11 Reports
Inspection Report — Jul 16, 2026
Date: Jul 16, 2026
Visit Reason
The inspection was a partial, unannounced visit conducted due to an incident at the facility.
Findings
No regulatory citations or deficiencies were identified during this inspection.
Report Facts
Residents served: 41
Current Hospice Residents: 7
Inspection Report — Mar 17, 2026
Renewal
Date: Mar 17, 2026
Visit Reason
The inspection was conducted as a renewal visit to assess compliance with licensing requirements for the facility.
Findings
No regulatory citations or deficiencies were identified during the inspection.
Report Facts
Residents served: 42
Current Hospice Residents: 7
Total Daily Staff: 48
Waking Staff: 36
Residents 60 Years or Older: 42
Residents with Mobility Need: 6
Residents with Physical Disability: 1
Inspection Report — Nov 18, 2025
Date: Nov 18, 2025
Visit Reason
The inspection was an unannounced partial licensing inspection conducted as an interim review by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing.
Findings
No regulatory citations or deficiencies were identified during this inspection.
Report Facts
Residents Served: 41
Current Hospice Residents: 5
Residents Age 60 or Older: 41
Residents with Mobility Need: 6
Inspection Report — Jul 15, 2025
Follow-Up
Date: Jul 15, 2025
Visit Reason
The inspection was a follow-up review to verify the implementation of a previously submitted plan of correction related to incidents and fall management at the facility.
Findings
The submitted plan of correction was determined to be fully implemented. The facility provided education to staff on fall management, changes in condition, and consent for treatment policies, and established ongoing reviews and audits to ensure compliance and timely medical interventions.
Citations (2)
42b Abuse/Neglect: A resident experienced multiple unwitnessed falls resulting in serious injury and decline in condition. Staff failed to prevent neglect and timely respond to the resident's needs.
142d Consent for treatment: The facility did not make reasonable efforts to obtain consent for treatment from the resident or designated person until after a serious medical event occurred following an unwitnessed fall.
Report Facts
Residents Served: 43
Unwitnessed falls: 13
Inspection Report — Mar 21, 2025
Renewal
Date: Mar 21, 2025
Visit Reason
The inspection was conducted as a renewal inspection of the facility's license.
Findings
No regulatory citations or deficiencies were identified during this licensing inspection.
Report Facts
Residents Served: 45
Current Residents in Hospice: 8
Residents Age 60 or Older: 45
Residents Diagnosed with Mental Illness: 2
Residents with Mobility Need: 10
Total Daily Staff: 55
Waking Staff: 41
Notice — Sep 10, 2024
Date: Sep 10, 2024
Visit Reason
This 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 residence.
Findings
The waiver outlines the training requirements for direct care staff administering GLP-1 agonist injections, including completion of Department-approved medication administration courses, in-person training by licensed healthcare professionals, and annual training hours. It also mandates policies for monitoring, documentation, and availability of clinical contacts.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Theresa Hartman | Bureau Director, Human Services Licensing | Signed the waiver approval letter. |
Inspection Report — Jan 11, 2024
Renewal
Date: Jan 11, 2024
Visit Reason
The inspection was conducted as a renewal licensing inspection of the Southwoods AL facility by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing.
Findings
No regulatory citations or deficiencies were identified during the inspection conducted on 01/11/2024.
Report Facts
Residents Served: 41
Current Hospice Residents: 3
Residents Age 60 or Older: 41
Residents with Mobility Need: 6
Resident Support Staff: 0
Total Daily Staff: 47
Waking Staff: 35
Inspection Report — Nov 2, 2023
Follow-Up
Date: Nov 2, 2023
Visit Reason
The inspection visit on 11/02/2023 was a partial, unannounced follow-up inspection triggered by a complaint and incident to verify the implementation of a previously submitted plan of correction.
Complaint Details
The visit was complaint-related, triggered by a complaint and incident. The plan of correction was submitted and accepted, with follow-up inspections to ensure compliance.
Findings
The submitted plan of correction related to a dignity and respect violation was found to be fully implemented. The facility demonstrated compliance with the requirement that residents be treated with dignity and respect, including staff retraining and ongoing monitoring plans.
Citations (1)
Violation of dignity and respect where staff member B pushed on a resident's injured leg causing pain and yelled at the resident, and later responded inappropriately to the resident's request for mail, causing distress.
Report Facts
Residents Served: 42
Total Daily Staff: 48
Waking Staff: 36
Inspection Report — Mar 14, 2023
Renewal
Date: Mar 14, 2023
Visit Reason
The inspection was conducted as a renewal licensing inspection of the Southwoods AL facility on 03/14/2023, 03/15/2023, and 03/16/2023.
Findings
No regulatory citations or deficiencies were identified as a result of this licensing inspection.
Report Facts
Residents served: 43
Current hospice residents: 3
Residents age 60 or older: 43
Residents with mobility need: 5
Total daily staff: 48
Waking staff: 36
Inspection Report — Sep 15, 2022
Original Licensing
Date: Sep 15, 2022
Visit Reason
The inspection was conducted due to a change in the legal entity operating the assisted living facility, Southwoods Assisted Living, to assess compliance with licensing regulations.
Findings
The facility was found to be in substantial compliance with applicable regulations, but the licensing inspector was unable to complete a full inspection because this is a new legal entity operating the home. No deficiencies were found during this partial inspection.
Report Facts
Total Daily Staff: 51
Waking Staff: 38
Residents Served: 43
Current Residents in Hospice: 6
Residents Age 60 or Older: 43
Residents with Mobility Need: 8
Inspection Report — Sep 15, 2022
Original Licensing
Date: Sep 15, 2022
Visit Reason
The inspection was conducted as part of the licensing process for a new legal entity operating the assisted living facility.
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 three months of the license effective date.
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