Inspection Reports for
Spring Mill Pointe
2002 Joshua Rd, Lafayette Hill, PA 19444, United States, PA, 19444
Back to Facility Profile19 Reports
Inspection Report — Aug 6, 2025
Renewal
Date: Aug 6, 2025
Visit Reason
The inspection was conducted as a renewal inspection of the facility's license.
Findings
The inspection found several deficiencies including uncovered trash outside, improperly stored food, missing posted menus for the upcoming week, and a medication labeling error. The facility submitted and fully implemented a plan of correction to address these issues.
Citations (4)
Trash outside the home was not kept in covered receptacles, with debris found next to an open dumpster.
Food was not stored in closed or sealed containers; lids on five of eight ice-cream cartons were not securely fastened.
Menus for the upcoming week were not posted as required; the menu for the week starting 8/11/25 was missing.
A resident's prescription medication label had incorrect administration instructions differing from the prescription.
Report Facts
Residents Served: 43
Residents Served in Secured Dementia Care Unit: 22
Current Hospice Residents: 5
Residents with Mobility Need: 24
Total Daily Staff: 67
Waking Staff: 50
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Building and Grounds | Educated on trash regulation and responsible for daily dumpster inspections | |
| Director of Dining Services | Educated on food storage and menu posting regulations; responsible for inspections | |
| Administrator | Educated dining team on food storage regulation | |
| Director of Resident Services | Responsible for monthly medication cart audits | |
| Charge Nurse | Responsible for monthly medication cart audits |
Inspection Report — Sep 25, 2024
Renewal
Date: Sep 25, 2024
Visit Reason
The inspection was conducted as a renewal visit to review the facility's compliance and licensing status.
Findings
The submitted plan of correction was determined to be fully implemented. Deficiencies were identified related to contract signatures, bedside lighting, and medication storage, all of which had corrective actions accepted and implemented.
Citations (3)
The resident-home contract for residents #1 and #2 was not signed by the residents.
Resident #2 did not have access to a source of light that can be turned on/off at bedside.
Medication cards for residents #3, #4, and #5 were observed to have punctured blister foil with medication still present.
Report Facts
Residents Served: 45
Secured Dementia Care Unit Residents Served: 27
Hospice Current Residents: 3
Residents Age 60 or Older: 45
Residents with Mobility Need: 29
Total Daily Staff: 74
Waking Staff: 56
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Resident Services | Involved in discarding and reordering medications and re-education on medication storage regulation | |
| Nurse | Assisted in discarding medication for resident #5 | |
| Administrator | Re-educated on contract signature regulation and responsible for auditing resident contracts | |
| Director of Sales | Re-educated on contract signature regulation | |
| Director of Building and Grounds | Educated on bedside lamp regulation | |
| Resident Services Coordinator | Responsible for conducting audits related to bedside lamp and medication storage compliance |
Inspection Report — May 24, 2023
Renewal
Date: May 24, 2023
Visit Reason
The inspection was conducted as a renewal visit to review compliance and verify the submitted plan of correction for the facility.
Findings
The facility was found to have several deficiencies related to evacuation times, medication labeling and administration, resident assessments, medical evaluations, and admission support plans. All deficiencies had plans of correction submitted and were determined to be fully implemented by the follow-up dates.
Citations (6)
During the fire drill on 10/25/22 at 9:40AM, it took 7 minutes to evacuate the home, exceeding the maximum safe evacuation time of 6 minutes specified by a fire safety expert.
Resident 1's medication label and controlled substance log times did not match the prescribed administration times.
Resident 1’s controlled substance log did not include the initials of the staff person who administered medication on 5/24/23 at 1:11PM.
Resident 3’s initial assessment was not completed within 15 days of admission.
Resident 3’s medical evaluation did not include the need for the resident to be served in a secured dementia care unit.
Resident 3’s initial support plan was not completed within 72 hours of admission to the secured dementia care unit.
Report Facts
Residents Served: 47
Secured Dementia Care Unit Residents Served: 27
Hospice Current Residents: 4
Residents Age 60 or Older: 47
Residents with Mobility Need: 27
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Resident Services | Named in multiple findings related to medication labeling, medication administration, resident assessments, medical evaluations, and admission support plans. | |
| Administrator | Provided training and education related to evacuation drill deficiencies and resident assessments. | |
| Director of Building and Grounds | Received training regarding evacuation drill regulations and responsible for reporting evacuation drill durations. |
Inspection Report — Jan 9, 2023
Follow-Up
Date: Jan 9, 2023
Visit Reason
The inspection visit on 01/09/2023 was a partial, unannounced review triggered by an incident to verify the implementation of a previously submitted plan of correction.
Findings
The submitted plan of correction was determined to be fully implemented. Deficiencies included issues with contract signatures, signed statements acknowledging receipt of resident rights, treatment of residents without consent, labeling of over-the-counter medications, and resident education on the right to refuse medication. Corrective actions and staff education were completed and ongoing monitoring was planned.
Citations (5)
The resident-home contract for resident #1 was not signed by the resident.
Resident #1's record did not contain a signed statement acknowledging receipt of resident rights and complaint procedures.
Staff person A treated resident #1 with diaper change and barrier cream despite resident refusal, causing distress.
A bottle of cough syrup in the memory care medication cart was not labeled with a resident's name.
Resident #1 had not been educated on the right to refuse medication if a medication error is suspected.
Report Facts
Residents Served: 46
Secured Dementia Care Unit Residents Served: 24
Hospice Current Residents: 2
Resident Support Staff: 106
Total Daily Staff: 176
Waking Staff: 132
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Sales | Educated on policies related to contract signatures, signed statements, and resident education | |
| Administrator | Reviewed contracts and responsible for monthly contract reviews and reporting to QAPI | |
| Nurse Supervisor | Will interview random team members monthly to review compliance with treatment of residents |
Notice — Oct 19, 2021
Date: Oct 19, 2021
Visit Reason
The document serves as a renewal notification and issuance of a regular license for the Personal Care Home 'Spring Mill Pointe' following receipt of the renewal application dated October 19, 2021.
Findings
No inspection findings are reported; the document confirms the issuance of a regular license and advises that an onsite inspection will be conducted within the next twelve months as required by regulation.
Report Facts
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary, Office of Long-term Living | Signed the renewal notification letter |
Inspection Report — Sep 8, 2021
Renewal
Date: Sep 8, 2021
Visit Reason
The inspection was an unannounced renewal inspection conducted on 09/08/2021 to assess compliance with licensing regulations at Spring Mill Pointe.
Findings
Multiple deficiencies were identified including privacy violations due to camera use, lack of criminal background checks for contractors, improper storage of poisonous materials, unsanitary conditions, ventilation issues, missing emergency telephone numbers, incomplete first aid kits, medication storage and labeling issues, documentation errors, and support plan signature deficiencies. Plans of correction were accepted for all findings.
Citations (18)
Camera in resident room #144 violated resident privacy.
Five contractors were in the building without criminal background checks since May 2021.
Unlabeled bottle of cleaner unsecured on housekeeping cart in Cedar Brook.
Bleach Germicidal Wipes and Flex Disinfectant Wipes unlocked and accessible to residents in memory care unit.
Sticky substances in bottom of refrigerator in memory care kitchen; strong odors and soiled clothing in resident rooms #144 and #151.
Resident rooms 144 and 151 lacked operable ventilation; exhaust fans needed repair.
No emergency telephone numbers posted by telephone in room #106.
First aid kit in memory care unit missing required items.
Memory care staff did not know location of first aid kit.
Opened and unsealed food items in refrigerator.
Two loose pills found in medication cart in memory care unit.
No pharmacy label on Medline Skintegrity wound cleanser.
Glucometer readings for resident #1 were not documented correctly on medication administration record.
Resident #2's most recent assessment date missing.
Resident #3 participated in support plan development but did not sign the plan.
Resident #3's refusal or inability to sign support plan was not documented.
Directions for operating locking mechanism not posted near door in Secure Dementia Care Unit.
Correction fluid used on resident #4's contract.
Report Facts
Residents Served: 50
Residents in Secured Dementia Care Unit: 26
Hospice Residents: 1
Contractors without background checks: 5
Inspection Report — Jun 30, 2021
Date: Jun 30, 2021
Visit Reason
The inspection was conducted as a partial, unannounced visit due to an incident.
Findings
No regulatory citations or deficiencies were identified during the inspection.
Report Facts
Residents Served: 48
Secured Dementia Care Unit Residents Served: 22
Residents Age 60 or Older: 48
Residents with Mobility Need: 27
Residents with Physical Disability: 2
Total Daily Staff: 75
Waking Staff: 56
Inspection Report — Nov 19, 2020
Renewal
Date: Nov 19, 2020
Visit Reason
The inspection was a renewal visit conducted by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing to review compliance and licensing status of Spring Mill Pointe.
Findings
The inspection identified multiple deficiencies related to privacy signage, sanitary conditions, refrigerator/freezer temperatures, menu accuracy, medication labeling, medication storage procedures, and medication record completeness. Plans of correction were accepted and documented as implemented.
Citations (7)
42s - Privacy: Cameras in public areas lacked proper signage indicating video recording in Cedar Grove and on the second floor.
85a - Sanitary Conditions: Resident #1's glucometer was not working and had outdated readings as of 11/13/2020.
103f - Refrigerator/Freezer Temps: Ice cream freezer thermometer showed 22°F, exceeding required temperature of 40°F or below.
162c - Menus Posted: The posted menu titled 'Spring Menu' did not accurately reflect the meals being served.
184a - Labeling OTC/CAM: Resident #2's medication labels did not match the medication administration record directions.
185a - Implement Storage Procedures: Resident #1's glucometer was not set to the correct date and time.
187a - Medication Record: Residents #1 and #3's medication administration records lacked diagnosis or purpose for medications, marked as 'diagnosis exempt'.
Report Facts
Residents Served: 46
Secured Dementia Care Unit Residents Served: 22
Hospice Current Residents: 1
Residents Age 60 or Older: 46
Residents with Mobility Need: 29
Notice — Oct 30, 2020
Date: Oct 30, 2020
Visit Reason
This document serves as a license renewal notification and certificate of compliance for the Personal Care Home 'Spring Mill Pointe'. It informs the facility that an annual onsite inspection will be conducted 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 and outlines the requirement for future annual inspections.
Report Facts
Notice — May 15, 2020
Date: May 15, 2020
Visit Reason
The document serves to notify the facility of a new license issuance due to a recent name change from Spring Mill Presbyterian Village to Spring Mill Pointe. The license expiration date remains unchanged.
Findings
No inspection findings are reported as this is a licensing notice related to a name change and license reissuance.
Report Facts
Notice — Sep 19, 2019
Date: Sep 19, 2019
Visit Reason
The document serves as a renewal certificate and notification for the operation of Spring Mill Presbyterian Village as a Personal Care Home, confirming receipt of the renewal application and outlining 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 renewal notice confirming the license and the facility's capacity.
Report Facts
Inspection Report — Aug 1, 2019
Annual Inspection
Date: Aug 1, 2019
Visit Reason
The visit was the Department’s Bureau of Human Services Licensing annual inspection of the facility.
Findings
The facility was found to be in compliance with 55 Pa. Code Ch. 2600 relating to Personal Care Homes.
Inspection Report — May 30, 2019
Complaint Investigation
Date: May 30, 2019
Visit Reason
The inspection was conducted as a complaint investigation due to an incident involving resident treatment and staff qualifications at Spring Mill Presbyterian Village.
Complaint Details
The visit was complaint-related due to an incident on 05/11/19 involving staff forcibly seating and physically restraining a resident. Staff person A was suspended and terminated following the investigation.
Findings
Violations were found related to improper treatment of a resident involving forced seating and physical restraint, and a direct care staff member lacking required qualifications. Plans of correction were partially implemented as of the approval date.
Citations (3)
42c. A resident was forced to a seated position and pushed back to the dinner table against their wishes during dinner on 05/11/19.
54a. Direct care staff person B did not have a high school diploma, GED, or active registry status on the Pennsylvania nurse aide registry.
202. Staff person A physically restrained a resident by forcing her to sit in a chair and pushed the chair back to the dining table on 05/11/19.
Report Facts
Residents Served: 48
Secured Dementia Care Unit Residents Served: 21
Residents Age 60 or Older: 45
Residents with Mobility Need: 24
Total Daily Staff: 72
Waking Staff: 54
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Carisa Livingston | Administrator | Named as administrator and legal entity representative signing plans of correction |
| Mia Johnson | Human Services Licensing Supervisor | Inspection report author and approver of plan of correction |
Inspection Report — Aug 28, 2018
Renewal
Date: Aug 28, 2018
Visit Reason
The document is a renewal license issued to Spring Mill Presbyterian Village to operate a Personal Care Home. The Department of Human Services will conduct an onsite inspection within the next twelve months as part of the annual inspection requirement.
Findings
No inspection findings are reported in this document. It primarily serves as a license renewal certificate and notification letter.
Report Facts
Inspection Report — Jul 12, 2018
Routine
Date: Jul 12, 2018
Visit Reason
The Department's Bureau of Human Services Licensing representatives conducted an inspection of the facility on July 12, 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 |
|---|---|---|
| Kenneth L. Wilson | Human Services Licensing Supervisor | Signed the inspection report letter. |
Inspection Report — Jun 4, 2018
Renewal
Date: Jun 4, 2018
Visit Reason
The visit was a renewal inspection conducted by the Department's Bureau of Human Services Licensing to assess compliance with 55 Pa. Code Chapter 2600 for Personal Care Homes.
Findings
Violations of 55 Pa. Code Chapter 2600 were found during the inspection. A fire drill during sleeping hours was not conducted every six months as required, with the last drill conducted on 4/28/17 and the previous on 9/20/16.
Citations (1)
55 Pa.Code §2600.132(e) requires a fire drill during sleeping hours every six months. The last drill was conducted on 4/28/17 and the previous on 9/20/16, failing to meet the six-month requirement.
Report Facts
Number of Residents Served: 43
Total Daily Staff: 89
Waking Staff: 62
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Carisa Livingston | Administrator | Named as administrator and signed plan of correction. |
Inspection Report — Aug 29, 2017
Renewal
Date: Aug 29, 2017
Visit Reason
This document is a renewal license issued to Spring Mill Presbyterian Village to operate a Personal Care Home. It notifies 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 serves as a license renewal confirmation and notification of future inspection requirements.
Report Facts
Inspection Report — Nov 15, 2016
Annual Inspection
Date: Nov 15, 2016
Visit Reason
The inspection was an annual licensing inspection conducted by the Department of Human Services on November 15, 2016, for Spring Mill Presbyterian Village to assess compliance with 55 Pa.Code Chapter 2600 relating to Personal Care Homes.
Findings
Violations related to pre-admission screening and initial resident assessments were found. Plans of correction were developed and partially implemented to address these deficiencies.
Citations (2)
55 Pa.Code 2600.224(a) requires a determination within 30 days prior to admission documented on the preadmission screening form. The form for resident #1 admitted on 1/15 was dated 1/17/16, not meeting this requirement.
55 Pa.Code 2600.225(a) requires a written initial assessment within 15 days of admission. The initial assessment for resident #1 admitted on 6/6 was completed on 6/10/16, not within the required timeframe.
Report Facts
Number of Residents Served: 53
Total Daily Staff: 78
Walking Staff: 59
Number of Residents 60 Years or Older: 53
Number of Residents with Mental Illness: 1
Number of Residents with Mobility Need: 25
Number of Residents in Secured Dementia Care Unit: 24
Inspection Report — Sep 2, 2016
Renewal
Date: Sep 2, 2016
Visit Reason
The document is a renewal license issued to Spring Mill Presbyterian Village to operate a Personal Care Home. The Department will conduct an onsite inspection within the next twelve months as part of the renewal process.
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
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