Inspection Reports for
Spring Village at Pocono
329 EAST BROWN STREET,, EAST STROUDSBURG, PA, 19301
Back to Facility Profile32 Reports
Inspection Report — Apr 9, 2026
Renewal
Date: Apr 9, 2026
Visit Reason
The inspection was an unannounced full renewal inspection with an incident review conducted by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing.
Findings
Multiple deficiencies were identified including unsecured resident equipment, missing grab bars, lack of posted emergency procedures, obstructed egress, incomplete medical evaluations, medication errors, improper medication storage, and incomplete resident assessments and support plans. All deficiencies had accepted plans of correction and were implemented by May 18, 2026.
Citations (12)
Regulation 2600.81.b: A bed enabler was found secured only by the mattress weight and installed without facility approval. It was removed after family education.
Regulation 2600.102.d: No grab bars, handrails, or assist bars were present in the toilet area of room 307. Appropriate handrails were installed.
Regulation 2600.107.a: The local municipality’s emergency procedures were not posted in the home. A copy was obtained and posted.
Regulation 2600.121.a: A table and four chairs obstructed the fire exit door on the patio outside the dining room. The obstruction was removed.
Regulation 2600.141.a: Resident #2’s initial medical evaluation did not include an assessment of ability to self-administer medications. The evaluation was corrected immediately.
Regulation 2600.181.c: Resident #3’s annual medical assessment incorrectly stated inability to self-administer medications while medications were found at bedside. Medications were removed and families educated.
Regulation 2600.183.d: Discontinued medication for Resident #4 was found on the medication cart. Discontinued meds were removed and staff educated.
Regulation 2600.185.a: Fourteen oxygen tanks in room 218 were not properly secured. Additional storage stands were obtained and secured.
Regulation 2600.187.d: Resident #5 received only 2 units of insulin instead of 4 units as ordered. A medication error report was filed and staff educated.
Regulation 2600.224.a: Resident #6’s preadmission screening form incorrectly indicated the home could not meet the resident’s needs. The error was corrected and staff educated.
Regulation 2600.225.c: Resident #1’s annual assessment did not include the need or use of an enabler bar, which was found installed without approval and subsequently removed.
Regulation 2600.234.e: Resident #1’s annual Assessment and Support Plan was not signed or marked to indicate resident participation or refusal. Nurse was educated and audits planned.
Report Facts
Residents Served: 81
Secured Dementia Care Unit Residents Served: 37
Hospice Current Residents: 13
Residents Age 60 or Older: 81
Residents with Mobility Need: 50
Residents with Physical Disability: 1
Staff Total Daily: 131
Staff Waking: 98
Oxygen Tanks: 14
Obstruction Distance: 27
Medication Dosage Error: 2
Inspection Report — Jan 15, 2026
Complaint Investigation
Date: Jan 15, 2026
Visit Reason
The inspection was conducted as a complaint investigation to review compliance and verify the submitted plan of correction for Spring Village at Pocono.
Complaint Details
The inspection was triggered by a complaint. The submitted plan of correction was reviewed and determined to be fully implemented as of 01/15/2026.
Findings
The inspection found deficiencies related to contract signatures, unobstructed egress routes, and missing no objection statements for admission to the secured dementia care unit. The submitted plan of correction was accepted and fully implemented.
Citations (3)
Regulation 2600.25.b: The resident-home contract was not signed by the resident or did not note that the resident was given an opportunity to sign.
Regulation 2600.121.a: The door to the North Hallway stairwell in the Secured Dementia Care Unit was obstructed by a yellow strip banner with a Stop Sign, causing confusion about egress.
Regulation 2600.231.e: Resident records lacked documentation that the resident and designated person did not object to admission or transfer to the secured dementia care unit.
Report Facts
Residents Served: 85
Secured Dementia Care Unit Residents Served: 38
Hospice Current Residents: 19
Notice — Sep 17, 2025
Date: Sep 17, 2025
Visit Reason
The document serves to notify the facility that a waiver request to 55 Pa.Code § 2600.54(a)(2) regarding direct care staff qualifications has been granted.
Findings
The waiver allows a specific employee to serve in a direct care position despite not meeting the standard high school diploma or registry requirements, based on documented education obtained outside the United States. The waiver is subject to annual review during inspections and compliance with specified conditions.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Theresa Hartman | Bureau Director, Human Services Licensing | Signed the waiver approval letter. |
Inspection Report — Aug 12, 2025
Renewal
Date: Aug 12, 2025
Visit Reason
The inspection was conducted as a renewal inspection combined with a complaint investigation at Spring Village at Pocono.
Complaint Details
The inspection included a complaint investigation component, as indicated by the reason for inspection being 'Renewal, Complaint'. Specific substantiation status is not stated.
Findings
The inspection identified multiple deficiencies including issues with resident record confidentiality, contract signatures, fee schedules, staff qualifications, locking of poisonous materials, trash receptacles, room safety hazards, soap dispensers, fire extinguisher inspection, medical evaluations, medication storage and labeling, and preadmission screening. Plans of correction were accepted and implemented with follow-up dates scheduled.
Citations (17)
Resident treatment sheets and refill order forms were left unattended and accessible, violating resident record confidentiality.
Resident-home contracts were not signed or dated by some residents.
Fee schedule did not specify actual amounts charged for individual personal need services for a resident.
Direct care staff person lacked a high school diploma, GED, or active registry status on the Pennsylvania nurse aide registry.
Poisonous materials were unlocked and accessible to residents in the beauty shop and bathroom closet.
Uncovered trash can found in employee bathroom.
Tripping hazard due to cord extended from bed to wall outlet in a resident's bedroom.
Unlabeled used bar of soap found in shared resident bathroom.
Fire extinguisher in facility transport van expired and was not inspected.
Initial medical evaluations for several residents were incomplete or missing required information.
Annual medical evaluations for some residents were incomplete or missing required information.
Prescription medication (Ketoconazole shampoo) was unlocked and accessible in a resident's bathroom.
Prescription medications were stored improperly; opened insulin pens stored in refrigerator contrary to manufacturer instructions.
Resident medication lacked proper pharmacy labeling.
Over-the-counter medications and creams were not labeled with resident names.
Medication cards were opened and resealed with tape; some medications were missing from the medication cart.
Cognitive preadmission screening form for a resident was incomplete, missing date and transcriber information.
Report Facts
Residents Served: 87
Secured Dementia Care Unit Residents Served: 39
Hospice Residents: 11
Residents 60 Years or Older: 87
Residents with Mobility Need: 56
Residents with Physical Disability: 7
Inspection Dates: 2
Total Daily Staff: 143
Waking Staff: 107
Inspection Report — Mar 4, 2025
Follow-Up
Date: Mar 4, 2025
Visit Reason
The inspection was conducted due to a change in legal entity and included a follow-up review of the submitted plan of correction to verify full implementation.
Findings
The submitted plan of correction was found to be fully implemented. Deficiencies related to locking poisonous materials, lighting in the Secure Dementia Care Unit stairwell, and emergency management agency submission were addressed with corrective actions completed by mid-April 2025.
Citations (3)
Unlocked poisonous materials including Lysol wipes and sprays found accessible to residents in the memory care unit.
Lighting in the 3rd floor stairwell (Secure Dementia Care Unit) was unlit and could only be turned on from another floor.
Lack of verification that emergency procedures were reviewed annually and submitted to the local emergency management agency.
Report Facts
Residents Served: 85
Residents Served in Secured Dementia Care Unit: 38
Current Hospice Residents: 10
Residents 60 Years or Older: 84
Residents Diagnosed with Mental Illness: 5
Residents with Mobility Need: 51
Residents with Physical Disability: 7
Inspection Report — Mar 4, 2025
Re-Inspection
Date: Mar 4, 2025
Visit Reason
The inspection was conducted due to a change in legal entity and as a re-inspection within 3 months of the effective date of the new license to verify compliance with applicable regulations.
Findings
The facility was found to be in substantial compliance with 55 Pa. Code Chapter 2600 regulations. Citations were found during the inspection but the submitted plan of correction was fully implemented and compliance was maintained.
Citations (3)
2600.82c Poisonous materials were found unlocked and accessible to residents in multiple locations within the Secure Dementia Care Unit, including Lysol disinfecting wipes and sprays. The facility implemented chemical safety training and locked cabinets to secure these materials.
2600.87 Lighting in the 3rd floor stairwell of the Secure Dementia Care Unit was unlit and could only be turned on from another floor. Maintenance replaced bulbs and established monthly lighting audits.
2600.107d The facility lacked verification that emergency procedures were reviewed and submitted annually to the local emergency management agency. The emergency preparedness plan was sent certified mail and will be reviewed annually.
Report Facts
Residents Served: 85
Secure Dementia Care Unit Residents Served: 38
Hospice Current Residents: 10
Total Daily Staff: 136
Waking Staff: 102
Inspection Report — Aug 6, 2024
Renewal
Date: Aug 6, 2024
Visit Reason
The inspection was conducted as a renewal inspection of the facility's license.
Findings
The inspection found multiple deficiencies including contract signature issues, missing annual staff training, sanitary condition violations, unsecured linen room, improper food labeling, fire drill and safety inspection deficiencies, incomplete resident support plans, and missing medical evaluations for secured dementia care residents. Plans of correction were accepted and implemented for all deficiencies.
Citations (11)
Resident #2’s contract was not signed by the administrator or designee of the facility.
Staff Person “A” and Staff Person “B” did not receive the required annual training in Medication Self-Administration for the year 2023.
Blood stains were noted on Resident #1’s glucometer.
On the Secured Dementia floor, the linen room was found unlocked and the door propped open, posing a fall hazard due to an open laundry chute.
An unidentifiable container of food in the freezer on the 2nd floor had no label or date.
The refrigerator contained 2 bottles of condiments not labeled with open dates.
The most recent supervised fire drill was held on 8/6/24; the previous was on 7/1/2022, indicating a lapse in annual inspection.
Fire drill logs indicated a sleeping hour drill on 12/21/23 with 9 staff participating, but only 5 staff were scheduled, indicating inaccurate documentation.
A second sleeping hour fire drill was not conducted by 6/20/24 as required.
Residents’ support plans did not include risks and details associated with use of bed enabler bars observed in residents’ rooms.
Resident #6’s most recent medical evaluation did not document the need for secured dementia care.
Report Facts
Residents Served: 83
Secured Dementia Care Unit Residents Served: 32
Current Hospice Residents: 14
Residents Diagnosed with Mental Illness: 2
Residents with Mobility Need: 59
Residents Aged 60 or Older: 83
Residents with Physical Disability: 3
Total Daily Staff: 142
Waking Staff: 107
Resident Files Audited: All resident files audited on August 28, 2024.
Fire Drill Staff Participants: 9
Fire Drill Staff Scheduled: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lorraine Howey | Director of Nursing | Responsible for retraining staff on medication self-administration and monitoring bed enabler audits. |
| Ryan Lohman | Administrator | Revised staff training topics and oversaw contract signature compliance. |
| Li Juan Zhou | Personal Care Coordinator | Monitors daily for unapproved food in refrigerator. |
| Unnamed Executive Director | Executive Director | Schedules fire drills and monitors compliance with fire drill logs. |
| Unnamed Director of Community Relations | Director of Community Relations | Obtained missing resident contract signatures. |
Inspection Report — Jun 11, 2024
Date: Jun 11, 2024
Visit Reason
The inspection was conducted as a partial, unannounced visit due to an incident at the facility on 06/11/2024.
Findings
No regulatory citations or deficiencies were identified during this inspection.
Report Facts
Total Daily Staff: 128
Waking Staff: 96
Residents Served: 83
Secured Dementia Care Unit Residents Served: 33
Hospice Current Residents: 13
Residents Age 60 or Older: 83
Residents Diagnosed with Mental Illness: 2
Residents with Mobility Need: 45
Residents with Physical Disability: 1
Inspection Report — Jan 18, 2024
Date: Jan 18, 2024
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 as a result of the inspection conducted on 01/18/2024 and 01/29/2024.
Report Facts
Residents Served: 86
Secured Dementia Care Unit Residents Served: 37
Hospice Current Residents: 12
Resident Support Staff: 1
Total Daily Staff: 136
Waking Staff: 102
Inspection Report — Jun 13, 2023
Renewal
Date: Jun 13, 2023
Visit Reason
The inspection was conducted as a full, unannounced visit for renewal and complaint reasons on June 13 and 14, 2023.
Findings
The submitted plan of correction was found to be fully implemented. Several deficiencies were identified related to staff training, resident access to bedrooms, fire drills during sleeping hours, and missing emergency exit codes on keypads, all of which have been addressed with corrective actions and oversight plans.
Citations (5)
Direct care staff person “A” did not have proof of required annual training covering resident needs and personal care service needs for 2022.
Direct care staff person “B” did not have proof of annual training in Emergency Preparedness procedures for 2022.
Residents on the third floor secured dementia unit did not have immediate access to their bedrooms as doors were locked and residents had to ask staff to enter.
The home did not conduct a fire drill during sleeping hours in the past 12 months; the last was on 8/30/22 at 11:15 PM.
The third-floor secured unit keypads were missing posted codes for two emergency stair exits.
Report Facts
Residents Served: 81
Secured Dementia Care Unit Residents Served: 37
Current Hospice Residents: 13
Residents Diagnosed with Mental Illness: 3
Residents with Mobility Need: 56
Residents with Physical Disability: 6
Residents Age 60 or Older: 81
Inspection Report — May 17, 2022
Renewal
Date: May 17, 2022
Visit Reason
The inspection was conducted as a renewal visit to assess compliance with licensing requirements at Spring Village at Pocono.
Findings
The inspection identified multiple deficiencies including missing resident contract signatures, missing signed resident rights statements, unsecured window screens, outdated food in the kitchen, lack of annual fire safety inspection documentation, incomplete medical evaluations, missing posted menus in the secured dementia unit, incomplete resident support plans, missing no objection statements for secured dementia care unit transfers, and outdated resident photographs. Plans of correction were accepted and documented as implemented.
Citations (10)
Residents #2, #3, and #5 did not sign their contracts and there was no notation indicating opportunity to sign.
Resident #4 and Resident #2 did not sign their residents' rights.
Window in the 2nd floor common area was open without a screen.
Outdated food found in kitchen walk-in refrigerator including expired coleslaw.
Last documented fire safety inspection was completed on 09/09/2016; no other documentation available.
Resident #2's medical evaluation did not contain resident's height.
Menus were not posted in a public and conspicuous area on the secured dementia unit.
Resident #5's support plan did not accurately reflect mobility status.
Resident #7 and Resident #2 did not have documentation of no objection to transfer to secured dementia care unit.
Resident #7's photograph in record was more than 2 years old.
Report Facts
Residents Served: 77
Secured Dementia Care Unit Residents Served: 39
Hospice Current Residents: 11
Total Daily Staff: 126
Waking Staff: 95
Inspection Report — Apr 19, 2022
Routine
Date: Apr 19, 2022
Visit Reason
The inspection was conducted as a licensing inspection by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing on 04/19/2022.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Michele Moskalczyk | Human Services Licensing Supervisor | Signed the inspection report letter. |
Inspection Report — Apr 14, 2022
Routine
Date: Apr 14, 2022
Visit Reason
The inspection was conducted as a licensing inspection by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing.
Findings
No regulatory citations were identified as a result of this inspection.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Michele Moskalczyk | Human Services Licensing Supervisor | Signed the inspection report letter. |
Inspection Report — Feb 24, 2022
Complaint Investigation
Date: Feb 24, 2022
Visit Reason
The inspection was conducted as a complaint investigation to review the facility's compliance with regulations.
Complaint Details
The visit was complaint-related and the submitted plan of correction was fully implemented as of 02/24/2022.
Findings
The inspection found a violation related to obstructed emergency egress in the first floor dining room, where chairs and patio furniture blocked exit routes. The facility submitted a plan of correction which was determined to be fully implemented.
Citations (1)
The facility’s first floor dining room had an emergency egress that was blocked by chairs and stacked patio furniture, obstructing exit from the home.
Report Facts
Residents Served: 83
Secured Dementia Care Unit Residents Served: 33
Hospice Current Residents: 7
Residents with Mobility Need: 28
Residents 60 Years or Older: 83
Total Daily Staff: 111
Waking Staff: 83
Inspection Report — Jan 20, 2022
Routine
Date: Jan 20, 2022
Visit Reason
The inspection was conducted as a licensing inspection by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing on 01/20/2022.
Findings
No regulatory citations were identified as a result of this inspection.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Michele Moskalczyk | Human Services Licensing Supervisor | Signed the inspection report letter. |
Notice — Jun 15, 2021
Date: Jun 15, 2021
Visit Reason
The document serves as a license renewal approval and notification that the Department will conduct an onsite inspection within the next twelve months as required by regulation.
Findings
The Department issued a regular license in response to the renewal application and advised that an annual inspection will be conducted within the next year to ensure compliance with applicable regulations.
Report Facts
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary | Signed the renewal approval letter |
| Eric Francescangeli | Executive Director | Recipient of the renewal approval letter |
Inspection Report — Apr 20, 2021
Renewal
Date: Apr 20, 2021
Visit Reason
The inspection was conducted as a renewal review of the facility Spring Village at Pocono on 04/20/2021 through 04/22/2021 to assess compliance with licensing requirements.
Findings
The facility was found to have multiple deficiencies including failure to post the current licensing inspection summary, lack of a carbon monoxide detector near gas dryers, uncovered trash receptacle in the kitchen, missing thermometer in a refrigerator, lint accumulation in dryer lint trap, incomplete medication documentation, and unsigned resident support plans. All deficiencies had plans of correction accepted and were reported as implemented.
Citations (7)
The current Licensing Inspection Summary dated 3/13/2020 was not displayed in a public place.
No carbon monoxide detector located near the laundry room with gas dryers.
One garbage can in the kitchen was not covered and not actively used by staff.
One refrigerator in the kitchen did not have a thermometer to determine proper food storage temperature.
About ¼ inch of lint found in the lint trap of an empty dryer in the 1st floor laundry room.
Glucometer readings for Resident 1 were not fully documented; only one of two blood sugar readings was recorded in the MAR.
Resident Assessment and Support Plan for Resident 2 was not signed by the resident and refusal or inability to sign was not documented.
Report Facts
Inspection dates: 3
Total daily staff: 107
Waking staff: 80
Residents served: 64
Secured Dementia Care Unit residents served: 33
Hospice current residents: 10
Residents with mobility need: 43
Residents 60 years or older: 64
Residents diagnosed with mental illness: 2
Residents with physical disability: 1
Inspection Report — Mar 18, 2021
Routine
Date: Mar 18, 2021
Visit Reason
The inspection was conducted as a licensing inspection by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing.
Findings
No regulatory citations were identified as a result of this inspection.
Notice — Nov 25, 2020
Date: Nov 25, 2020
Visit Reason
The document serves to grant a waiver to Spring Village at Pocono allowing an administrator to serve without completing the Department-approved orientation program due to its current unavailability.
Findings
The waiver is granted under specific conditions including scheduling attendance within 15 days of program availability and maintaining documentation of training and qualifications. The Department will review compliance with this waiver during its annual inspection.
Inspection Report — Apr 28, 2020
Renewal
Date: Apr 28, 2020
Visit Reason
The document is a renewal application and license issuance for Spring Village at Pocono Personal Care Home. The Department notifies that an onsite inspection will be conducted within the next twelve months as part of the annual inspection requirement.
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 — Apr 7, 2020
Renewal
Date: Apr 7, 2020
Visit Reason
The inspection was conducted as a licensing inspection by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing.
Findings
No regulatory citations were identified as a result of this inspection.
Inspection Report — Mar 13, 2020
Renewal
Date: Mar 13, 2020
Visit Reason
The inspection was an unannounced renewal visit triggered by a complaint to assess compliance with licensing regulations.
Complaint Details
The inspection was conducted as a renewal visit with a complaint reason indicated. No substantiation status was explicitly stated.
Findings
Multiple violations were found including missing signatures on resident cash disbursement receipts, unsanitary conditions related to cat litter and vomit, unlabeled leftover food, uninspected fire extinguishers, improperly labeled medication, and incomplete pre-admission screening documentation. All deficiencies had plans of correction implemented and approved.
Citations (6)
20b3 - Written Receipts: Resident #1's written receipts of cash disbursements lacked the resident's or witness's signature.
85a - Sanitary Conditions: Resident room #226 had an odorous, unkempt cat litter box and cat vomit on the floor.
103e - Left Overs: Containers of pudding, whipped cream, and pureed food in the dementia unit kitchen were not labeled or dated.
131f - Fire Extinguisher Inspection: Three fire extinguishers were missed during the 2019 inspection; two on the 2nd floor and one on the 3rd floor had expired dates.
184a - Labeling OTC/CAM: Resident #2's B-12 injection solution lacked a pharmacy label.
231c - Preadmission Screening: Resident #3's cognitive pre-admission screening was completed late, after admission to the memory care unit.
Report Facts
Residents Served: 83
Residents Served in Dementia Unit: 38
Current Hospice Residents: 6
Residents Age 60 or Older: 83
Residents with Mobility Need: 38
Residents with Physical Disability: 1
Fire Extinguishers Missed: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Chris Behm | Senior Executive Director | Named in multiple plans of correction and legal entity representative signature |
Inspection Report — Apr 17, 2019
Annual Inspection
Date: Apr 17, 2019
Visit Reason
The visit was the Department’s Bureau of Human Services Licensing annual inspection of the facility 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 — Apr 4, 2019
Routine
Date: Apr 4, 2019
Visit Reason
The inspection was a licensing inspection conducted by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing.
Findings
No regulatory citations were identified as a result of this inspection.
Inspection Report — Mar 11, 2019
Renewal
Date: Mar 11, 2019
Visit Reason
This document is a renewal application and license issuance for the Personal Care Home 'Spring Village at Pocono' pursuant to Title 55, PA Code, Chapter 2600. It notifies the facility that the Department will conduct an onsite annual 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
Notice — Sep 14, 2018
Date: Sep 14, 2018
Visit Reason
The document is a response to a waiver request related to qualifications for direct care staff persons under 55 Pa.Code Ch. 2600.
Findings
The Department of Human Services determined that the waiver is not needed because the individual has obtained a Diploma of Science in Hotel & Restaurant Management from Montessori Professional College in the Philippines, meeting the educational requirement to serve as a direct care staff person.
Inspection Report — Jun 27, 2018
Complaint Investigation
Date: Jun 27, 2018
Visit Reason
The inspection was conducted as a result of an incident complaint at the facility.
Complaint Details
The visit was triggered by an incident complaint. Resident #1 had multiple falls between 1/10/2018 and 5/10/2018, and the facility failed to update the Resident Assessment and Support Plan accordingly.
Findings
Violations of 55 Pa. Code Chapter 2600 related to resident support plans and fall incidents were found. The facility failed to update the Resident Assessment and Support Plan to reflect frequent falls and the need for assistive ambulatory devices.
Citations (1)
Regulation 55 Pa.Code §2600 requires each home to document medical, dental, vision, hearing, mental health, or behavioral care services in the resident's support plan. Resident #1 suffered multiple falls and the support plan was not updated to reflect these falls or the need for assistive ambulatory devices.
Report Facts
Number of Residents Served: 78
Number of Residents Served in Secured Dementia Care Unit: 33
Number of Current Hospice Residents: 6
Number of Hospice Residents in past year: 21
Number of Residents Age 60 or Older: 78
Number of Residents with Mental Illness: 3
Number of Residents with Mobility Need: 8
Number of Residents with Physical Disability: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Chris Behm | Senior Executive Director | Signed the Plan of Correction related to the deficiency |
| Amy Deluca | Department Representative on-site during inspection |
Notice — May 7, 2018
Date: May 7, 2018
Visit Reason
This document is a letter granting a waiver for administrator qualifications and training requirements at Spring Village at Pocono personal care home.
Findings
The waiver is granted with conditions requiring the administrator to complete specified training, education credits, and competency testing by set deadlines. The Department will review compliance annually during inspections.
Report Facts
Educational credits required: 33
Total educational credits required: 60
Scheduled dates: May 23, 2018
Scheduled dates: May 14, 2018
Scheduled dates: Jul 20, 2018
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jacqueline L. Rowe | Director | Signed the waiver approval letter |
Inspection Report — Apr 26, 2018
Renewal
Date: Apr 26, 2018
Visit Reason
The inspection was a renewal inspection conducted by the Department of Human Services Bureau of Human Services Licensing for Spring Village at Pocono.
Findings
Violations were found related to fire safety evacuation times, medication management, and safe storage and use of medications. Plans of correction were submitted and partially implemented as of the report date.
Citations (3)
REGULATION 55 Pa.Code §2600 2600.132(d) - The home's fire drill evacuation time on 12/28/17 was 17 minutes and 41 seconds, exceeding the designated 12 minutes by a fire safety expert.
REGULATION 55 Pa.Code §2600 2600.183(d) - Only current prescription, OTC, sample and CAM medications may be kept in the home. Discontinued medications were found in residents' medication carts.
REGULATION 55 Pa.Code §2600 2600.185(a) - The home failed to develop and implement procedures for safe storage, access, security, distribution and use of medications and medical equipment by trained staff. A prescribed ointment was not available as needed.
Report Facts
Number of Residents Served in Secured Dementia Care Unit: 33
Number of Current Hospice Residents: 5
Number of Hospice Residents in past year: 17
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Chris Behm | Administrator | Named in report header as facility administrator |
| Kimberli Foulkes | Inspector | On-site inspector for the inspection |
| Gerald Dumas | Inspector | On-site inspector for the inspection |
Inspection Report — Apr 5, 2018
Complaint Investigation
Date: Apr 5, 2018
Visit Reason
The inspection was conducted due to an incident complaint at the facility.
Complaint Details
The visit was complaint-related due to an incident involving suspected abuse where Resident #1 raised their arm to hit Resident #2, causing Resident #2 to fall and fracture their femur. The complaint was substantiated by the findings.
Findings
Violations of 55 Pa. Code Chapter 2600 related to suspected abuse and failure to update a resident's support plan were found. The facility was required to correct these violations and maintain compliance.
Citations (2)
55 Pa.Code §2600.15(a) requires immediate reporting of suspected resident abuse. Resident #1 raised their arm to hit Resident #2, who lost balance and fell, resulting in a fractured right femoral neck. No contact was made after the incident.
55 Pa.Code §2600.234(d) requires support plans to be revised at least annually and as resident conditions change. Resident #1's support plan was not updated with a plan, frequency, or responsible party to meet their needs after redirection issues.
Report Facts
Number of Residents Served: 88
Number of Deficiencies: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kimberli Foulkes | Department Representative | On-site inspector during the inspection visit on 04/05/2018. |
| Chris Behm | Administrator | Facility administrator named in the report header. |
Inspection Report — Mar 28, 2018
Complaint Investigation
Date: Mar 28, 2018
Visit Reason
The inspection was conducted as a complaint investigation at Spring Village at Pocono to assess compliance with 55 Pa. Code Chapter 2600 relating to Personal Care Homes.
Complaint Details
The inspection was triggered by a complaint. The report does not state substantiation status.
Findings
Two violations were found related to securing wheelchair devices and documentation for secured dementia care unit placement. Plans of correction were developed and partially implemented as of May 18, 2018.
Citations (2)
55 Pa.Code §2600.142(d) - The home did not secure a gel cushion and anti-tippers for a resident's wheelchair until several weeks after the order was dated.
55 Pa.Code §2600.231(b) - Documentation did not indicate the need for the secured dementia care unit for a resident with dementia as required within 60 days prior to admission.
Report Facts
Number of Residents Served: 88
Number of Residents Served in Secured Dementia Care Unit: 37
Number of Current Hospice Residents: 6
Number of Hospice Residents in Past Year: 22
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Chris Behm | Senior Executive Director | Signed plan of correction and named as Administrator |
| Ryan Novak | Department Representative conducting the inspection |
Inspection Report — Dec 14, 2017
Original Licensing
Date: Dec 14, 2017
Visit Reason
The inspection was conducted due to a change in the legal entity operating the facility and was a licensing inspection.
Findings
The facility was found to be in substantial compliance with regulations but had several violations that required correction. Violations included safety hazards, improper food storage, lint buildup in dryer vents, incomplete fire department notification, and missing directions for locking devices.
Citations (5)
55 Pa.Code §2600.81(b) - Resident room #225 had an enabler bar attached to the bed without a cover, creating a safety hazard.
55 Pa.Code §2600.103(g) - Food items in the home's walk-in freezer, including large bags of frozen corn and peas, were not properly sealed.
55 Pa.Code §2600.105(g)(2) - The home had lint buildup on three dryer vents on the outside rear of the building, posing a fire hazard.
55 Pa.Code §2600.124 - The home's notification to the local fire department did not include the total capacity of the home.
55 Pa.Code §2600.233(c) - Directions for operating the home's locking mechanism were not conspicuously posted near the door in the secured dementia care unit stairwell.
Report Facts
Residents in Secured Dementia Care Unit: 35
Current Hospice Residents: 5
Hospice Residents in Past Year: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christopher Behm | Administrator / Executive Director | Named in relation to plan of correction signatures and responsibility for compliance |
| Jason Harvey | Inspector | Conducted the inspection on-site |
| Kimberli Foulkes | Inspector | Conducted the inspection on-site |
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