Inspection Reports for
Sunrise of Lafayette Hill

PA, 19444

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32 Reports

2017–2026

Inspection Report — May 29, 2026

Complaint Investigation
Date: May 29, 2026

Visit Reason
The inspection was conducted as a complaint investigation triggered by an incident involving an anonymous fax alleging medication mishandling and privacy violations at the facility.

Complaint Details
The complaint involved an anonymous fax alleging that staff member A removed residents' medications, including narcotics, from the facility. The fax included photos of medications. An internal investigation and DHS inspection confirmed privacy violations and procedural failures. Law enforcement was notified on 5/29/2026, but no further action was reported as of 7/10/2026.
Findings
The investigation found multiple violations related to HIPAA privacy breaches, improper medication destruction, incomplete medication labeling, missing documentation of medication administration, and failure to report suspected missing medications to law enforcement. Staff member A was terminated due to privacy violations. Corrective actions including staff retraining and audits were implemented.

Citations (6)
Regulation 2600.18: The facility received a fax containing residents' medications outside the facility, unlocked and unattended, violating HIPAA privacy rules.
Regulation 2600.183f: Discontinued medications were destroyed improperly; photos of medications were sent by fax from an unknown source, violating environmental and safety regulations.
Regulation 2600.184a: A resident's medication label did not include current administration instructions, causing a discrepancy with the medication administration record.
Regulation 2600.185b: The home's medication procedures lacked a process to investigate and report missing medications; the facility failed to notify law enforcement after receiving an anonymous fax alleging medication removal.
Regulation 2600.187b: Medication administration records for a resident did not include staff initials for several medication administrations.
Regulation 2600.187d: A resident was prescribed medication not administered as ordered; documentation was amended after discovery.
Report Facts
Residents Served: 70 Secured Dementia Care Unit Residents Served: 18 Hospice Current Residents: 10 Residents Age 60 or Older: 70 Residents with Mental Illness: 2 Residents with Mobility Need: 40

Inspection Report — Aug 4, 2025

Renewal
Date: Aug 4, 2025

Visit Reason
The inspection was conducted as a renewal inspection of the facility's license to ensure compliance with regulatory requirements.

Findings
The inspection identified multiple deficiencies including issues with record confidentiality, resident fund refunds, sanitary conditions, food storage, fire drill evacuation procedures, and medication storage and security. All deficiencies had plans of correction accepted and were implemented by the facility.

Citations (7)
License inspection summary with privacy coding attached was shown in a prominent and public location.
Resident 1 did not receive the required refund within 30 days of discharge.
Main kitchen freezer was dirty inside and out with a white substance crusted over; water dispenser exterior was discolored and covered in grime.
Three 3-gallon containers were opened and unsealed in the ice cream freezer.
During fire drills, residents were not evacuating to a designated meeting place away from the building or within the fire-safe area unless the fire was occurring in their area.
Second-floor and third-floor medication carts were unlocked and unattended at specific times.
Lorazepam 5 mg blister packs for two residents were torn on the back with pills still in place.
Report Facts
Residents Served: 68 Secured Dementia Care Unit Residents Served: 22 Hospice Residents: 13 Resident with Mental Illness: 1 Resident with Intellectual Disability: 1 Residents with Mobility Need: 46 Residents 60 Years or Older: 68 Resident Support Staff Hours: 0 Total Daily Staff: 114 Waking Staff: 86

Employees mentioned
NameTitleContext
Executive DirectorNamed in multiple findings related to plan of correction implementation and retraining.
Business Office CoordinatorNamed in findings related to resident fund refunds and retraining.
Lead Care ManagerNamed in findings related to cleaning and sanitation corrections.
Reminiscence CoordinatorNamed in findings related to daily sanitation checks.
Dining Services CoordinatorNamed in findings related to food storage compliance checks.
Maintenance CoordinatorNamed in findings related to medication cart security and fire safety.
Resident Care DirectorNamed in findings related to medication storage checks and plan of correction monitoring.
Wellness NurseNamed in findings related to medication storage and retraining.
Medication Care ManagerNamed in findings related to medication storage and retraining.

Inspection Report — Nov 4, 2024

Follow-Up
Date: Nov 4, 2024

Visit Reason
The inspection visit on 11/04/2024 was a partial, unannounced follow-up inspection triggered by an incident to verify the implementation of a previously submitted plan of correction.

Findings
The plan of correction related to a substantiated allegation of staff disrespect and verbal abuse toward a resident in the secure dementia care unit was found to be fully implemented. Staff training was conducted, and ongoing monitoring and QAPI meetings were scheduled to ensure continued compliance.

Citations (1)
Resident was subjected to verbal abuse by a staff member in the secure dementia care unit, violating the requirement that a resident shall be treated with dignity and respect.
Report Facts
Residents Served: 64 Residents Served: 22 Current Residents: 16 Residents Age 60 or Older: 64 Residents with Mobility Need: 46

Employees mentioned
NameTitleContext
Colleen MillerExecutive DirectorTerminated employment of staff member involved in verbal abuse incident and conducted staff training on dignity and respect

Inspection Report — Dec 5, 2023

Plan of Correction
Date: Dec 5, 2023

Visit Reason
The inspection was conducted as a complaint investigation and incident review related to resident care and abuse allegations.

Complaint Details
The visit was complaint-related involving substantiated allegations of neglect and abuse. The incident involved a resident left on the toilet for 45 minutes and subsequent intimidation and verbal abuse by a staff member. The staff member who failed to report the incident was retrained and placed on final warning, and the abusive staff member was terminated.
Findings
The facility was found to have failed to report an incident involving a resident left on the toilet for 45 minutes, causing emotional distress, and subsequent abuse and intimidation by a staff member. Corrective actions including staff training and termination of the involved employee were implemented.

Citations (2)
Failure to report an incident of a resident left on the toilet for 45 minutes causing emotional distress.
Resident was verbally abused and intimidated by a staff member, including threats and property damage.
Report Facts
Residents Served: 64 Secured Dementia Care Unit Residents Served: 19 Hospice Current Residents: 12 Residents Age 60 or Older: 63 Residents with Mobility Need: 43 Residents with Physical Disability: 1 Residents Diagnosed with Intellectual Disability: 1 Residents Diagnosed with Mental Illness: 0 Residents Receiving Supplemental Security Income: 0

Employees mentioned
NameTitleContext
Staff Person ANamed in findings related to neglect, abuse, intimidation, and termination following investigation
Staff Person BNamed in findings related to failure to report incident and retraining with final written warning

Inspection Report — Sep 14, 2023

Complaint Investigation
Date: Sep 14, 2023

Visit Reason
The inspection was conducted as a complaint and incident investigation at the facility.

Complaint Details
The inspection was complaint-related and the follow-up type was noted as not required, indicating no substantiated deficiencies.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.

Report Facts
Residents Served: 65 Secured Dementia Care Unit Residents Served: 21 Resident Count Diagnosed with Mental Illness: 1 Resident Count with Mobility Need: 42 Resident Count Age 60 or Older: 64 Resident Count with Physical Disability: 1

Inspection Report — Jun 16, 2023

Complaint Investigation
Date: Jun 16, 2023

Visit Reason
The inspection was conducted as a complaint and incident investigation involving behavioral issues and safety concerns between residents at the facility.

Complaint Details
The visit was complaint-related, investigating incidents of resident-to-resident aggression and staff abuse. The complaint was substantiated as evidenced by documented incidents and staff disciplinary actions.
Findings
The facility failed to prevent and properly manage aggressive behaviors between residents, resulting in physical altercations causing injury. The home also failed to report behavioral changes to physicians and did not implement adequate positive interventions or safety measures. Staff misconduct involving abuse was identified and addressed with termination and training.

Citations (3)
Resident 1 and Resident 2 engaged in aggressive behavior resulting in injury; the facility failed to report behavioral changes and neglected resident safety by housing them together.
Staff person B engaged in abusive behavior towards Resident 2, violating home policy, resulting in suspension and termination.
The home failed to implement positive interventions to modify or eliminate aggressive behaviors of residents 1 and 2, leading to a physical altercation causing injury.
Report Facts
Residents Served: 60 Residents Served in Secured Dementia Care Unit: 18 Current Hospice Residents: 13 Residents Age 60 or Older: 59 Residents with Mobility Need: 39

Inspection Report — Apr 20, 2023

Complaint Investigation
Date: Apr 20, 2023

Visit Reason
The inspection was conducted as a complaint investigation to review compliance and the submitted plan of correction for the facility.

Complaint Details
The visit was complaint-related as indicated by the inspection reason. The submitted plan of correction was fully implemented and compliance was maintained.
Findings
The inspection found that a poisonous material (Revlon makeup compact) was unlocked and accessible to a resident who was not assessed capable of safely using or avoiding poisonous materials. The facility implemented corrective actions including securing the item, staff training, and ongoing monitoring.

Citations (1)
Poisonous materials were not kept locked and inaccessible to residents; specifically, a Revlon makeup compact was unlocked and accessible to resident #1 who was not assessed capable of safely using or avoiding poisons.
Report Facts
Residents Served: 52 Residents Served in Secured Dementia Care Unit: 18 Current Hospice Residents: 14 Residents Age 60 or Older: 52 Residents with Mobility Need: 33 Residents with Physical Disability: 3 Total Daily Staff: 85 Waking Staff: 64

Inspection Report — Mar 7, 2023

Complaint Investigation
Date: Mar 7, 2023

Visit Reason
The inspection was conducted as a complaint and incident investigation at the facility on 03/07/2023.

Complaint Details
The visit was complaint-related, investigating medication administration and support plan documentation issues. The submitted plan of correction was determined to be fully implemented as of 03/07/2023.
Findings
The inspection identified deficiencies related to medication administration discrepancies, failure to follow prescriber's orders, and lack of notation for refusal to sign support plans. Plans of correction were accepted and implemented with ongoing monitoring.

Citations (3)
Resident's medication label directions did not match the medication administration record (MAR) directions, resulting in improper timing of medication administration.
Failure to follow prescriber's orders with medications administered at incorrect times and PRN medications given less than four hours after a straight order.
Resident participated in support plan development but was unable to sign; the facility did not document the resident's inability to sign.
Report Facts
Residents Served: 45 Secured Dementia Care Unit Residents Served: 12 Hospice Current Residents: 7 Residents Age 60 or Older: 44 Residents with Mobility Need: 28 Residents with Mental Illness: 1 Residents with Physical Disability: 2

Employees mentioned
NameTitleContext
Resident Care DirectorConducted audits, provided training, and monitored medication administration and support plan compliance
Executive DirectorInvolved in retraining staff and discussing plans of correction during QAPI meetings

Inspection Report — Dec 13, 2022

Renewal
Date: Dec 13, 2022

Visit Reason
The inspection was conducted as a renewal inspection combined with complaint and incident investigations at the facility.

Findings
The inspection identified multiple deficiencies including failure to provide required assistance with activities of daily living and personal hygiene to residents, mistreatment of residents, improper combustible storage, overdue fire extinguisher inspections, lack of physician's order for an external catheter device, and failure to document refusal to sign support plans. Plans of correction were accepted and implemented by March 17, 2023.

Citations (7)
Failure to provide assistance with bladder and bowel management as required by resident's assessment and support plan.
Failure to provide assistance with dressing, undressing, and care of clothes as required by resident's assessment and support plan.
Resident was treated without dignity and respect; staff member hollered at resident and undressed resident roughly.
Combustible cardboard boxes stored in the boiler room near heat sources.
Fire extinguishers on multiple floors had not been inspected by a fire safety expert since 11/2021.
Use of external catheter without physician's order initially; order obtained after inspection.
Failure to document resident's inability or refusal to sign support plan.
Report Facts
Residents Served: 47 Residents Served in Dementia Unit: 11 Hospice Residents: 7 Total Daily Staff: 76 Waking Staff: 57 Residents Age 60 or Older: 46 Residents with Mobility Need: 29 Residents with Physical Disability: 2 Residents Diagnosed with Mental Illness: 1

Inspection Report — Sep 19, 2022

Follow-Up
Date: Sep 19, 2022

Visit Reason
The visit was a partial, unannounced follow-up inspection conducted to review the submitted plan of correction related to an incident involving resident treatment.

Findings
The inspection found that the submitted plan of correction was fully implemented, including staff training on resident rights and dignity, investigation of incidents, and ongoing monitoring to prevent recurrence.

Citations (2)
Staff person A cleared a call bell without asking the resident what they needed and made an inappropriate comment in front of others.
Staff person B intimidated a resident by warning them not to ring the call bell again, causing fear.
Report Facts
Residents served in secured dementia care unit: 10 Residents aged 60 or older: 54 Residents with mobility need: 28 Residents with physical disability: 1 Total daily staff: 82 Waking staff: 62

Inspection Report — Sep 7, 2022

Date: Sep 7, 2022

Visit Reason
The inspection was conducted as a licensing inspection by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing, with the reason noted as 'Incident'.

Findings
No regulatory citations or deficiencies were identified as a result of this inspection.

Report Facts
Residents Served: 56 Secured Dementia Care Unit Residents Served: 10 Hospice Residents: 4 Residents Age 60 or Older: 55 Residents Diagnosed with Mental Illness: 1 Residents with Mobility Need: 30 Residents with Physical Disability: 2 Total Daily Staff: 86 Waking Staff: 65

Inspection Report — Aug 8, 2022

Date: Aug 8, 2022

Visit Reason
The inspection was a partial, unannounced licensing inspection conducted as an incident review.

Findings
No regulatory citations or deficiencies were identified during the inspection.

Report Facts
Total Daily Staff: 83 Waking Staff: 62 Residents Served: 54 Secured Dementia Care Unit Residents Served: 12 Hospice Current Residents: 7 Residents Age 60 or Older: 54 Residents with Mobility Need: 29 Residents with Physical Disability: 2

Inspection Report — Jul 15, 2022

Follow-Up
Date: Jul 15, 2022

Visit Reason
The inspection was a partial, unannounced follow-up visit triggered by an incident, to review the submitted plan of correction and verify compliance with prior deficiencies.

Complaint Details
The visit was incident-driven following allegations of resident abuse and privacy violations. The Executive Director immediately investigated and reported incidents to appropriate authorities. Staff involved were placed on administrative leave and terminated after investigation.
Findings
The facility was found to have multiple violations including failure to immediately report suspected resident abuse, violations of resident privacy and dignity, and incomplete resident records. The submitted plan of correction was accepted and fully implemented by 12/14/2022.

Citations (4)
Failure to immediately report suspected abuse of residents as required by the Older Adult Protective Services Act.
Violation of privacy rules by staff recording residents without permission and posting videos on social media.
Residents were not treated with dignity and respect; staff used intimidating tone and recorded residents without consent.
Resident records did not include incident reports for residents involved in abuse allegations.
Report Facts
Residents Served in Dementia Care Unit: 13 Staffing - Total Daily Staff: 88 Staffing - Waking Staff: 66 Residents Age 60 or Older: 54 Residents with Mobility Need: 32

Employees mentioned
NameTitleContext
Staff person AWitnessed and reported abuse incidents; involved in privacy violations and recording residents without permission.
Staff person BAlleged to have abused resident 1 and used intimidating tone.
Staff person CReceived abuse report from staff person A but delayed reporting to management.
Staff person DAlleged to have hit resident 2 and made threatening statement.
Staff person EInvolved in recording residents without permission and privacy violations.
Executive DirectorExecutive DirectorImmediately commenced investigation, reported incidents to authorities, placed staff on administrative leave, and oversaw corrective actions.
Resident Care DirectorResident Care DirectorConducted reporting requirements training with staff.

Inspection Report — Jun 23, 2022

Follow-Up
Date: Jun 23, 2022

Visit Reason
The inspection was a partial, unannounced visit triggered by an incident to review compliance and follow up on a plan of correction submission.

Findings
The facility initially denied access to investigation documents, constituting a violation, but later complied. There were failures in timely reporting of suspected resident abuse and failure to respect residents' rights regarding personal care timing. Plans of correction were submitted and implemented with ongoing monitoring.

Citations (3)
Denied immediate access to the home's investigation documents requested by the Department.
Failure to immediately report suspected abuse involving residents; staff failed to follow proper reporting policy.
Residents were woken between 2 am and 6 am for personal care against their wishes, violating dignity and respect.
Report Facts
Staffing: 78 Staffing: 59 Residents age 60 or older: 64 Residents with mobility need: 14 Residents with physical disability: 1

Inspection Report — May 17, 2022

Complaint Investigation
Date: May 17, 2022

Visit Reason
The inspection was conducted as a complaint and incident investigation to review allegations of resident abuse and safety concerns at the facility.

Complaint Details
The visit was complaint-related with substantiated findings of resident abuse and neglect. The facility was found noncompliant with reporting and intervention requirements.
Findings
The investigation found multiple incidents of resident-to-resident physical abuse involving Resident #1 attacking other residents. The facility failed to immediately report suspected abuse to the local area agency on aging and did not implement timely positive interventions or safety measures to prevent further incidents. The facility submitted a plan of correction including staff training, daily incident reviews, and updated support plans.

Citations (3)
Failure to immediately report suspected resident abuse to the local area agency on aging.
Resident #1 attacked multiple residents; the facility did not implement positive interventions or update care plans timely.
Failure to provide adequate supervision and safety measures resulting in physical assaults among residents.
Report Facts
Inspection dates: 3 Residents served: 54 Residents in secured dementia care unit: 12 Hospice current residents: 4 Residents aged 60 or older: 54 Residents with mobility need: 14 Residents with physical disability: 1 Total daily staff: 68 Waking staff: 51

Inspection Report — Mar 29, 2022

Date: Mar 29, 2022

Visit Reason
The inspection was conducted as a licensing inspection by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing, due to an incident.

Findings
No regulatory citations or deficiencies were identified as a result of this inspection.

Report Facts
Residents Served: 43 Secured Dementia Care Unit Residents Served: 14 Resident Support Staff: 0 Total Daily Staff: 58 Waking Staff: 44 Residents Age 60 or Older: 43 Residents with Mobility Need: 15 Residents with Physical Disability: 1

Inspection Report — Oct 1, 2021

Follow-Up
Date: Oct 1, 2021

Visit Reason
The inspection was a partial, unannounced follow-up visit conducted due to an incident, to review the submitted plan of correction.

Complaint Details
The visit was triggered by an incident involving alleged resident abuse by staff. The facility was found to have not reported the abuse allegation properly and failed to suspend or supervise the staff involved initially. The plan of correction included reporting to the Area Agency on Aging and Department of Human Services, staff education, and monitoring. The complaint was substantiated as indicated by the violations and corrective actions.
Findings
The submitted plan of correction was determined to be fully implemented following the review. The report details violations related to resident abuse and treatment, with corrective actions and training provided to staff to ensure compliance and prevent recurrence.

Citations (3)
Failure to immediately report suspected abuse of a resident; staff threatened a resident and the incident was not reported in accordance with OAPSA.
Failure to develop and implement a plan of supervision or suspend staff involved in alleged abuse.
Repeat violation of treating a resident without dignity and respect; staff displayed an angry demeanor and made inappropriate comments to a resident requesting pain medication.
Report Facts
Residents Served: 55 Secured Dementia Care Unit Residents Served: 10 Current Hospice Residents: 4 Residents Age 60 or Older: 50 Residents with Mobility Need: 10 Residents Diagnosed with Mental Illness: 1 Residents with Physical Disability: 1

Employees mentioned
NameTitleContext
Staff ANamed in resident abuse and treatment violations
Executive DirectorResponsible for reporting abuse allegations and providing staff education and training
Personal Care CoordinatorInvolved in investigation and staff education regarding resident rights and abuse reporting
Director of OperationsProvided education and training on placing staff on administrative leave following abuse allegations
Resident Care DirectorReceived education and training on administrative leave requirements
Reminiscence CoordinatorReceived education and training on administrative leave requirements

Inspection Report — Sep 28, 2021

Renewal
Date: Sep 28, 2021

Visit Reason
The inspection was a full, unannounced renewal inspection conducted on 09/28/2021 and 09/29/2021 to assess compliance with licensing requirements for the facility.

Findings
The inspection identified several deficiencies including missing emergency telephone numbers by resident telephones, improper refrigerator/freezer temperatures, emergency procedures not posted conspicuously, missing pharmacy labels on prescription medications, and lack of documentation for refusal to sign support plans. Plans of correction were accepted and implemented with ongoing monitoring.

Citations (5)
No emergency telephone numbers including nearest hospital and fire department posted on or by the telephone in room 208.
Temperature in the ice cream freezer was 36 degrees Fahrenheit, exceeding required refrigeration temperature.
Emergency procedures were not posted in a conspicuous and public place in the home.
No pharmacy label or directions for resident #1's prescription medication.
Resident #2 did not sign the support plan nor was there documentation of inability or refusal to sign.
Report Facts
Residents Served: 52 Secured Dementia Care Unit Residents Served: 12 Hospice Residents: 4 Total Daily Staff: 71 Waking Staff: 53 Residents with Mobility Need: 19

Inspection Report — Aug 23, 2021

Monitoring
Date: Aug 23, 2021

Visit Reason
The visit was a monitoring inspection conducted by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing to verify the implementation of a previously submitted plan of correction.

Findings
The inspection found multiple deficiencies including broken motion sensor light, incomplete first aid kit, improper refrigerator/freezer temperatures, unsecured medications in resident rooms, expired test strips, incorrect medication labels, missing medications, inaccurate medication administration records, and unsigned support plans. All deficiencies had plans of correction accepted and were being monitored for effectiveness.

Citations (10)
Broken plastic motion sensor light in bathroom in Memory Care bedroom.
First aid kit in Reminiscence community missing adhesive tape.
Refrigerator/freezer temperatures out of required range: ice cream freezer at 5°F and milk refrigerator at 44°F.
Medications stored unsecured in resident #4's bedroom, accessible and unattended.
Expired True Matrix test strips belonging to resident #3 found in medication cart.
Medication label for resident #2's Albuterol Sulfate HFA incorrect, stating every 6 hours instead of every 8 hours.
Medication for resident #1 (Voltaren Gel 1%) not available in the home as prescribed.
Medication administration records for resident #1 contained blood sugar readings not found on glucometers, indicating inaccurate documentation.
Resident #1 did not have prescribed blood sugar checks completed as ordered on multiple dates.
Support plans for residents #5, #6, and #7 were completed but not signed or marked for refusal by the residents.
Report Facts
Residents Served: 53 Residents Served in Secured Dementia Care Unit: 11 Residents Age 60 or Older: 53 Residents with Mobility Need: 15 Current Residents in Hospice: 3

Employees mentioned
NameTitleContext
Shawn ParkerSigned letters regarding inspection results and plan of correction acceptance.
Menerva PhilsonAdministratorFacility administrator addressed in letters.
Executive DirectorNamed in multiple plans of correction and monitoring activities.
Maintenance DirectorReplaced broken motion sensor light.
Dining Services CoordinatorResponsible for monitoring refrigerator/freezer temperatures.
Wellness NurseConducted medication reviews and audits.
Medication Care ManagerInvolved in medication administration and documentation corrections.
Care CoordinatorMet with residents and responsible parties to obtain support plan signatures.

Notice — Dec 30, 2020

Date: Dec 30, 2020

Visit Reason
This document serves as a renewal notification and certificate of compliance for the Personal Care Home 'Sunrise of Lafayette Hill'. It informs the facility that an annual onsite inspection will be conducted within the next twelve months as required by regulation.

Findings
The Department has issued a regular license in response to the renewal application. No findings or deficiencies are reported in this document.

Report Facts

Inspection Report — Dec 3, 2020

Follow-Up
Date: Dec 3, 2020

Visit Reason
The visit was a follow-up review of the submitted plan of correction for the facility conducted on 12/03/2020, 12/07/2020, and 12/11/2020 to verify correction of previous deficiencies.

Findings
The submitted plan of correction was determined to be fully implemented with continued compliance required. Deficiencies involved treatment of residents, support plan signatures, refusal to sign support plans, and missing incident reports in resident records, all of which were addressed with corrective actions and monitoring plans.

Citations (4)
42c - Treatment of Residents: Resident #1 was not treated with dignity and respect when staff failed to properly assist with a sit-to-stand lift and made an inappropriate comment overheard by the resident.
227g - Support Plan Signatures: The facility did not keep a copy of the signature page for Resident #1's updated support plan dated 11/04/2020.
227h - Support Plan Refuse Sign: Residents #2 and #3 did not sign their support plans and the facility failed to document their inability or refusal to sign.
252 - Record Content: Incident reports for residents #1, #2, and #3 were missing from their records.
Report Facts
Residents Served: 58 Residents Served in Dementia Unit: 18 Residents Age 60 or Older: 61 Residents with Mental Illness: 2 Residents with Mobility Need: 20

Inspection Report — Nov 4, 2020

Renewal
Date: Nov 4, 2020

Visit Reason
The inspection was a full, unannounced renewal inspection conducted on 11/04/2020 and 11/05/2020 to assess compliance with licensing regulations.

Findings
The facility was found to have multiple deficiencies including lack of posted emergency telephone numbers, inoperable staff communication system, missing fire extinguisher glass casing, unlabeled food items, missing thermometer in freezer, discontinued medications not removed timely, unlabeled over-the-counter medications, unavailable prescribed medications, and medication administration errors. Plans of correction were accepted and implemented for all deficiencies.

Citations (10)
44g - Telephone Number: Required emergency telephone numbers were not posted in a conspicuous and public place in the home.
90b - Staff Communication: The home did not have an operable system allowing staff to communicate immediately in an emergency on 11/4/20 when serving 62 residents.
91 - Telephone Numbers: Emergency telephone numbers including nearest hospital and fire department were not posted on or by the telephone in room #204.
95 - Furniture and Equipment: The fire extinguisher cabinet outside the rear exit door of the memory care unit was missing the glass casing.
103e - Left Overs: Unlabeled, undated liquid condiments were found in bottles in the memory care refrigerator.
103f - Refrigerator/Freezer Temps: No thermometer was present in the freezer located in the memory care unit.
183f - Discontinued Medications: Nystatin cream discontinued on 10/22/20 was still observed on the medication cart, which is not an approved destruction method.
184a - Labeling OTC/CAM: Resident #2's Tums tablet chewable did not have a pharmacy label.
185a - Implement Storage Procedures: Prescribed medications for resident #2 were not available in the home on 11/4/20.
187d - Follow Prescriber's Orders: Resident #3 was administered Klonopin 0.5 mg at 9:30 am instead of the prescribed 5:00 pm on 2/26/20.
Report Facts
Residents served: 62 Residents served in secured dementia care unit: 17 Current hospice residents: 6 Staff total daily: 94 Waking staff: 71

Inspection Report — Sep 10, 2020

Complaint Investigation
Date: Sep 10, 2020

Visit Reason
The inspection was conducted as a complaint investigation following concerns raised about resident care at the facility.

Complaint Details
The complaint investigation substantiated that resident #1 was not properly assessed for pain in the left leg, which was later found to be fractured. The facility took corrective actions including notifying the physician, ordering an x-ray, and sending the resident to the hospital.
Findings
The investigation found that a resident experienced pain and a fractured left ankle that was not promptly assessed by staff. The facility implemented a plan of correction including staff training on pain management and auditing of resident records to prevent recurrence.

Citations (1)
Failure to promptly assess and respond to a resident's pain and injury, resulting in delayed diagnosis of a fractured left ankle.
Report Facts
Residents Served: 66 Secured Dementia Care Unit Residents Served: 20 Current Hospice Residents: 7 Residents Age 60 or Older: 66 Residents with Mobility Need: 34 Residents with Physical Disability: 1

Inspection Report — Jul 7, 2020

Complaint Investigation
Date: Jul 7, 2020

Visit Reason
The inspection was conducted as a complaint investigation with unannounced partial inspections on multiple dates from 07/07/2020 to 07/13/2020.

Complaint Details
The inspection was complaint-related and the follow-up type was noted as not required. No substantiation status was provided.
Findings
No regulatory citations or deficiencies were identified during the inspection.

Report Facts
Residents Served: 66 Secured Dementia Care Unit Residents Served: 20 Total Daily Staff: 103 Waking Staff: 77 Residents 60 Years or Older: 66 Residents with Mobility Need: 37 Residents with Physical Disability: 1

Inspection Report — Sep 10, 2019

Renewal
Date: Sep 10, 2019

Visit Reason
The document is a renewal application response and license issuance for the Personal Care Home Sunrise of Lafayette Hill. The Department notifies 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 serves as a license renewal confirmation and notification of future inspection requirements.

Report Facts

Inspection Report — May 6, 2019

Renewal
Date: May 6, 2019

Visit Reason
The inspection was an annual licensing renewal inspection conducted by the Department's Bureau of Human Services Licensing on May 6 and 7, 2019.

Findings
The inspection found violations related to sanitary conditions, specifically improper storage of a resident's glucometer. A plan of correction was submitted and partially implemented to address the issue.

Citations (1)
55 Pa. Code 2600.85a requires sanitary conditions to be maintained. On 05/07/19, a resident's glucometer was found on the medication cart not stored in a container, risking communicable disease spread.
Report Facts
Residents Served: 78 Residents Served in Secured Dementia Care Unit: 21 Current Hospice Residents: 5 Residents Age 60 or Older: 77 Residents with Mobility Need: 41

Employees mentioned
NameTitleContext
Kelly BieberRN Executive DirectorNamed in plan of correction signature and responsible for corrective actions

Inspection Report — Apr 15, 2019

Routine
Date: Apr 15, 2019

Visit Reason
The Department’s Bureau of Human Services Licensing conducted an inspection of the facility to assess compliance with 55 Pa. Code Ch. 2600 relating to Personal Care Homes.

Findings
No regulatory citations or deficiencies were identified as a result of this inspection.

Inspection Report — Jan 10, 2019

Complaint Investigation
Date: Jan 10, 2019

Visit Reason
The inspection was conducted as an incident investigation related to violations of 55 Pa. Code Chapter 2600 for Personal Care Homes at Sunrise of Lafayette Hill.

Complaint Details
The visit was triggered by an incident complaint. Specific substantiation status is not stated.
Findings
The facility was found to have violations related to medication administration where a resident was not administered Levothyroxine Sodium on multiple dates. A plan of correction was submitted addressing the medication error and ongoing monitoring.

Citations (1)
55 Pa.Code §2600.187(d) - The home failed to follow the directions of the prescriber. Resident #1 was not administered Levothyroxine Sodium on multiple dates in late 2018.
Report Facts
Number of Residents Present: 85 Number of Current Hospice Residents: 3 Number of Hospice Residents in Past Year: 15

Employees mentioned
NameTitleContext
Kelly BleberExecutive DirectorNamed as Administrator and signatory on plan of correction related to medication error.

Inspection Report — Dec 7, 2018

Routine
Date: Dec 7, 2018

Visit Reason
The Department's Bureau of Human Services Licensing representatives conducted an inspection of the facility on December 7, 2018.

Findings
No regulatory citations with 55 Pa. Code Ch. 2600 (relating to Personal Care Homes) were identified as a result of this inspection.

Employees mentioned
NameTitleContext
Shawn ParkerHuman Services Licensing SupervisorSigned the inspection report letter.

Notice — Aug 23, 2018

Date: Aug 23, 2018

Visit Reason
This document is a renewal license notification for the Personal Care Home Sunrise of Lafayette Hill, informing the facility of the renewal application receipt and 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 upcoming inspection requirements.

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Notice — Dec 15, 2017

Date: Dec 15, 2017

Visit Reason
Issuance of a new license due to corporate restructuring and change of the legal entity name for the facility Sunrise of Lafayette Hill.

Findings
The document confirms the granting of a license to Welltower OpCo Group LLC to operate Sunrise of Lafayette Hill with a maximum capacity of 105 persons and a secure dementia care unit capacity of 25.

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Notice — October 4, 2021

Date: October 4, 2021

Visit Reason
The document serves as a renewal notification and license issuance for the Personal Care Home 'Sunrise of Lafayette Hill' following receipt of the renewal application dated September 21, 2021. It also advises 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 is a license renewal notice and certificate of compliance.

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Employees mentioned
NameTitleContext
Jamie L. BuchenauerDeputy Secretary, Office of Long-term LivingSigned the renewal notification letter.

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