Inspection Reports for
Tapestry Senior Living – Moon Township

The facility was found to have multiple deficiencies related to staff background checks, training, medication management, sanitary conditions, and resident rights. Plans of correction were accepted and implemented for all identified violations.

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

The inspection was complaint-related, triggered by allegations of resident abuse involving staff pushing residents and bruising of unknown origin. The allegations were substantiated by findings of failure to report and respond appropriately to abuse incidents.

The facility failed to immediately report suspected and alleged resident abuse incidents to the Department of Aging and other required authorities. Additional deficiencies included failure to suspend involved staff immediately, delayed incident reporting, privacy violations involving unauthorized sharing of resident photos, and multiple documentation deficiencies related to medical evaluations, assessments, and support plans for residents.

No regulatory citations or deficiencies were identified during the inspection.

The inspection was triggered by a complaint and incident, as stated under Inspection Information with reason 'Complaint, Incident'.

Two deficiencies were identified: snow and ice were not properly removed from emergency exit steps and patio areas creating slipping hazards, and discrepancies were found in a resident's support plan regarding frequency of care checks.

The Department reviewed the submitted information and determined that the informed consent process includes voluntary participation, the right to discontinue device use, and notification of resident rights, satisfying regulatory privacy requirements.

The waiver allows a specific employee to serve as direct care staff despite not having a high school diploma, GED, or active registry status, based on credential evaluation of foreign education equivalent to an Associate degree. The waiver is subject to conditions including documentation retention and annual review during inspections.

No regulatory citations or deficiencies were identified during this inspection.

The visit was complaint-related as indicated by the inspection information section stating the reason as 'Complaint, Incident'.

The facility was found to have deficiencies including improperly labeled poisonous materials, unsanitary bathroom conditions, incomplete or outdated resident assessments, and missing preadmission cognitive screenings for the special care unit. Corrective actions were accepted and implemented with ongoing monitoring planned.

The visit was complaint-related due to an allegation of neglect of care needs involving a resident. The complaint was substantiated by the finding that the facility failed to report the incident as required.

The facility failed to submit an incident report to the Department after protective services investigated the allegation. The plan of correction was accepted and implemented to ensure timely reporting of such incidents in the future.

The inspection was complaint-related, but no deficiencies or citations were found, indicating no substantiated issues.

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

The inspection included a complaint investigation component. Specific complaint details are not explicitly stated, but deficiencies related to medication administration and sanitary conditions were addressed. Substantiation status is not provided.

The facility was found to have multiple deficiencies including expired boiler certificates, sanitary condition issues in the memory care kitchenette and common areas, furniture and equipment in disrepair, lack of soap dispensers in resident bathrooms, and medication record discrepancies. Plans of correction were accepted and fully implemented by 08/20/2024.

The visit was complaint-related and involved a substantiated deficiency regarding inadequate assistance with transfers for a resident requiring two-person physical assistance.

The submitted plan of correction was determined to be fully implemented. The deficiency involved failure to provide total physical assistance with transfers as required by the resident's support plan, which required two-person assistance. Staff were in-serviced and procedures updated to ensure compliance.

The complaint investigation was substantiated with findings of abuse/neglect. Resident #2 was injured and hospitalized. Mandatory abuse reports were filed with OAPS, AAA, and the department. The facility took corrective actions including supervision and psychological consultation.

The investigation found that resident #1 physically abused resident #2 by pulling and dragging them across the bedroom floor, resulting in multiple injuries to resident #2. The facility implemented a plan of correction including immediate notification of families and authorities, one-on-one supervision, medical and psychological assessments, staff education, and ongoing monitoring.

The inspection was triggered by a complaint as noted in the inspection information section.

Multiple deficiencies were identified including unsecured poisonous materials, tripping hazards, lack of hot and cold water in a resident's unit, absence of refrigerator thermometers, outdated food, and medication record errors. Plans of correction were accepted and implemented by early June 2023.

The inspection included a complaint investigation as indicated by the reason for visit. The submitted plan of correction was fully implemented and compliance was maintained.

Multiple deficiencies were identified including unsecured poisonous materials, uncovered trash cans, lack of operable bedside lamps, expired fire extinguisher inspection tags, unlabeled over-the-counter medications, and incomplete medication administration records. Plans of correction were accepted and implemented by mid-December 2022.

The visit was complaint-related, with substantiation implied by the deficiencies cited and follow-up actions required. The plan of correction was submitted and accepted, with implementation dates noted.

The submitted plan of correction was determined to be fully implemented, with continued compliance required. Specific deficiencies related to assistance with ADLs, follow prescriber’s orders, and assessment updates were addressed with documented corrective actions.

The visit was complaint-related with substantiation implied by findings of unmet resident care needs, multiple unwitnessed falls, combative and aggressive behaviors, and failure to update assessments and support plans accordingly.

The report found significant deficiencies related to resident care, including failure to update resident assessments and support plans to address changes in health, cognitive decline, and safety risks such as falls and agitation. Multiple unwitnessed falls and behavioral issues were documented, with plans of correction submitted and accepted.

The visit was complaint-related. The complaint involved medication storage and administration issues. The submitted plan of correction was fully implemented and compliance was maintained.

Two deficiencies were identified: improper medication storage where a loose Tylenol caplet was found on the floor in the secured dementia unit, and failure to follow prescriber’s orders resulting in administration of discontinued medications to a resident. Plans of correction were accepted and fully implemented.

The facility was found to be in compliance with the applicable regulations during the licensing inspections. As a result, a regular license was issued to the facility.

The inspection was complaint-related, with the reason stated as Complaint, Provisional, Interim. The violation was a repeat violation from previous dates 5/28/2021 and 11/9/2020.

A violation was found regarding confidentiality of resident records when a 24-hour report binder containing sensitive resident information was left unlocked and unattended at the nurses station. The facility was directed to remove the binder and implement ongoing HIPAA compliance training and audits.

The facility failed to immediately suspend or place on a plan of supervision two staff members involved in alleged physical abuse incidents reported by a resident. Additionally, the facility did not submit required notices of suspension or plans of supervision to the Department for these staff members. The submitted plan of correction was determined to be fully implemented.

The facility was found to be in compliance with the Assisted Living Residence regulations overall, but multiple deficiencies were cited including failure to post current license conspicuously, confidentiality breaches, incomplete criminal background checks for staff, incomplete direct care training, unlocked poisonous materials accessible to residents, missing emergency telephone numbers, missing window screens, incomplete first aid kit, improper refrigerator/freezer temperatures, insufficient emergency water supply, incomplete medical evaluations, medication storage issues, inconsistent documentation of self-administered medications, missing resident consent for special care unit admission, missing directions for key-locking devices, and use of outdated standardized forms.

The facility is deemed to be licensed in accordance with 55 Pa. Code Ch. 2800 until the inspection results are processed. This letter serves as verification of continued lawful operation and licensure in good standing.

Inspection was complaint-related and included a fine. The plan of correction was submitted and fully implemented.

The inspection found multiple deficiencies including an unsigned resident contract, unlabeled and undated leftover food items in refrigerators, and improperly stored food in unsealed containers. Plans of correction were accepted and implemented.

The inspection was complaint-driven; however, no deficiencies or citations were found, indicating no substantiated issues.

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

The inspection identified multiple deficiencies including repeat violations related to confidentiality of resident records, medication storage and labeling, privacy concerns with monitoring devices, safety hazards such as unguarded heat sources and missing handrails, and incomplete resident assessments and documentation. Plans of correction were accepted for all findings with scheduled staff education and monitoring.

The visit was complaint-related due to an incident involving alleged improper use of restraint on Resident #1. The plan of correction was approved and fully implemented as of June 12, 2020.

The investigation found that a manual restraint was used on Resident #1 during shower assistance, which is prohibited. Additionally, Resident #1's written initial assessment was found deficient as it did not fully reflect the resident's agitation and aggression behaviors.

The inspection was complaint-driven and unannounced. The complaint was substantiated based on dietary violations found related to Resident #1.

The facility was found to have violations related to the dietary needs and assessments of Resident #1, specifically regarding the provision of prescribed mechanical soft diet and documentation of special dietary needs. The submitted plan of correction was fully implemented as of June 12, 2020.

The complaint was substantiated based on the incident of a resident's unwitnessed fall on 1/19/2020, which was not reported to the Department until 3/3/2020.

The facility failed to report a resident's unwitnessed fall and head injury to the Department within the required 24-hour timeframe. The submitted plan of correction was later fully implemented.

The inspection was complaint-driven with multiple unannounced visits triggered by complaints and allegations including suspected sexual abuse, medication errors, and other regulatory concerns. The sexual abuse allegation involving resident #1 was not reported to the local Area Agency on Aging until nearly a month after the incident.

The facility was found to have multiple violations including untimely access to clinical records, missing resident contract signatures, incomplete criminal background checks, inadequate staff training, missing dementia training, unsafe physical environment conditions, medication labeling and administration issues, failure to report alleged resident abuse timely, confidentiality breaches, and fire safety deficiencies. Plans of correction were submitted and partially implemented.

The facility was found in substantial compliance with 55 Pa.Code Ch. 2800 but with citations noted on the violation report. Several deficiencies were identified related to signage, safety equipment, privacy, and emergency procedures, with plans of correction partially implemented.