43 Reports
Inspection Report — Mar 26, 2026
Follow-Up
Date: Mar 26, 2026
Visit Reason
The inspection was an unannounced partial review conducted due to an incident at the facility.
Findings
The facility had multiple deficiencies including a broken concrete sidewalk posing a tripping hazard, combustible materials accessible to residents, missing resident signatures on support plans, incorrect posting of key-locking device operation instructions, and support plans not fully addressing residents' needs.
Citations (5)
100a Exterior Free of Hazards: The concrete sidewalk was broken and shattered, creating a tripping hazard for residents on the porch outside the home.
125b Combustible Restrictions: Two nail polish bins with flammable caution labels were unlocked, unattended, and accessible to residents in the memory care unit.
227g Support Plan Signatures: A resident participated in the development of their support plan but did not sign it as required.
233c Key-Locking Devices: Directions for operating the locking mechanism were not conspicuously posted near the Secure Dementia Care Unit exit, and the wrong code was posted on the door.
234b Support Plan Needs Elements: A resident's support plan did not address the need for thin liquids as identified in a speech consult, despite observed coughing and vomiting during meals.
Report Facts
Residents Served: 53
Secured Dementia Care Unit Residents Served: 24
Hospice Current Residents: 11
Residents Age 60 or Older: 75
Residents Diagnosed with Mental Illness: 4
Residents Diagnosed with Intellectual Disability: 2
Residents with Mobility Need: 32
Inspection Report — Mar 2, 2026
Renewal
Date: Mar 2, 2026
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 multiple deficiencies including contract signature issues, missing signed statements, criminal background check lapses, staff qualification deficiencies, sanitary condition violations, emergency procedure posting issues, fire drill scheduling deficiencies, menu posting lapses, medication administration errors, resident rights education gaps, support plan signature omissions, and record entry legibility problems. All deficiencies had plans of correction accepted and were implemented by May 4, 2026.
Citations (15)
25b Contract Signatures: The resident-home contract was not signed by the resident.
41e Signed Statement: Resident's record lacked a signed statement acknowledging receipt of resident rights and complaint procedures.
51 Criminal Background Check: Vendor was in the home without supervision and without a criminal background check on file.
54a Direct Care Staff: A direct care staff person did not have a high school diploma, GED, or active registry status on the Pennsylvania nurse aide registry.
85a Sanitary Conditions: Refrigerator in the activity room had spills that needed cleaning.
101j7 Lighting/Operable Lamp: Resident did not have access to a source of light that can be turned on/off at bedside.
103f Refrigerator/Freezer Temps: No thermometer was present in the freezer section of the activity room refrigerator.
103g Storing Food: A bag of frozen veggie burger patties in the walk-in freezer was opened and unsealed.
123b Emergency Procedures Posted: Emergency procedures were kept in a drawer and not posted in a conspicuous and public place.
132g Fire Drills Days/Times: No fire drill was held during weekends since January 2025.
162c Menus Posted: Weekly menu was not posted in the home's Secured Dementia Care Unit.
187d Follow Prescriber's Orders: Resident's blood pressure was not measured before administering medication with special instructions to hold if systolic BP was less than 120.
191 Resident Right to Refuse: Resident was not educated on the right to refuse medication if a medication error is suspected.
227g Support Plan Signatures: Resident participated in support plan development but did not sign the plan, and no notation was made regarding refusal or inability to sign.
251b Record Entries Legible: Correction fluid was used on resident's signature page and dates were written over without proper notation.
Report Facts
Residents Served: 84
Secured Dementia Care Unit Residents Served: 24
Hospice Current Residents: 16
Residents 60 Years or Older: 83
Residents Diagnosed with Mental Illness: 14
Residents Diagnosed with Intellectual Disability: 2
Residents with Mobility Need: 52
Inspection Report — Nov 26, 2025
Complaint Investigation
Date: Nov 26, 2025
Visit Reason
The inspection was conducted as a complaint investigation to review compliance with regulations and verify the submitted plan of correction.
Complaint Details
The inspection was complaint-driven as indicated by the inspection information section stating the reason as 'Complaint'.
Findings
The facility was found to have multiple deficiencies including failure to report resident falls to the Department, incomplete criminal background checks for staff, and inadequate staff training in medication administration, the Older Adult Protective Services Act, dementia care, and preadmission screening documentation. The submitted plan of correction was determined to be fully implemented as of the follow-up.
Citations (6)
2600.16c - The home failed to report two resident falls resulting in head injuries and hospitalizations to the Department within 24 hours as required.
2600.51 - A staff member did not have a criminal background check completed until after their date of hire.
2600.65f - A direct care staff person did not receive medication self-administration training during the 2024 training year.
2600.65g - A direct care staff person did not receive training on The Older Adult Protective Services Act during the 2024 training year.
2600.224a - Two residents' preadmission screening forms did not include determinations that their needs could be met by the home.
2600.236 - A direct care staff person working in the secured dementia care unit had only 5.5 hours of dementia care training during the 2024 training year instead of the required 6 hours.
Report Facts
Residents Served: 86
Secured Dementia Care Unit Residents Served: 25
Hospice Current Residents: 20
Inspection Report — Jan 22, 2025
Renewal
Date: Jan 22, 2025
Visit Reason
The inspection was conducted as a renewal visit for the facility license at Sunrise Senior Living of Lower Makefield.
Findings
The inspection identified multiple deficiencies including sanitary conditions, food labeling, pet vaccination records, annual medical evaluations, menu posting, medication storage and labeling, adherence to prescriber's orders, mobility assessments, and support plan revisions. All deficiencies had plans of correction accepted and were implemented by March 17, 2025.
Citations (10)
Carpet in room #130 was stained with an unknown substance.
Several unlabeled, undated bags of food items found in walk-in refrigerator and freezer.
Resident cat did not have a current certificate of rabies vaccination.
Resident #4’s most recent medical evaluation was missing or incomplete.
Home's menu was not posted in a conspicuous and public place; reminiscence area lacked current week menu.
Resident #5's Refresh Tear Drops medication was expired beyond 90 days of opening.
Resident #6's medication label did not match physician's order regarding blood sugar instructions.
Resident #1 was not administered Lorazepam as prescribed on 01/11/25 at 8am.
Resident #7's assessment did not include a bedside mobility device despite doctor's order.
Support plan for resident #4 was not revised timely; previous plan completion date missing.
Report Facts
Residents Served: 64
Residents Served in Dementia Unit: 21
Hospice Residents: 10
Residents Age 60 or Older: 63
Residents with Mobility Need: 32
Residents with Physical Disability: 32
Total Daily Staff: 96
Waking Staff: 72
Inspection Report — Jul 8, 2024
Monitoring
Date: Jul 8, 2024
Visit Reason
The inspection was a monitoring visit conducted on 07/08/2024 as a partial, unannounced inspection to assess ongoing compliance of the facility.
Findings
No regulatory citations or deficiencies were identified during this inspection.
Report Facts
Residents Served: 60
Secured Dementia Care Unit Residents Served: 16
Hospice Residents: 4
Residents Age 60 or Older: 60
Residents Diagnosed with Mental Illness: 2
Residents with Mobility Need: 31
Resident Support Staff Hours: 91
Waking Staff Hours: 68
Inspection Report — May 15, 2024
Complaint Investigation
Date: May 15, 2024
Visit Reason
The inspection was conducted as a complaint investigation with an unannounced partial inspection on 05/15/2024.
Complaint Details
The inspection was complaint-related; however, no deficiencies were found and no follow-up was required.
Findings
No regulatory citations or deficiencies were identified during this inspection.
Report Facts
Residents Served: 56
Residents Served in Dementia Unit: 16
Hospice Current Residents: 12
Resident Support Staff Hours: 0
Total Daily Staff: 90
Waking Staff: 68
Residents Age 60 or Older: 56
Residents Diagnosed with Mental Illness: 2
Residents Diagnosed with Intellectual Disability: 2
Residents with Mobility Need: 34
Residents with Physical Disability: 0
Inspection Report — May 2, 2024
Complaint Investigation
Date: May 2, 2024
Visit Reason
The inspection was conducted as a complaint investigation with an unannounced partial inspection on 05/02/2024 to review compliance and follow up on submitted plans of correction.
Complaint Details
The inspection was complaint-driven and included a follow-up on the submitted plan of correction, which was found to be fully implemented.
Findings
The inspection identified deficiencies related to delayed response to call bells for bowel and bladder management, insufficient direct care staffing hours for residents with mobility needs, inadequate waking hours coverage, and incomplete resident medical evaluation documentation. Plans of correction were accepted and implemented to address these issues.
Citations (4)
Resident required total assistance with bowel and bladder management but call bell log showed no response within 27 minutes on multiple occasions.
Direct care staff hours were below the required minimum for residents with mobility needs on multiple dates.
Less than 75% of personal care service hours were provided during waking hours on multiple dates.
Resident medical evaluation documentation did not indicate the resident's cognitive functioning.
Report Facts
Residents Served: 55
Residents Served in Dementia Unit: 14
Hospice Residents: 11
Residents with Mobility Need: 34
Direct Care Hours Required: 59
Direct Care Hours Provided: 46
Direct Care Hours Required: 60
Direct Care Hours Provided: 56.5
Direct Care Hours Provided: 57.8
Percentage of Direct Care Hours Provided During Waking Hours: 52
Percentage of Direct Care Hours Provided During Waking Hours: 69
Percentage of Direct Care Hours Provided During Waking Hours: 72
Inspection Report — Mar 21, 2024
Complaint Investigation
Date: Mar 21, 2024
Visit Reason
The inspection was conducted as a complaint and incident investigation following an unannounced partial inspection on 03/21/2024.
Complaint Details
The complaint investigation involved an incident where one resident physically assaulted another in their personal care neighborhood. The assaulted resident sustained injuries to the face and jawline. The incident was unprovoked with no prior history of aggression. The facility implemented a plan of correction including staff training on sexual abuse and signs.
Findings
The investigation found an incident of resident-to-resident abuse involving physical assault, and a deficiency in medical evaluations where body positioning and movement stimulation were not documented. The submitted plan of correction was accepted and fully implemented by 05/09/2024.
Citations (2)
Resident-to-resident abuse incident where one resident physically assaulted another, resulting in injuries.
Resident medical evaluation did not include body positioning and movement stimulation documentation.
Report Facts
Residents Served: 65
Secured Dementia Care Unit Residents Served: 14
Hospice Residents: 6
Resident with Supplemental Security Income: 1
Residents 60 Years or Older: 65
Residents Diagnosed with Intellectual Disability: 2
Residents with Mobility Need: 34
Total Daily Staff: 99
Waking Staff: 74
Inspection Report — Jan 17, 2024
Renewal
Date: Jan 17, 2024
Visit Reason
The inspection was conducted as a renewal and incident review of the facility to determine compliance with licensing requirements and to verify the submitted plan of correction was fully implemented.
Findings
The inspection identified multiple deficiencies including failure to submit an approved plan of supervision for a staff member, delayed incident reporting, inadequate staff orientation and training, unsecured poisonous materials, sanitary issues, uncovered trash receptacles, lack of operable bedside lamps, missed fire drills, loose medication pills, and unsigned support plan documents. Plans of correction were accepted and implemented with ongoing monitoring.
Citations (15)
Failure to submit an approved plan of supervision for a staff member who returned to work after alleged abuse incident.
Incident involving alleged resident abuse was not reported to the department within 24 hours.
Refund for deceased resident not issued within required timeframe per Elder Care Payment Restitution Act.
Direct care staff did not receive required orientation on fire safety and emergency preparedness on first day of work.
Direct care staff did not complete required training within 40 scheduled work hours on resident rights, emergency medical plan, mandatory abuse reporting, and reporting of incidents.
Direct care staff did not receive required annual training on meeting resident needs and safe management techniques.
Direct care staff did not receive annual fire safety training by a fire safety expert or trained staff.
Poisonous materials (toothpaste) found unlocked and accessible to residents not assessed as safe to use poisons.
Soiled piece of toilet paper found on outside of toilet bowl in public restroom.
Outside dumpsters were not covered with attached lids.
Resident did not have access to an operable lamp or other source of lighting at bedside.
Unannounced fire drills were not held during January, April, June, and December 2023.
Fire drill during sleeping hours not conducted within required 6-month interval.
Loose pills found in medication cart drawers.
Support plan signature pages for residents were signed but not dated by any signing parties.
Report Facts
Residents Served: 71
Secured Dementia Care Unit Residents Served: 15
Current Hospice Residents: 4
Residents Age 60 or Older: 71
Residents with Mobility Need: 31
Residents Diagnosed with Intellectual Disability: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff member B | Named in abuse incident and supervision plan deficiency; terminated 12/15/23. | |
| Staff member A | Noticed resident holding left shoulder and reported abuse incident. | |
| Staff person C | Received immediate report of abuse incident. | |
| Staff person D | Did not receive required fire safety orientation and 40-hour training. | |
| Direct care staff person E | Did not receive required annual training on resident needs and safe management. | |
| Staff person F | Did not receive required annual fire safety training. |
Inspection Report — May 22, 2023
Follow-Up
Date: May 22, 2023
Visit Reason
The inspection was a partial, unannounced follow-up visit triggered by an incident to verify the implementation of a previously submitted plan of correction.
Findings
The facility was found to have fully implemented the submitted plan of correction related to multiple deficiencies including abuse, safeguarding resident property, direct care staff qualifications, and support plan signatures. Continued compliance is required.
Citations (5)
Staff person A grabbed and yanked the arm and wrist of resident 1 during transfer, causing bruising and pain.
Failure to safeguard valuables of resident 2 after death, including two Apple iPads taken from the resident's room.
Direct care staff person A lacked a high school diploma, GED, or active registry status on the Pennsylvania nurse aide registry.
Resident 1 and Resident 2 participated in support plan development but did not sign the support plan.
No notation was made regarding resident 2's refusal or inability to sign the support plan.
Report Facts
Residents Served: 78
Secured Dementia Care Unit Residents Served: 15
Residents Age 60 or Older: 78
Residents with Intellectual Disability: 2
Residents with Mobility Need: 62
Total Daily Staff: 140
Waking Staff: 105
Inspection Report — Oct 5, 2022
Follow-Up
Date: Oct 5, 2022
Visit Reason
The inspection was a partial, unannounced follow-up visit triggered by an incident at the facility to review the submitted plan of correction.
Findings
The facility was found to have fully implemented the submitted plan of correction related to resident supervision, abuse prevention, documentation of no objection statements for dementia care admissions, and support plan needs. No additional concerns were identified during the follow-up.
Citations (4)
Resident #1 was left unattended in the courtyard leading to an elopement risk due to unsecured gate and lack of supervision.
Resident #2 reported missing money; internal investigation initiated and staff member suspended.
Lack of documentation that resident and designated person had no objection to admission to secured dementia care unit.
Support plan for resident #1 did not address frequent attempts to elope and exit-seeking behavior.
Report Facts
Residents Served: 75
Residents Served in Dementia Unit: 23
Current Hospice Residents: 8
Resident Mobility Need: 54
Residents Diagnosed with Intellectual Disability: 2
Residents Diagnosed with Physical Disability: 1
Total Daily Staff: 129
Waking Staff: 97
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff member A | Involved in resident #1 elopement incident | |
| Staff member B | Notified of resident #1 elopement and found resident | |
| Staff member C | Reported missing money incident involving resident #2 and was suspended | |
| Reminiscence Coordinator | RC | Secured courtyard gate, updated support plans, and conducted staff in-service |
| Maintenance Coordinator | MC | Secured courtyard gate and conducted quarterly elopement drill |
| Executive Director | ED | Conducted townhall meetings, internal investigations, and oversight of plans of correction |
| Business Office Coordinator | BOC | Confirms team members complete resident abuse training |
Inspection Report — Aug 1, 2022
Follow-Up
Date: Aug 1, 2022
Visit Reason
The inspection was a partial, unannounced follow-up visit triggered by an incident to verify the implementation of a submitted plan of correction.
Findings
The facility was found to have fully implemented the submitted plan of correction related to a delayed incident report of missing resident funds and lack of a safeguarding policy for resident belongings. The Executive Director took corrective actions including staff training, updating the resident handbook, and scheduled ongoing quality management reviews.
Citations (2)
Failure to report a resident's missing money incident to the Department within 24 hours.
Lack of a policy or procedure regarding a system to safeguard resident belongings or valuables, and failure to communicate available safeguarding options to residents.
Report Facts
Residents Served: 75
Secured Dementia Care Unit Residents Served: 22
Hospice Residents: 7
Residents with Mobility Need: 52
Residents 60 Years or Older: 75
Residents Diagnosed with Intellectual Disability: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shawn Parker | Signed the letter confirming full implementation of the plan of correction. | |
| Executive Director | Executive Director (ED) | Named in relation to submitting incident reports, conducting staff training, updating policies, and overseeing plan of correction implementation. |
Inspection Report — Mar 10, 2022
Follow-Up
Date: Mar 10, 2022
Visit Reason
The inspection was a partial, unannounced follow-up visit conducted on 03/10/2022 to verify the implementation of a previously submitted plan of correction related to an incident.
Findings
The facility was found to have sanitary and safety deficiencies including clutter and unclean laundry room, dryer maintenance issues, lint accumulation, combustible storage near boilers, and evacuation protocol non-compliance. Plans of correction were accepted and implemented with ongoing monitoring and education.
Citations (5)
Main laundry room cluttered with plastic bins, unfolded linens, and unclean washer machine.
Dryer on second-floor laundry room was out of order with unsecured duct work insulation sleeve causing fire alarm activation.
Approximately 10 inches of lint accumulation in lint trap of main dryer; duct cleaning done every 6 months instead of every 3 months as per manufacturer.
Twelve cardboard boxes stored near the boiler and paper manufacturer's instructions taped onto boilers.
Resident #1 did not evacuate to a public thoroughfare or fire safe area during fire alarm, remaining in bistro area.
Report Facts
Residents Served: 55
Residents Served in Secured Dementia Care Unit: 14
Hospice Residents: 5
Total Daily Staff: 84
Waking Staff: 63
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Coordinator | Maintenance Coordinator (MC) | Named in multiple findings related to laundry room cleanliness, dryer repair, combustible storage removal, and fire drill evacuation. |
| Executive Director | Executive Director (ED) | Named in findings related to staff education, fire safety meetings, and oversight of corrective actions. |
Inspection Report — Feb 8, 2022
Follow-Up
Date: Feb 8, 2022
Visit Reason
The inspection was a partial, unannounced follow-up visit triggered by an incident to verify the implementation of a submitted plan of correction.
Findings
The submitted plan of correction was determined to be fully implemented as of the review dates. The facility was found to have corrected prior deficiencies related to trash removal and evacuation procedures.
Citations (2)
Trash was left in a resident's room for longer than one week, violating the requirement that trash be removed at least once a week.
Residents were not evacuated to a public thoroughfare or fire-safe area during a fire alarm on 2/1/22; staff believed it was a false alarm and redirected residents back to their rooms.
Report Facts
Residents Served: 57
Memory Care Residents Served: 16
Total Daily Staff: 97
Waking Staff: 73
Residents with Mobility Need: 40
Inspection Report — Jan 31, 2022
Complaint Investigation
Date: Jan 31, 2022
Visit Reason
The inspection was conducted as a complaint investigation with an unannounced partial review of the facility on 01/31/2022 and 02/01/2022.
Complaint Details
The inspection was triggered by a complaint and conducted as an unannounced partial review on 01/31/2022 and 02/01/2022.
Findings
The inspection identified multiple deficiencies related to quality management, staff orientation, and sanitary conditions in the kitchen including food storage and protection issues. Plans of correction were submitted and accepted, with measures implemented to address the violations.
Citations (6)
The home's quality management plan did not include development and implementation of measures to address dining services concerns related to hot food.
Ancillary staff person did not have a general orientation to specific job functions regarding use of the kiosk for dietary guidelines and resident preferences.
Sanitary conditions were not maintained: a Dunkin Donuts cup with liquid was found on the kitchen preparation table, stove covered with food spills, and a plastic bin for rice had old dried rice and debris.
Food was not protected from contamination: uncovered container of bacon and sausage stored on top of the stove.
Food was stored on the floor: boxes of food observed stored on the refrigerator floor.
Food was stored in unsealed containers: a box of Domino Premium Cane Powdered sugar was opened and unsealed.
Report Facts
Residents Served: 56
Secured Dementia Care Unit Residents Served: 16
Resident with Mobility Need: 37
Resident Age 60 or Older: 56
Inspection Report — Dec 13, 2021
Follow-Up
Date: Dec 13, 2021
Visit Reason
The inspection was a partial, unannounced follow-up visit conducted due to an incident, with a Plan of Correction (POC) submission follow-up.
Findings
The facility was found to have implemented the submitted Plan of Correction fully. Deficiencies involved treatment of residents with dignity and respect, direct care staff qualifications, and initial direct care training requirements, all of which were addressed with corrective actions and training.
Citations (3)
Staff person A refused to give Resident #1 a scheduled shower and used disrespectful language.
Direct care staff person A did not have a high school diploma, GED, or active registry status on the Pennsylvania nurse aide registry.
Direct care staff person A did not complete and pass the Department-approved direct care training course and competency test and continued to provide unsupervised ADL services.
Report Facts
Residents Served: 59
Residents Served in Secured Dementia Care Unit: 18
Total Daily Staff: 100
Waking Staff: 75
Residents with Mobility Need: 41
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff person A | Named in deficiencies related to refusal to provide scheduled shower, lack of qualifications, and incomplete direct care training | |
| Executive Director | Conducted training and oversaw implementation of Plan of Correction | |
| Business Office Coordinator | Responsible for reporting on training compliance and monitoring as part of QAPI |
Inspection Report — Sep 21, 2021
Follow-Up
Date: Sep 21, 2021
Visit Reason
The inspection was a partial, unannounced follow-up visit triggered by an incident to verify the implementation of a previously submitted plan of correction.
Findings
The submitted plan of correction related to a support plan signature deficiency was found to be fully implemented. The deficiency involved a resident who participated in the development of their support plan but did not sign it. The facility implemented training and monitoring to ensure compliance.
Citations (1)
Resident #1 participated in the development of the support plan but did not sign the support plan.
Report Facts
Residents Served: 62
Secured Dementia Care Unit Residents Served: 16
Total Daily Staff: 105
Waking Staff: 79
Inspection Report — May 18, 2021
Renewal
Date: May 18, 2021
Visit Reason
The inspection was conducted as a renewal inspection of the Sunrise Senior Living of Lower Makefield facility on 05/18/2021 and 05/19/2021.
Findings
The inspection identified multiple deficiencies including failure to post required influenza information, direct care staff providing unsupervised ADL services without completing required training, unsecured poisonous materials accessible to residents, lack of operable bedside lighting for a resident, and missing resident signatures on support plans.
Citations (5)
The home did not have an influenza poster posted anywhere as required by the Influenza Awareness Act.
Direct care staff person A provided unsupervised ADL services without completing and passing the Department-approved direct care training and competency test until 05/18/21.
A 2.5 ounce tube of Colgate Cavity Protection Toothpaste labeled as poisonous was unlocked, unattended, and accessible to residents in the bathroom of room 130 in the Reminiscence Unit.
Resident #1 did not have access to a source of light that can be turned on/off at bedside.
Residents 1, 2, 3, 4 and 5 participated in the development of their support plans but did not sign the support plans, with no documentation of attempts or refusals.
Report Facts
Residents Served: 58
Secured Dementia Care Unit Residents Served: 16
Hospice Residents: 10
Residents Age 60 or Older: 59
Residents with Mobility Need: 40
Total Daily Staff: 98
Waking Staff: 74
Inspection Report — Apr 29, 2021
Renewal
Date: Apr 29, 2021
Visit Reason
The document is a renewal application and license issuance for Sunrise Senior Living of Lower Makefield, a Personal Care Home, pursuant to Title 55, PA Code, Chapter 2600.
Findings
A regular license is being issued in response to the renewal application. The Department will conduct an onsite inspection within the next twelve months to ensure compliance with applicable regulations.
Report Facts
Inspection Report — Jan 14, 2021
Date: Jan 14, 2021
Visit Reason
The inspection was conducted as a partial, unannounced visit due to an incident, with multiple off-site inspection dates and an on-site visit on 01/14/2021.
Findings
No regulatory citations or deficiencies were identified during the inspection.
Report Facts
Residents Served: 62
Residents Served in Secured Dementia Care Unit: 19
Inspection Report — Dec 2, 2019
Renewal
Date: Dec 2, 2019
Visit Reason
The inspection was an unannounced renewal inspection conducted on December 2, 3, and 4, 2019 to review compliance with licensing regulations.
Findings
The facility was found to have multiple violations including resident abuse reporting delays, failure to comply with ServSafe certification requirements, staff orientation deficiencies, and medication administration errors. All cited violations had approved plans of correction that were implemented as of May 11, 2020.
Citations (10)
2600 15.a. The home failed to immediately report suspected abuse of a resident; staff person B yelled at resident #1 on 11/13/19 but the incident was not reported until 11/27/19.
2600 18. The home failed to comply with ServSafe certification; only one staff was certified and not available during all hours of operation.
2600 42.c. Staff person B cursed and yelled at resident #1 while providing care and showed the resident a soiled personal product.
2600 65.a. Agency staff did not receive orientation on fire safety, emergency evacuation, and related procedures prior to or on their first work day.
2600 65.b. Agency staff were not trained in the emergency medical plan for the home.
2600 85.a. An unlabeled razor was found in a shared cabinet in memory care, presenting an unsanitary condition.
2600 107.c. The home did not have a designated space for nonperishable food storage for 81 residents in an emergency; violation was withdrawn.
2600 181.a. The home failed to provide assistance to resident #1 with self-administering medications, resulting in failure to follow prescribers' orders and incorrect medication labeling.
2600 184.a. The pharmacy labels for resident #2's Gabapentin and Lexapro tablets did not reflect the correct dosages.
2600 187.d. Resident #2 cut Lexapro tablet in half to create a 5 mg dose, contrary to prescribed 10 mg daily dose.
Report Facts
Residents Served: 81
Dementia Unit Residents Served: 26
Hospice Current Residents: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shanna Garland | Executive Director | Named in multiple plans of correction and signature on documents |
| Natasha Braswell | On-site department representative during inspection | |
| Dean Gray | On-site department representative during inspection |
Inspection Report — Oct 9, 2019
Follow-Up
Date: Oct 9, 2019
Visit Reason
The visit was a follow-up review to verify that the previously submitted plan of correction was fully implemented following an incident-related partial inspection.
Findings
The submitted plan of correction was determined to be fully implemented. The facility demonstrated compliance with regulations related to medical evaluations and support plan signatures.
Citations (3)
2600.141.a Resident #1's medical evaluation dated 7/10/19 did not include medical information pertinent to diagnosis and treatment and health status.
2600.227.g Resident #1 participated in the development of his/her support plan on 07/11/19 but did not sign the support plan.
2600.227.h Resident #1 participated in the development of his/her support plan on 07/11/19 but was unable to sign and the home did not document the resident's inability to sign.
Report Facts
Residents Served: 84
Secured Dementia Care Unit Residents Served: 28
Hospice Current Residents: 14
Inspection Report — Jul 11, 2019
Complaint Investigation
Date: Jul 11, 2019
Visit Reason
The inspection was conducted as a complaint and incident investigation at Sunrise Senior Living of Lower Makefield.
Complaint Details
The inspection was triggered by a complaint and incident. The violation regarding the unsigned resident-home contract was substantiated.
Findings
Violations of 55 Pa. Code Chapter 2600 related to Personal Care Homes were found, specifically a resident-home contract was not signed by the administrator or designee. A plan of correction was submitted to address the contract signature issue.
Citations (1)
55 Pa. Code 2600.25b: The resident-home contract dated 2/28/17 for resident #1 was not signed by the Personal Care Home Administrator or Designee.
Report Facts
Residents Served: 77
Secured Dementia Care Unit Residents Served: 28
Hospice Current Residents: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shanna Garland | Executive Director | Named in plan of correction and contract signature violation |
Inspection Report — Apr 26, 2019
Renewal
Date: Apr 26, 2019
Visit Reason
The document is a renewal application and license issuance for Sunrise Senior Living of Lower Makefield as a Personal Care Home. The Department will conduct an onsite inspection within the next twelve months as required by regulation.
Findings
No inspection findings are reported in this document. It serves as a license renewal notification and confirmation of the facility's permitted capacity.
Report Facts
Inspection Report — Apr 23, 2019
Routine
Date: Apr 23, 2019
Visit Reason
The Department’s Bureau of Human Services Licensing conducted an inspection of Sunrise Senior Living of Lower Makefield 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 — Feb 4, 2019
Complaint Investigation
Date: Feb 4, 2019
Visit Reason
The inspection was conducted as a complaint investigation triggered by an incident involving suspected abuse at the facility.
Complaint Details
The complaint was substantiated as staff delayed reporting suspected abuse of a resident by 24 hours, violating mandatory reporting requirements.
Findings
The facility was found to have violated 55 Pa. Code Chapter 2600 related to personal care homes, specifically for failing to immediately report suspected abuse of a resident. A plan of correction was submitted addressing the reporting deficiencies and staff training requirements.
Citations (1)
55 Pa.Code §2600.15(a) requires immediate reporting of suspected resident abuse. Staff member B waited 24 hours before reporting allegations of abuse against resident #1 to the team lead on the 3pm-11pm shift.
Report Facts
Number of Residents Served: 79
Number of Current Hospice Residents: 7
Number of Residents Served in Secured Dementia Care Unit: 27
Number of Hospice Residents in Past Year: 48
Number of Residents Age 60 or Older: 79
Number of Residents with Mobility Need: 37
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shanna Garland | Administrator | Named as facility administrator in report header |
| Natasha Braswell | Department representative on-site during inspection | |
| Francine Colaneri | Business Office Coordinator | Signed Plan of Correction document |
Inspection Report — Dec 4, 2018
Annual Inspection
Date: Dec 4, 2018
Visit Reason
The inspection was the Department of Human Services Licensing annual inspection of Sunrise Senior Living of Lower Makefield conducted on December 4 and 7, 2018, to assess compliance with 55 Pa. Code Chapter 2600 relating to Personal Care Homes.
Findings
The inspection identified violations related to resident dignity and respect, use of chemical restraints, and food storage practices. A plan of correction was submitted and partially implemented with adequate progress as of April 1, 2019.
Citations (4)
Regulation 55 Pa.Code 2600.42(a) - A resident was not treated with dignity and respect during the night shift as staff failed to communicate and showed lack of respect by leaving the resident lying down and not resting in bed.
Regulation 55 Pa.Code 2600.42(p) - Staff used chemical restraints on a resident without trying other behavioral management methods and stayed in the room to ensure medication took effect before leaving.
Regulation 55 Pa.Code 2600.103(g) - Several food items in the Reminisce refrigerator were open, unsealed, and unlabeled, including cocktail sauce, ice cream, and cookies.
Regulation 55 Pa.Code 2600.202 - The use of involuntary confinement, aversive conditioning, pain techniques, chemical restraints, mechanical restraints, and manual restraints are prohibited; staff chemically restrained a resident without proper procedures.
Report Facts
Number of Residents Served: 76
Total Daily Staff: 127
Walking Staff: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shanna Garland | Executive Director | Named as legal entity representative and signer of the plan of correction. |
| Tahesla Thomas | Named as inspector on-site during inspection dates. |
Inspection Report — Aug 14, 2018
Complaint Investigation
Date: Aug 14, 2018
Visit Reason
The inspection was conducted as a complaint investigation following an incident reported by Resident 1 regarding staff conduct.
Complaint Details
The complaint was submitted by Resident 1 on 07/31/18 regarding staff A. The home failed to report the incident to the Department until 08/03/18.
Findings
The facility failed to report an incident to the Department within 24 hours as required by regulation. Additionally, Resident 1's most recent assessment did not address the need for adult briefs.
Citations (2)
Regulation 55 Pa.Code §2600.16(c): The home did not submit an incident report to the Department within 24 hours after Resident 1 submitted a written complaint about staff.
Regulation 55 Pa.Code §2600.225(c): Resident 1's most recent assessment completed on 03/26/18 did not address the resident's need for adult briefs.
Report Facts
Number of Residents Served: 70
Number of Current Hospice Residents: 7
Number of Hospice Residents in past year: 29
Total Daily Staff: 114
Waking Staff: 88
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shanna Garland | Administrator and Executive Director | Named as Executive Director signing the Plan of Correction and involved in corrective actions |
Inspection Report — May 7, 2018
Routine
Date: May 7, 2018
Visit Reason
The Department's Bureau of Human Services Licensing representatives conducted an inspection of the facility on May 7, 2018.
Findings
No regulatory violations with 55 Pa. Code Ch. 2600 (relating to Personal Care Homes) were identified as a result of this inspection.
Notice — Apr 20, 2018
Date: Apr 20, 2018
Visit Reason
This document serves as a renewal notification and license issuance for Sunrise Senior Living of Lower Makefield, confirming receipt of the renewal application and advising of the requirement for an annual onsite inspection within the next twelve months.
Findings
No inspection findings are reported in this document; it is a licensing renewal notice with no compliance or deficiency information.
Report Facts
Inspection Report — Apr 2, 2018
Complaint Investigation
Date: Apr 2, 2018
Visit Reason
The inspection was conducted as a complaint investigation triggered by an incident involving a resident fall.
Complaint Details
The visit was complaint-related due to an incident involving a resident fall. The violation was substantiated as the facility failed to complete a required new assessment.
Findings
The facility was found to have violated 55 Pa.Code Chapter 2600 by failing to complete a new assessment for a resident who experienced a fall on 11/3/17 and 03/21/18. The home had not updated the resident's needs to reflect these changes.
Citations (1)
55 Pa.Code §2600.225(c): The resident who experienced a fall on 11/3/17 and 03/21/18 did not have a new assessment completed to reflect changes in needs.
Report Facts
Number of Residents Served: 70
Number of Current Hospice Residents: 10
Number of Hospice Residents in past year: 16
Number of Residents who are 60 Years of Age or Older: 70
Number of Residents who Have a Mobility Need: 36
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shanna Garland | Administrator, MSM-HCA | Named as Administrator and Legal Entity Representative signing Plan of Correction |
| Dean Gray | Department Representative on-site during inspection |
Inspection Report — Nov 16, 2017
Complaint Investigation
Date: Nov 16, 2017
Visit Reason
The inspection was conducted due to a complaint and incident at Sunrise Senior Living of Lower Makefield.
Complaint Details
The inspection was triggered by a complaint and incident. Specific substantiation status is not stated.
Findings
Two violations of 55 Pa.Code Chapter 2600 were found: one involving a staff member forcing a resident to disrobe and shower against repeated requests, and another involving a resident's medical evaluation not being conducted annually as required.
Citations (2)
55 Pa.Code §2600.42(c) - A staff member forced a resident to disrobe and shower despite repeated requests to stop.
55 Pa.Code §2600.141(b)(1) - A resident's most recent medical evaluation was not conducted annually; the last evaluation was over a year old.
Report Facts
Number of Residents Served: 78
Number of Residents Served in Secured Dementia Care Unit: 24
Number of Current Hospice Residents: 15
Number of Hospice Residents in Past Year: 32
Number of Residents Age 60 or Older: 78
Number of Residents with Mental Illness: 1
Number of Residents with Mobility Need: 35
Number of Residents with Physical Disability: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shanna Garland | Executive Director | Named in plan of correction and signature as legal entity representative |
| Dean Gray | Department representative on-site during inspection |
Inspection Report — Aug 23, 2017
Complaint Investigation
Date: Aug 23, 2017
Visit Reason
The inspection was conducted as a complaint investigation triggered by an incident involving a resident's privacy violation and medication administration issues.
Complaint Details
The investigation was triggered by a complaint regarding a staff member video recording a resident without consent and sharing the video. Additional findings included medication administration errors affecting multiple residents.
Findings
The inspection found violations related to resident dignity and respect, privacy of self and possessions, safe medication storage and administration, and adherence to prescriber orders. Multiple residents missed medications or received incorrect dosages due to medication errors and policy noncompliance.
Citations (5)
55 Pa.Code §2600.42(c): A resident was video taped on the home's property by staff, violating the resident's dignity and rights. The video was shared via a media application.
55 Pa.Code §2600.42(s): A resident's privacy was violated when video taping occurred on the property by staff, invading the resident's privacy during bathing, dressing, and medical procedures.
55 Pa.Code §2600.185(a): From June 2 to June 15, 2017, 26 residents missed various medication doses because medications were not available in the home.
55 Pa.Code §2600.185(b): Resident #3 had medication misused; Percocet dosage was decreased without proper administration. The home continued to administer Percocet against prescriber orders on multiple dates.
55 Pa.Code §2600.187(d): The home failed to follow prescriber orders for multiple residents, including incorrect administration of Tylenol and Colace, and missed medications for 25 residents due to unavailability.
Report Facts
Number of Residents Served: 78
Number of Residents Missing Medication: 26
Number of Current Hospice Residents: 14
Number of Hospice Residents in Past Year: 19
Number of Residents Served in Secured Dementia Care Unit: 22
Number of Residents Age 60 or Older: 78
Number of Residents with Mobility Need: 45
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shanna Garland | Executive Director | Named in plan of correction and legal entity representative |
Inspection Report — May 11, 2017
Renewal
Date: May 11, 2017
Visit Reason
The inspection was conducted as part of the Department of Human Services' annual licensing renewal inspections on May 11 and May 12, 2017, for Sunrise Senior Living of Lower Makefield.
Findings
The inspection identified multiple violations related to fire safety, medication labeling and administration, medication storage and training, and resident admission procedures. Plans of correction were submitted and partially implemented with adequate progress noted.
Citations (6)
55 Pa.Code §2600.105(g)(1): A large accumulation of lint was found in the lint trap of the dryer in the main laundry room on the first floor on 05-12-17.
55 Pa.Code §2600.184(a): The label for resident #1's Lantus insulin stated 14 units, but the MAR stated 6 units were to be injected.
55 Pa.Code §2600.185(a): Residents #2 and #3's PRN medications (Loperamide 2 mg and Acetaminophen 325 mg) were not available in the home.
55 Pa.Code §2600.190(c): Staff person A's Diabetes Education Training Certificate expired on 10-14-16 and was renewed on 01-23-17, but the certificate was expired during November and December 2016 while administering insulin.
55 Pa.Code §2600.224(a): Resident #4 was admitted with a pre-screening completed 01-04-17, exceeding the required 30 days prior to admission.
55 Pa.Code §2600.227(d): Resident #5's support plan incorrectly stated that family is responsible for assistance with agitation and aggression issues, which is invalid as family is not always present.
Report Facts
Number of Current Hospice Residents: 15
Number of Hospice Residents in Past Year: 22
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shanna Garland | Executive Director | Named as Administrator and legal entity representative signing plans of correction. |
| Shawn Parker | Inspector conducting the violation report. |
Notice — May 1, 2017
Date: May 1, 2017
Visit Reason
The document serves as a renewal notification and license issuance for Sunrise Senior Living of Lower Makefield following the submission of a renewal application.
Findings
No inspection findings are reported in this document. It confirms the license issuance and outlines the requirement for an annual onsite inspection within the next twelve months.
Report Facts
Inspection Report — Nov 28, 2016
Complaint Investigation
Date: Nov 28, 2016
Visit Reason
The inspection was conducted as a complaint investigation triggered by an incident involving medication administration at Sunrise Senior Living of Lower Makefield.
Complaint Details
The visit was complaint-related due to an incident where a resident did not receive prescribed medications. The plan of correction was partially implemented as of the latest update.
Findings
The facility failed to follow the directions of the prescriber by not administering prescribed medications to a resident. A plan of correction was submitted and partially implemented to address the medication delivery and documentation process.
Citations (1)
55 Pa.Code §2600 187(d): The home did not follow the directions of the prescriber by failing to administer prescribed medications to a resident on the specified date and time.
Report Facts
Date of inspection: Nov 28, 2016
Date of previous violation: May 26, 2016
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Francine Szatkowski | Administrator/Business Office Coordinator | Signed the Plan of Correction |
| Tahesla Thomas | Inspector conducting the off-site inspection |
Inspection Report — Aug 23, 2016
Complaint Investigation
Date: Aug 23, 2016
Visit Reason
The inspection was conducted as a complaint investigation triggered by an incident involving Resident #1 leaving the community without supervision.
Complaint Details
The visit was complaint-related due to an incident where Resident #1 left the community without supervision. The complaint was substantiated by the finding of the violation.
Findings
The facility was found to have a violation of 55 Pa.Code Ch. 2600 related to inadequate supervision of Resident #1 who left the community unsupervised. A plan of correction was implemented to address the resident's supervision needs and prevent future elopements.
Citations (1)
55 Pa.Code §2600.23(a) requires a home to provide assistance with daily living activities as indicated in the resident's plan. Resident #1 was found to be at elopement risk and left the community without supervision on 8/5/16.
Report Facts
Number of Residents Served: 89
Number of Current Hospice Residents: 14
Number of Hospice Residents in past year: 10
Number of Residents Served in Secured Dementia Care Unit: 28
Residents Age 60 or Older: 89
Residents with Mental Illness: 3
Residents with Mobility Need: 27
Residents with Physical Disability: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| David Allen | Executive Director | Named in relation to facility administration and plan of correction |
| Patricia Adams | Human Services Licensing Supervisor | Signed the licensing inspection letter |
Inspection Report — May 26, 2016
Renewal
Date: May 26, 2016
Visit Reason
The inspection was a renewal licensing inspection conducted by the Pennsylvania Department of Human Services on May 26, 2016, for Sunrise Senior Living of Lower Makefield.
Findings
The inspection identified multiple violations related to food storage temperatures, medication administration documentation, outdated or dented food containers, medication labeling, and medication administration training. Plans of correction were submitted and partially implemented with adequate progress noted.
Citations (6)
Regulation 55 Pa.Code §2600.103(f): There was no thermometer in the freezer on the Reminiscence Unit during the inspection.
Regulation 55 Pa.Code §2600.103(i): A dented can of chocolate pudding was observed in the kitchen pantry.
Regulation 55 Pa.Code §2600.182(c): The home failed to document medication administration records based on glucometer readings on May 18, 2016.
Regulation 55 Pa.Code §2600.184(a): Medication labels for resident #2 documented four times daily for Hydralazine HCL 10 mg and twice daily for Furosemide 40 mg did not match the medication administration record.
Regulation 55 Pa.Code §2600.187(d): The home failed to follow prescriber directions for medication administration for residents #1, #2, and #3, including documentation errors and discontinued medications.
Regulation 55 Pa.Code §2600.190(c): The home's medication administration training record for staff person A lacked documentation of the first medication administration review, pass results, and observation date.
Report Facts
Number of Residents Served: 89
Number of Deficiencies: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Francine Szatkowski | Administrator/Business Office Coordinator | Named as legal entity representative signing plans of correction and involved in findings. |
Notice — May 12, 2016
Date: May 12, 2016
Visit Reason
This document serves as a renewal notification for the Personal Care Home license of Sunrise Senior Living of Lower Makefield, confirming the license issuance and advising of the requirement for an annual onsite inspection within the next twelve months.
Findings
No inspection findings are reported in this document. It is a license renewal notice confirming the facility's authorized capacity and renewal status.
Report Facts
Inspection Report — Mar 22, 2016
Complaint Investigation
Date: Mar 22, 2016
Visit Reason
The inspection was conducted as a complaint investigation following an incident involving alleged abuse of a resident.
Complaint Details
The investigation was triggered by an incident on 3/16/16 involving alleged abuse of resident #1. The allegation was not immediately reported as required. The complaint was substantiated by the violation found.
Findings
The facility was found to have violated 55 Pa.Code Chapter 2600 related to reporting suspected abuse of a resident. The home failed to immediately report an allegation of abuse made on 3/16/16 involving resident #1.
Citations (1)
55 Pa.Code §2600.15(a) requires immediate reporting of suspected abuse of a resident. The home did not report an allegation of abuse against resident #1 made on 3/16/16 until 3/18/16, and the family member addressed it with staff instead.
Report Facts
Number of Residents Served: 88
Number of Current Hospice Residents: 11
Number of Residents Served in Secured Dementia Care Unit: 28
Number of Hospice Residents in Past Year: 27
Number of Residents Age 60 or Older: 68
Number of Residents with Mental Illness: 3
Number of Residents with Mobility Need: 55
Number of Residents with Physical Disability: 1
Inspection Report — Mar 15, 2016
Complaint Investigation
Date: Mar 15, 2016
Visit Reason
The inspection was conducted as a complaint investigation at Sunrise Senior Living of Lower Makefield on March 15, 2016.
Complaint Details
The inspection was triggered by a complaint. The report does not explicitly state the substantiation status.
Findings
The facility was found to have violations related to resident assessments under 55 Pa.Code Chapter 2600. Specifically, the resident care needs assessments were not updated to reflect significant changes in condition. A plan of correction was submitted addressing these issues.
Citations (1)
55 Pa.Code §2600.225(c) - The facility failed to complete a new assessment of Resident #1's needs to reflect significant mental and physical decline from January to February 2016. The resident exhibited hallucinations, confusion, aggression, and increased need for supervision and wheelchair use, but the home did not update the assessment accordingly.
Report Facts
Number of Residents Served: 89
Number of Current Hospice Residents: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Francine Szatkowski | Administrator/Business Office Coordinator | Signed the Plan of Correction related to the deficiency. |
Notice — June 10, 2020
Date: June 10, 2020
Visit Reason
This document serves as a renewal notification and license issuance for the Personal Care Home, Sunrise Senior Living of Lower Makefield, confirming compliance and informing about the requirement for an annual onsite inspection within the next twelve months.
Findings
The Department has issued a regular license in response to the renewal application and advises that an annual inspection will be conducted within the next twelve months. Enforcement action will be taken if noncompliance is found during the inspection.
Document — January 30, 2017
Date: January 30, 2017
Visit Reason
The document is a response letter to a waiver request related to qualifications for direct care staff persons under Pennsylvania Code Chapter 2600 for personal care homes.
Findings
The waiver request is being returned for additional information. The letter outlines acceptable alternatives to a GED or US high school diploma for direct care staff qualifications.
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