17 Reports
Inspection Report — Jun 15, 2026
Renewal
Date: Jun 15, 2026
Visit Reason
The inspection was conducted as a renewal review of the facility's licensing compliance by the Pennsylvania Department of Human Services.
Findings
The inspection identified multiple deficiencies related to resident record confidentiality, posting of correct telephone numbers, facility maintenance issues including water damage, food storage and labeling violations, medication storage and administration record inaccuracies, and failure to follow prescriber orders. All deficiencies were addressed with corrective plans and re-education.
Citations (8)
Resident records were posted unsecured on a paper towel dispenser in an unlocked laundry room, violating confidentiality requirements.
The telephone number of the local Ombudsman posted throughout the facility was incorrect and required updating.
Water damage caused bubbled, peeling paint and a slit in the kitchen ceiling in room 201, requiring repair.
Unlabeled, unsealed, and undated food items including sausage links, cookie dough, sausages, and raw chicken were found in kitchen freezers and refrigerators.
Outdated or spoiled food items such as unlabeled meatloaf and spoiled spinach were found in refrigerators and discarded.
Resident 1's self-administered medications were not stored in a locked container or behind a locked door, making them accessible to others.
Medication Administration Records for Resident 2 did not include instructions to take Levothyroxine and Pantoprazole before meals.
Resident 1's medication administration record showed Vitamin B12 was administered once daily instead of the prescribed twice daily.
Report Facts
Residents Served: 100
Special Care Unit Residents Served: 31
Hospice Current Residents: 1
Notice — Mar 12, 2026
Date: Mar 12, 2026
Visit Reason
The document serves to notify the facility that a waiver request to 55 Pa.Code § 2800.54(a)(2) regarding direct care staff qualifications has been granted.
Findings
The waiver allows a specified employee to serve as direct care staff despite education obtained outside the United States, subject to conditions including documentation retention and annual review during inspections.
Notice — Mar 11, 2026
Date: Mar 11, 2026
Visit Reason
The document serves to notify the facility that a waiver request to 55 Pa.Code § 2800.54(a)(2) regarding direct care staff qualifications has been granted.
Findings
The waiver allows a specific employee to serve as direct care staff despite education obtained outside the United States, subject to conditions including documentation and annual review during inspections.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Theresa Hartman | Bureau Director, Human Services Licensing | Signed the waiver approval letter. |
Notice — Mar 1, 2026
Date: Mar 1, 2026
Visit Reason
The document serves to notify the facility that their request to waive the requirement for direct care staff to have a high school diploma, GED, or active registry status has been granted under specified conditions.
Findings
The waiver is granted based on submitted documentation showing equivalent education obtained outside the United States. The Department will review compliance with waiver conditions annually during inspections.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Theresa Hartman | Bureau Director, Human Services Licensing | Signed the waiver approval letter. |
Notice — Feb 13, 2026
Date: Feb 13, 2026
Visit Reason
The document serves to notify the facility that a waiver request to waive the high school diploma or GED requirement for a direct care staff person has been granted under specified conditions.
Findings
The waiver is granted based on submitted transcripts showing graduation from high school outside the United States and at least three years of coursework in math and science. The Department will review this waiver annually during inspections to ensure compliance with conditions.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Theresa Hartman | Bureau Director, Human Services Licensing | Signed the waiver approval letter. |
Inspection Report — Feb 12, 2026
Follow-Up
Date: Feb 12, 2026
Visit Reason
This was a follow-up inspection to review the submitted plan of correction after an incident involving a resident eloping from the Secure Care Unit.
Findings
The inspection found multiple deficiencies including failure to prevent resident elopement, unqualified direct care staff, lack of required fire safety training, improper storage of poisonous materials, snow and ice obstructions on emergency exit paths, missing fire extinguisher inspection dates, and incomplete cognitive preadmission screening for a special care unit resident. Plans of correction were accepted and implemented.
Citations (8)
42b Abuse/Neglect: A resident eloped from the Secure Care Unit despite alarms and staff notifications. The resident sustained injuries after being found outside the facility.
54a Direct care staff quals: Direct care staff person A lacked a high school diploma, GED, or active Pennsylvania nurse aide registry status.
65j Annual training content: Staff persons A and B did not receive required fire safety training completed by a fire safety expert during the training year.
82a Poisons original containers: Two unlabeled cleaning squirt bottles with unidentified liquid were found on an unattended housekeeping cart outside room 309.
82c Locked poisons: The same unlabeled cleaning bottles were not kept locked and inaccessible to residents, including those unable to safely use poisons.
100b Removal snow/obstructions: Snow and ice accumulation blocked emergency exit pathways and sidewalks outside stairwells 8, 9, and 10.
131f Fire extinguisher inspection: Fire extinguishers near elevator 3 and near a room lacked visible inspection dates.
231c1 Preadmit screening: A special care unit resident was admitted without a written cognitive preadmission screening completed within 72 hours prior to admission.
Report Facts
Residents Served: 102
Residents Served in Special Care Unit: 40
Current Residents in Hospice: 4
Staff Total Daily: 147
Waking Staff: 110
Resident Mobility Need: 45
Notice — Dec 1, 2025
Date: Dec 1, 2025
Visit Reason
The document serves to notify the facility that a waiver request to waive the high school diploma or GED requirement for a direct care staff member has been granted under Pennsylvania regulations.
Findings
The waiver is granted with conditions including documentation of professional credential evaluation and maintenance of records. The Department will review the waiver annually during inspections to ensure compliance.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Theresa Hartman | Bureau Director, Human Services Licensing | Signed the waiver approval letter. |
Inspection Report — May 12, 2025
Renewal
Date: May 12, 2025
Visit Reason
The inspection was conducted as a renewal inspection of THE 501 AT MATTISON ESTATE facility on 05/12/2025 and 05/13/2025.
Findings
The inspection identified multiple deficiencies including hot water temperatures exceeding 120°F in resident areas, lack of operable bedside lighting for a resident, unlabeled and undated leftover food in the kitchen, inaccurate fire drill evacuation records, incomplete medication records for a resident self-administering medications, and damaged medication blister packs. Plans of correction were submitted and fully implemented by 07/01/2025.
Citations (6)
Hot water temperature in resident living units exceeded 120°F at multiple sinks.
Resident #1 did not have access to a source of light that can be turned on/off at bedside.
Unlabeled, undated pie found in the main kitchen freezer.
Fire drill records did not include the correct number of residents evacuated during drills on 3/28/25 and 4/7/25.
Resident #1's medication record did not include a current list of medications despite medications being present in the living unit.
Resident #2's Tramadol 50 mg blister pack had tears in three places.
Report Facts
Residents Served: 92
Special Care Unit Residents Served: 29
Hospice Residents: 4
Residents Age 60 or Older: 91
Residents with Mental Illness: 2
Residents with Intellectual Disability: 1
Residents with Mobility Need: 37
Residents with Physical Disability: 0
Hot Water Temperature: 132.6
Hot Water Temperature: 135.1
Fire Drill Residents Evacuated (Incorrect Log): 28
Fire Drill Residents Evacuated (Incorrect Log): 26
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Health and Wellness Director | Health and Wellness Director (HWD) | Removed damaged medication blister pack and conducted re-education and audits related to medication storage. |
| Maintenance Director | Maintenance Director | Adjusted hot water temperatures and was retrained regarding fire drill evacuation documentation. |
| ALM | Assistant Living Manager (ALM) | Placed operable lamp at bedside, conducted audits on lighting and food storage, and responsible for ongoing compliance. |
| F&B Director | Food and Beverage Director | In-serviced dining staff on food storage regulations and responsible for auditing kitchen food storage. |
| Nurse on duty | Nurse | Contacted prescriber to secure necessary prescription order for resident medication. |
Notice — Apr 29, 2025
Date: Apr 29, 2025
Visit Reason
This document serves to notify the facility that a waiver request to Pennsylvania Code § 2800.54(a)(2) regarding direct care staff qualifications has been granted.
Findings
The waiver allows a specified 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. The Department will review this waiver annually during inspections to ensure compliance with conditions.
Notice — Nov 22, 2024
Date: Nov 22, 2024
Visit Reason
The document serves to notify the facility that a waiver request to waive the high school diploma requirement for a direct care staff person has been granted under 55 Pa.Code § 2800.19.
Findings
The waiver is granted with conditions including documentation of education and training to be kept on file and reviewed annually during inspections. Noncompliance may result in waiver termination or licensing action.
Notice — Oct 17, 2024
Date: Oct 17, 2024
Visit Reason
The document serves to notify the facility that a waiver request to waive the high school diploma requirement for a direct care staff person has been granted under specified conditions.
Findings
The waiver is granted based on submitted documentation of education and training from outside the United States. The Department will review the waiver annually during inspections to ensure compliance with conditions.
Inspection Report — Jun 4, 2024
Renewal
Date: Jun 4, 2024
Visit Reason
The inspection was conducted as a renewal, complaint, and incident review of THE 501 AT MATTISON ESTATE facility on 06/04/2024 and 06/05/2024.
Findings
The inspection found multiple deficiencies including failure to post required documents, issues with fire safety inspections and drills, medication management errors such as discontinued medications remaining in carts, incorrect medication labeling, improper storage procedures, incomplete medication administration records, failure to follow prescriber orders, illegible record entries, and missing official death certificate in a resident's record. All deficiencies had plans of correction accepted and were implemented by 08/30/2024.
Citations (10)
Residence did not post a copy of the required chapter in a conspicuous and public place.
Annual fire safety inspection was overdue; last completed on 11/29/2023.
Fire drill during sleeping hours not conducted every 6 months as required.
Discontinued medication (Mirtazapine 7.5 mg) remained in medication cart after discontinuation.
Pharmacy labels for medications did not match prescriber orders for residents #2 and #4.
Resident #1's glucometer was not calibrated to correct date and time; missing glucose monitoring entries.
Medication administration records missing staff initials for narcotic medications for residents #4 and #5.
Resident #4 was administered Tramadol 50 mg only 4 hours apart, not following prescribed 6-hour interval.
Controlled substance log had write overs and crossed out entries without proper notation.
Resident #6's record did not include an official death certificate after passing away unexpectedly.
Report Facts
Residents Served: 74
Special Care Unit Residents Served: 24
Hospice Residents: 1
Residents Age 60 or Older: 74
Residents with Mobility Need: 47
Total Daily Staff: 121
Waking Staff: 91
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Health and Wellness Director | Health and Wellness Director (HWD) | Named in multiple medication management and compliance findings and corrective actions. |
| Building Engineer | Building Engineer | Named in fire safety inspection and fire drill compliance findings and corrective actions. |
| Assisted Living Manager | ALM | Responsible for ongoing compliance and monitoring of corrective actions. |
Notice — Nov 6, 2023
Date: Nov 6, 2023
Visit Reason
The document serves to grant a waiver for a direct care staff person at The 501 at Mattison Estate who obtained their high school diploma outside the United States, allowing compliance with Pennsylvania staffing qualifications.
Findings
The waiver is granted with conditions requiring documentation of education and training to be maintained and reviewed annually during inspections. Noncompliance may result in waiver termination or licensing action.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Theresa Hartman | Director, Bureau of Human Services Licensing | Signed the waiver approval letter. |
Inspection Report — Jan 24, 2023
Monitoring
Date: Jan 24, 2023
Visit Reason
The visit was a monitoring inspection conducted on 01/24/2023 to review the facility's compliance with regulations and the implementation of a previously submitted plan of correction.
Findings
The inspection identified multiple deficiencies including unsigned resident contracts, missing signed statements acknowledging receipt of resident rights, improper food storage and outdated food items, incomplete medical evaluations, lack of resident education on medication refusal rights, and delayed support plan documentation. All deficiencies had plans of correction accepted and were implemented by early March 2023.
Citations (7)
Resident-residence contract for resident #1 was not signed by the resident.
Resident #1's record did not contain a signed statement acknowledging receipt of resident rights and complaint procedures.
Food was stored in unsealed containers including opened provolone cheese, chicken breast not in sealed container, and opened bags of grits and hot cocoa mix.
Outdated or spoiled food found: three unlabeled, undated blocks of cheese, a tray of chicken breast, and a dented can of pumpkin puree.
Medical evaluation for resident #2 did not include immunization history.
Resident #2 was not educated on the right to refuse medication if a medication error is suspected.
Resident #2's initial support plan was not completed within 72 hours of admission to the special care unit.
Report Facts
Residents Served: 17
Special Care Unit Residents Served: 4
Total Daily Staff: 25
Waking Staff: 19
Inspection Report — Dec 9, 2022
Complaint Investigation
Date: Dec 9, 2022
Visit Reason
The inspection was conducted as a complaint investigation at THE 501 AT MATTISON ESTATE facility on 12/09/2022.
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: 8
Memory Care Residents Served: 1
Inspection Report — Sep 12, 2022
Re-Inspection
Date: Sep 12, 2022
Visit Reason
The inspection was conducted as a licensing inspection of a newly licensed assisted living facility that is not yet serving four or more residents, requiring a re-inspection within three months to ensure full compliance.
Findings
The facility was found to be in substantial compliance with 55 Pa.Code Chapter 2800 regulations, but the licensing inspector was unable to complete a full inspection due to the low resident census. Citations were found and must be corrected by specified dates.
Inspection Report — Sep 12, 2022
Original Licensing
Date: Sep 12, 2022
Visit Reason
The inspection was an initial licensing inspection of a newly licensed assisted living residence that is not yet serving four or more residents.
Findings
The facility was found to be in substantial but not complete compliance with regulations. Several deficiencies were cited related to exterior hazards, fire safety areas, fire extinguisher inspections, and fire drills, all of which had accepted plans of correction with completion dates in September and October 2022.
Citations (4)
The courtyard in the Secured Dementia Care Unit had artificial turf that was not secured, causing ripples and posing a tripping hazard.
The 3rd floor memory care unit with capacity for 42 residents with mobility needs did not have a fire safe area specified in writing within the past year by a fire safety expert.
Fire extinguishers on the first, second, and third floors had not been inspected by a fire safety expert.
The residence lacked a written maximum evacuation time or fire safe areas determined by a fire safety expert's inspection.
Report Facts
Residents Served: 0
Inspection Date: Sep 12, 2022
Plan of Correction Completion Date: Oct 14, 2022
Plan of Correction Completion Date: Sep 27, 2022
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