessment issued to Rose Tree Place under 55 PA Code § 2600.
Findings
The invoice details a fine amount of $8,250.00 assessed between 6/12/2026 and 6/26/2026. It includes payment history and instructions for remittance.
Report Facts
Fine amount: 8250
Balance from last invoice: 11000
Payments since last invoice: 11000
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