Inspection Reports for
The Addison of Lowrie Place
100 Stirling Village, Meridian, PA 16001, United States, PA, 16001
Back to Facility Profile30 Reports
Inspection Report — Oct 17, 2025
Renewal
Date: Oct 17, 2025
Visit Reason
The inspection was a full, unannounced renewal inspection of THE ADDISON OF LOWRIE PLACE facility conducted on 10/17/2025.
Findings
The inspection identified four deficiencies related to resident personal equipment, handrails, refrigerator/freezer temperatures, and resident assessments. All deficiencies were addressed with plans of correction and were implemented by 12/15/2025.
Citations (4)
2600.81b: The enabler bar attached to a resident's bed was not securely attached, exposing an area that posed a potential entrapment hazard.
2600.93a: A concrete landing outside a resident's bedroom was approximately 7 inches above ground with no handrail present, posing a fall hazard.
2600.103f: There was no thermometer in the #3 freezer in the kitchen, which is required for food safety.
2600.225a: A resident's initial assessment did not document the specific need, intended use, risks, safe use ability, or FDA cover requirements for an enabler bar attached to the bed.
Report Facts
Residents Served: 41
Current Residents Hospice: 6
Inspection Report — Oct 8, 2024
Renewal
Date: Oct 8, 2024
Visit Reason
The inspection was conducted as a renewal review of the facility license by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing on 10/08/2024.
Findings
The inspection identified three deficiencies related to resident-home contracts not updated after a legal entity change, damaged window screens, and lack of an operable lamp at a resident's bedside. All deficiencies had plans of correction accepted and were implemented by 11/13/2024.
Citations (3)
Resident-home contracts were not updated for residents after a change of legal entity on 6/11/24.
Window screen next to the emergency exit near the staff break room had holes approximately 2" and 1" in size.
Resident #1 did not have an operable lamp at bedside.
Report Facts
Residents Served: 39
Current Hospice Residents: 5
Residents Age 60 or Older: 39
Residents Diagnosed with Mental Illness: 1
Residents with Mobility Need: 9
Total Daily Staff: 48
Waking Staff: 36
Inspection Report — Mar 21, 2024
Re-Inspection
Date: Mar 21, 2024
Visit Reason
The inspection was conducted due to a change in legal entity and as a re-inspection of a newly licensed personal care home to ensure compliance with 55 Pa. Code Chapter 2600 regulations.
Findings
The facility was found in substantial compliance with regulations but citations were issued related to sanitary conditions, trash receptacles, emergency procedures posting, and medication storage. Plans of correction were accepted and implemented by June 3, 2024.
Citations (5)
2600.85.a Sanitary conditions were not maintained as an uncovered container of old grease was stored under the kitchen sink with residue spread around it.
2600.85.d Trash receptacles in the kitchen were uncovered or damaged, including a trash can with a hole in its lid.
2600.85.e Trash outside the home was improperly stored as a large box was left on the ground between dumpsters.
2600.123.b Emergency procedures were not posted in a conspicuous and public place as the plan was stored on a shelf in the activities room.
2600.185.a Medication storage procedures were deficient as a resident's glucometer was not calibrated to the current date and time.
Report Facts
Residents Served: 38
Current Residents in Hospice: 3
Total Daily Staff: 50
Waking Staff: 38
Residents with Mobility Need: 12
Residents 60 Years or Older: 38
Residents Diagnosed with Mental Illness: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Juliet Marsala | Deputy Secretary | Signed the licensing letter and report cover letter |
| Health and Wellness Director | Named in medication storage deficiency and corrective actions | |
| Dining Director | Named in sanitary conditions and trash receptacle deficiencies and corrective actions | |
| Executive Director | Responsible for corrective actions and staff education related to deficiencies | |
| Director of Plant Operations | Named in trash outside home deficiency and corrective actions |
Inspection Report — Apr 10, 2023
Renewal
Date: Apr 10, 2023
Visit Reason
The inspection was conducted as a renewal licensing inspection of the facility.
Findings
No regulatory citations or deficiencies were identified during the inspection conducted on April 10 and 11, 2023.
Report Facts
Residents Served: 36
Current Hospice Residents: 4
Total Daily Staff: 49
Waking Staff: 37
Residents Age 60 or Older: 36
Residents Diagnosed with Mental Illness: 1
Residents with Mobility Need: 13
Inspection Report — Dec 22, 2022
Complaint Investigation
Date: Dec 22, 2022
Visit Reason
The inspection was conducted as a complaint investigation following allegations related to medication administration and supervision at the facility.
Complaint Details
The complaint investigation was triggered by allegations that Resident #1 did not receive prescribed Morphine Sulfate for pain and that the facility failed to report the incident and take appropriate supervisory actions. The facility disputed the findings, providing documentation that alternative pain medications were administered per physician orders and that the resident was appropriately evaluated and medicated.
Findings
The investigation focused on an incident involving Resident #1 who was reportedly in pain and did not receive prescribed Morphine Sulfate as ordered. The facility disputed the violations, stating that the resident was appropriately medicated with alternative pain medications (Acetaminophen and Lidocaine ointment) per physician orders and that no medication error or abuse occurred. The facility submitted plans of correction and implemented staff education and auditing to ensure compliance.
Citations (5)
Failure to immediately submit a plan of supervision or notice of suspension of the affected staff person after an incident involving pain medication administration.
Failure to report the prescription medication error to the Department.
Neglect and abuse related to failure to administer prescribed pain medication to Resident #1.
Failure to follow prescriber's orders regarding administration of Morphine Sulfate to Resident #1.
Failure to immediately report a medication error to the resident, designated person, and prescriber.
Report Facts
Residents Served: 32
Current Hospice Residents: 2
Residents 60 Years or Older: 32
Residents Diagnosed with Mental Illness: 1
Residents with Mobility Need: 5
Staffing Hours - Total Daily Staff: 37
Staffing Hours - Waking Staff: 28
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff person A | Named in findings related to medication administration and supervision involving Resident #1. | |
| Staff person B | Mentioned in relation to observation and reporting of Resident #1's condition during shift change. | |
| Staff person C | Mentioned in relation to observation and reporting of Resident #1's condition during shift change. |
Inspection Report — Jan 5, 2022
Renewal
Date: Jan 5, 2022
Visit Reason
The inspection was conducted as a renewal licensing inspection of the facility Lowrie Place on January 5 and 6, 2022.
Findings
The inspection found citations related to the storage of poisonous materials in unlabeled spray bottles. The facility submitted a plan of correction which was accepted and later determined to be fully implemented.
Citations (1)
Poisonous materials were stored in spray bottles labeled by staff with permanent marker instead of original manufacturer labels.
Report Facts
Number of spray bottles: 10
Residents Served: 28
Current Residents in Hospice: 4
Residents 60 Years or Older: 28
Residents Diagnosed with Mental Illness: 1
Residents with Mobility Need: 4
Residents with Physical Disability: 1
Notice — Apr 16, 2021
Date: Apr 16, 2021
Visit Reason
The document serves as a renewal license approval and notification that the Department will conduct an annual onsite inspection of the Personal Care Home within the next twelve months as required by regulation.
Findings
The Department has approved the renewal application and issued a regular license. No inspection findings are reported in this document.
Report Facts
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary | Signed the renewal approval letter. |
Inspection Report — Jan 21, 2021
Renewal
Date: Jan 21, 2021
Visit Reason
The inspection was conducted as a renewal review of the facility's compliance with licensing requirements.
Findings
Two deficiencies were identified: one related to failure to meet a resident's prescribed mechanical soft diet, and another involving an inaccurate medication administration record for a resident's morphine sulfate dosage. Plans of correction were accepted and implemented.
Citations (2)
Resident #1 was served food items not meeting the mechanical soft diet specifications as prescribed.
Resident #2's medication administration record incorrectly indicated Morphine Sulfate 20mg/ml instead of the prescribed 10mg/0.5ml every 2 hours as needed.
Report Facts
Residents Served: 29
Current Hospice Residents: 2
Residents Age 60 or Older: 29
Residents Diagnosed with Mental Illness: 1
Residents with Mobility Need: 2
Residents with Physical Disability: 1
Inspection Report — Jul 9, 2020
Complaint Investigation
Date: Jul 9, 2020
Visit Reason
The inspection was a partial, unannounced visit triggered by an incident involving alleged resident abuse.
Complaint Details
The visit was complaint-related due to an incident of alleged resident abuse involving staff person A and resident #1 on 6/6/2020. The allegation was substantiated with findings of delayed reporting, supervision, and notification.
Findings
The facility was found to have failed to timely report suspected resident abuse, delayed suspension and supervision of involved staff, and failed to provide required 30-day advance written notice of resident discharge. Plans of correction were accepted to address these deficiencies.
Citations (5)
Regulation 2600.15.a: The facility failed to immediately report suspected abuse of resident #1 to the Area Agency on Aging, delaying the report until 6/10/2020 after the incident on 6/6/2020.
Regulation 2600.15.b: The facility did not immediately develop a plan of supervision or suspend staff person A after the alleged abuse incident on 6/6/2020, allowing the staff to work unsupervised until 6/10/2020.
Regulation 2600.15.c: The facility failed to submit a plan of supervision or notice of suspension for staff person A to the Department until 6/10/2020, after the 6/6/2020 incident.
Regulation 2600.16.c: The facility did not report the abuse incident involving resident #1 to the Department Personal Care Home Regional Office within 24 hours as required.
Regulation 2600.228.b: The facility failed to provide a 30-day advance written notice of discharge to resident #1, the resident’s designated person, and referral agent, and did not obtain required certification that delay would jeopardize health or safety.
Report Facts
Residents Served: 38
Current Hospice Residents: 3
Residents 60 Years or Older: 38
Residents Diagnosed with Mental Illness: 5
Residents with Mobility Need: 4
Residents with Physical Disability: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff person A | Involved in the resident abuse incident and delayed suspension. | |
| Staff member B | Observed the abuse incident and was educated on reporting requirements. | |
| Staff member C | Observed the abuse incident, educated on reporting requirements, and no longer employed as of 07/31/2020. | |
| Cindy Naughton | Administrator | Facility administrator listed in the report. |
| Lori Gillette | Lead Inspector | Conducted the on-site inspection. |
| Suzy Quinn | Lead Reviewer | Reviewed the Plan of Correction submission. |
Inspection Report — Jan 15, 2020
Renewal
Date: Jan 15, 2020
Visit Reason
The inspection was a renewal inspection conducted as an unannounced full survey to assess compliance with licensing regulations.
Findings
The inspection identified multiple deficiencies including unsecured resident records, improper placement of carbon monoxide detectors, missing resident signatures on contracts, lack of emergency telephone numbers, missing window screens, inadequate lighting, combustible storage issues, evacuation procedure deficiencies, incomplete medical evaluations, and improper storage procedures. Plans of correction were submitted and fully implemented as of May 12, 2020.
Citations (11)
Regulation 2600.17: Resident lab results binder was found unlocked and accessible in a medication room file sleeve, exposing confidential information.
Regulation 2600.18: Carbon monoxide detectors were improperly placed or missing near resident rooms and kitchen furnace.
Regulation 2600.25.b: Resident-home contract for resident #1 dated 10/4/18 was not signed by the resident.
Regulation 2600.91: No emergency telephone numbers were posted near the telephone in resident bedroom #110.
Regulation 2600.92: The left window in resident room #117 had no screen installed.
Regulation 2600.101.j.7: Resident #2 did not have access to an operable lamp at bedside; lamp was placed 2 feet from bed.
Regulation 2600.125.a: Combustible materials were stored directly on or near furnaces in the furnace room and kitchen/staff lunch room.
Regulation 2600.132.h: Not all residents, including resident #3, evacuated to designated meeting place during fire drills.
Regulation 2600.141.a: Resident #4's medical evaluation dated 3/6/19 lacked height, weight, pulse rate, blood pressure, and temperature data.
Regulation 2600.185.a: Resident #5's glucometer was not set to the correct time or date.
Regulation 2600.227.d: Resident #4's support plan did not indicate need for trapeze bed assist bar, though it was installed on the bed.
Report Facts
Residents Served: 39
Current Hospice Residents: 7
Staff Counts: 42
Waking Staff: 32
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cindy Naughton | Administrator | Named as administrator and legal entity representative signing plans of correction |
Notice — Jan 14, 2020
Date: Jan 14, 2020
Visit Reason
This document serves as a renewal notification and license issuance for Lowrie Place, a Personal Care Home, confirming the facility's authorized capacity and informing about the requirement for an annual onsite inspection within the next twelve months.
Findings
No inspection findings are reported in this document. It only confirms the license renewal and outlines the Department's plan to conduct an annual inspection within the next year.
Report Facts
Inspection Report — Jul 31, 2019
Complaint Investigation
Date: Jul 31, 2019
Visit Reason
The inspection was conducted as a complaint investigation to assess compliance with 55 Pa. Code Ch. 2600 relating to Personal Care Homes.
Complaint Details
The inspection was complaint-driven and the violation involved incomplete documentation of hospice care services in a resident's support plan. The plan of correction was partially implemented by 9/24/19.
Findings
The inspection found a violation related to the resident support plan documentation, specifically that Resident #1's support plan did not indicate hospice care services that had started. A plan of correction was submitted and partially implemented as of 9/24/19.
Citations (1)
2600.227.d: Resident #1's support plan for significant change completed on 4/5/19 did not indicate hospice care and services or frequency of hospice services started on 4/3/19.
Report Facts
Residents Served: 45
Current Hospice Residents: 4
Total Daily Staff: 50
Waking Staff: 38
Inspection Report — May 30, 2019
Complaint Investigation
Date: May 30, 2019
Visit Reason
The inspection was conducted as a complaint investigation during an unannounced visit to Lowrie Place.
Complaint Details
The inspection was triggered by a complaint. The violations found included unsecured medication records, unsanitary conditions related to resident #3, and incomplete documentation of support plan signatures.
Findings
The inspection identified violations related to resident record confidentiality, sanitary conditions due to odor of urine, and incomplete support plan signatures. Plans of correction were partially implemented with ongoing staff education and audits planned.
Citations (3)
Regulation 2600.17: Resident medication administration records and narcotic count sheets were found unlocked and accessible to unauthorized persons.
Regulation 2600.85.a: A strong odor of urine was detected in resident #3's bedroom and the hallway outside the bedroom.
Regulation 2600.227.g: Staff person A participated in developing resident #3's support plan but did not sign the plan.
Report Facts
Residents Served: 42
Current Residents in Hospice: 2
Resident Support Staff Total Daily Staff: 50
Resident Support Staff Waking Staff: 38
Inspection Report — Feb 5, 2019
Renewal
Date: Feb 5, 2019
Visit Reason
The inspection was conducted as an annual licensing renewal inspection of Lowrie Place, a Personal Care Home, to assess compliance with 55 Pa. Code Chapter 2600.
Findings
The inspection identified four violations related to food refrigeration temperatures, annual furnace inspection, fire drill evacuation procedures, and medication storage. Plans of correction were submitted and partially implemented as of April 11, 2019.
Citations (4)
Regulation 55 Pa.Code 2600.103(f): The milk refrigerator temperatures were recorded at 46°F and 48°F, exceeding the required maximum of 40°F for refrigerated food storage.
Regulation 55 Pa.Code 2600.126(a): The home's seven gas-fueled furnaces had not been inspected in the past year; the last inspection was on 12/12/2017.
Regulation 55 Pa.Code 2600.132(h): During a fire drill on 6/28/2019, not all residents evacuated to a designated safe area; one resident refused to evacuate.
Regulation 55 Pa.Code 2600.183(d): Resident #1 had potassium and magnesium aspartate in the medication cart without a current order for this medication.
Report Facts
Staff Count: 50
Walking Staff Count: 38
Number of Current Hospice Residents: 3
Number of Hospice Residents in Past Year: 12
Residents Age 60 or Older: 42
Residents with Mobility Need: 8
Residents at Fire Drill: 35
Residents Evacuated at Fire Drill: 34
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cindy Naughton | Administrator | Named as legal entity representative signing violation reports and plans of correction |
| Josh Hoover | On-site inspector conducting the inspection | |
| Patricia Bartlett | On-site inspector conducting the inspection |
Inspection Report — Jan 2, 2019
Renewal
Date: Jan 2, 2019
Visit Reason
The document is a renewal application and license issuance for Lowrie Place Personal Care Home. The Department notifies that a regular onsite inspection will be conducted within the next twelve months as part of the renewal process.
Findings
No inspection findings are reported in this document. It serves as a license renewal notification and certificate issuance.
Report Facts
Inspection Report — Aug 23, 2018
Complaint Investigation
Date: Aug 23, 2018
Visit Reason
The inspection was conducted as a complaint investigation and incident review at Lowrie Place on August 23, 2018.
Complaint Details
The inspection was triggered by a complaint and incident involving improper resident transfer and medication administration errors. The complaint was substantiated as violations were found.
Findings
Multiple violations of 55 Pa. Code Chapter 2600 were found, including improper resident handling causing a fall, failure to follow prescriber directions for medication administration, incomplete resident assessments, and inadequate support plans. Plans of correction were submitted and partially implemented as of December 7, 2018.
Citations (4)
Regulation 2600.42(c): Staff transferred a resident using a sit-to-stand lift improperly, causing the resident to fall back into a wheelchair.
Regulation 2600.187(d): The home failed to administer Eliquis 25 mg twice daily to a resident from 7/16/18 through 8/3/18 as prescribed.
Regulation 2600.225(a): The initial assessment for a resident dated 10/13/17 showed minimal mobility needs but required two staff for transfers and use of a sit-to-stand lift device.
Regulation 2600.227(d): The resident's support plan dated 10/13/17 did not address the type or frequency of home health care services or need for Unna-boot wraps for skin protection.
Report Facts
Number of Residents Served: 42
Number of Current Hospice Residents: 6
Number of Residents Age 60 or Older: 42
Number of Residents with Mobility Need: 13
Inspection Report — Aug 2, 2018
Routine
Date: Aug 2, 2018
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 — Apr 17, 2018
Renewal
Date: Apr 17, 2018
Visit Reason
The document is a renewal application and certificate for Lowrie Place Personal Care Home. The Department of Human Services received the renewal application and will conduct an onsite inspection within the next twelve months as required by state regulations.
Findings
No inspection findings are reported in this document. It serves as a license renewal notification and certificate issuance.
Report Facts
Inspection Report — Apr 16, 2018
Complaint Investigation
Date: Apr 16, 2018
Visit Reason
The inspection was conducted as a complaint investigation triggered by an incident involving alleged resident abuse.
Complaint Details
The complaint involved alleged verbal and physical abuse of resident #1 by staff persons A and B on 4/5/18 at approximately 10:00 AM. The resident was agitated and staff became frustrated, using inappropriate language and physical aggression. The incident was reported late on 4/6/18 at 11:30 AM. Staff person B was suspended and is no longer employed.
Findings
The investigation found that staff persons A and B were verbally and physically aggressive toward resident #1, who has Alzheimer's disease. Staff failed to follow the resident's assessment and support plan, resulting in abuse and lack of dignity and respect toward the resident.
Citations (3)
55 Pa.Code §2600.15(a) - The home failed to immediately report suspected abuse of a resident. The incident was reported late to Protective Services.
55 Pa.Code §2600.23(a) - Staff did not follow several care needs outlined in resident #1's assessment and support plan (RASP).
55 Pa.Code §2600.42(c) - Resident #1 was not treated with dignity and respect during assistance with a shower.
Report Facts
Number of Residents Served: 38
Number of Current Hospice Residents: 6
Number of Hospice Residents in past year: 25
Inspection Report — Feb 20, 2018
Renewal
Date: Feb 20, 2018
Visit Reason
The inspection was conducted as a renewal inspection of the Lowrie Place Personal Care Home on February 20 and 21, 2018, to assess compliance with 55 Pa. Code Chapter 2600.
Findings
Multiple violations of 55 Pa. Code Chapter 2600 were found, including issues with wheelchair condition, hot water temperature, emergency telephone numbers, window screens, medication labeling, medication administration timing, and resident record documentation. Plans of correction were submitted and partially implemented with adequate progress noted.
Citations (7)
55 Pa.Code §2600.81(b) - Resident #1's wheelchair had worn armrests exposing wood, posing a skin tear hazard.
55 Pa.Code §2600.89(b) - Hot water temperature in bathroom sinks of bedrooms #130 and #113 exceeded 120°F.
55 Pa.Code §2600.91 - Emergency telephone numbers were not posted on or near resident telephones in bedrooms #130 and #111.
55 Pa.Code §2600.92 - Windows in bedrooms #103 and #121 lacked screens.
55 Pa.Code §2600.184(a) - Medication label for Resident #4's Triple Antibiotic ointment lacked frequency of dressing change.
55 Pa.Code §2600.187(d) - Resident #1's medication administration time did not match the prescribed time.
55 Pa.Code §2600.252 - Records of residents #2 and #3 lacked preadmission screening forms.
Report Facts
Number of Residents Served: 41
Number of Current Hospice Residents: 5
Number of Hospice Residents in past year: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brenda Daubner | Executive Director | Named as Administrator and Legal Entity Representative signing plans of correction. |
| Jody Garvey | Inspector | Conducted the inspection on 02/20/2018 and 02/21/2018. |
| Laurie Garrigan | Inspector | Conducted the inspection on 02/20/2018 and 02/21/2018. |
Inspection Report — Nov 16, 2017
Routine
Date: Nov 16, 2017
Visit Reason
The Department of Human Services licensing representatives conducted an inspection of Lowrie Place facility on November 16, 2017.
Findings
No regulatory violations were identified as a result of this inspection.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Larry Mazza | Acting Regional Licensing Director | Signed the inspection report letter. |
Inspection Report — Oct 3, 2017
Complaint Investigation
Date: Oct 3, 2017
Visit Reason
The inspection was conducted as a complaint investigation triggered by concerns at the facility.
Complaint Details
The inspection was conducted due to a complaint. Specific substantiation status is not stated.
Findings
Multiple violations of 55 Pa.Code Chapter 2600 were found, including unsanitary conditions, lack of toilet paper provision, and inadequate soap dispensers. Plans of correction were submitted addressing odor issues, toilet paper availability, and soap dispenser maintenance.
Citations (3)
55 Pa.Code 2600.85(a) - Resident bedroom #103 had a very strong smell of cat urine.
55 Pa.Code 2600.102(h) - The home does not provide toilet paper; residents must provide their own or have family supply it.
55 Pa.Code 2600.102(i) - The soap dispenser in bathroom of room #105 did not have any soap in it, and bar soap was unlabeled in a shared bathroom.
Report Facts
Number of Residents Served: 40
Total Daily Staff: 51
Waking Staff: 38
Number of Current Hospice Residents: 4
Number of Hospice Residents in Past Year: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Delisa LongDon | Executive Director | Named in relation to plan of correction signatures and oversight. |
Inspection Report — Aug 1, 2017
Complaint Investigation
Date: Aug 1, 2017
Visit Reason
The inspection was conducted as a complaint investigation triggered by an incident reported on 7/25/17 involving alleged resident abuse.
Complaint Details
The investigation was triggered by an incident on 7/25/17 involving alleged abuse of resident #1. The abuse was reported late to Protective Services and the resident's designated person. The staff member accused was suspended but the allegation was found unsubstantiated.
Findings
Multiple violations of 55 Pa.Code Chapter 2600 were found, including late reporting of alleged resident abuse to Protective Services and designated persons, incomplete criminal background checks for staff, and inaccurate resident assessments.
Citations (4)
2600.15(a)- Alleged resident abuse was reported late to Protective Services; the incident on 7/25/17 was reported on 7/27/17.
2600.15(d)- Alleged resident abuse was not reported to the resident's designated person within the required timeframe; notification occurred on 7/26/17 at 9:30 a.m.
2600.51- Staff person B, hired 11/17/16, did not have a completed criminal history background check until 3/20/17.
2600.225(a)- Resident #1's assessment did not have correct information about irritability, judgment, agitation, or aggression documented.
Report Facts
Number of Residents Served: 38
Number of Current Hospice Residents: 5
Number of Hospice Residents in past year: 8
Residents 60 Years or Older: 38
Residents with Mobility Need: 18
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brenda Daubner | Executive Director | Named as legal entity representative and involved in corrective action plans |
| Laurie Garrigan | Department representative conducting the inspection |
Inspection Report — Jul 6, 2017
Interim
Date: Jul 6, 2017
Visit Reason
The inspection was an unannounced interim licensing inspection conducted by the Pennsylvania Department of Human Services to evaluate compliance with 55 Pa.Code Chapter 2600 for Personal Care Homes.
Findings
The inspection found violations related to medication labeling, medication administration records, adherence to prescriber directions, and resident assessments. Plans of correction were submitted and partially implemented with adequate progress noted.
Citations (4)
55 Pa.Code §2600.184(a) - Prescription medication containers were not labeled correctly; Resident #1's Duloxetine label did not match the physician's order and Resident #2's Synthroid label had incorrect dosage instructions.
55 Pa.Code §2600.187(a) - Medication records lacked required details; Resident #2's medication administration record did not match the prescribed Synthroid dosage on multiple days.
55 Pa.Code §2600.187(d) - The home did not follow prescriber directions; Resident #2 incorrectly received levothyroxine sodium on 7/3/17, resulting in a medication error reported to DHS.
55 Pa.Code §2600.225(c) - Resident #3's assessment did not address how the home would meet the resident's supervision needs, leaving the section blank despite the resident requiring total physical assistance.
Report Facts
Number of Residents Served: 39
Number of Current Hospice Residents: 7
Number of Hospice Residents in Past Year: 12
Total Daily Staff: 57
Waking Staff: 43
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Delisa Longdon | Administrator | Named as facility administrator on page 2. |
| Brenda Daubner | Executive Director | Named as Executive Director and legal entity representative signing plans of correction on pages 3-6. |
| Vicky Summers | Department representative on-site during inspection on 7/6/2017. | |
| Michael Marini | Department representative on-site during inspection on 7/6/2017. |
Notice — Apr 20, 2017
Date: Apr 20, 2017
Visit Reason
This document serves as a renewal notification and license issuance for Lowrie Place, a Personal Care Home, confirming the facility's authorized capacity and informing about 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 and renewal communication without compliance or deficiency details.
Report Facts
Inspection Report — Feb 8, 2017
Annual Inspection
Date: Feb 8, 2017
Visit Reason
The inspection was conducted as part of the Department of Human Services' annual licensing inspections on February 8 and 9, 2017, for Lowrie Place, a Personal Care Home in Butler, Pennsylvania.
Findings
Multiple violations of 55 Pa.Code Chapter 2600 were found, including issues with resident record confidentiality, criminal history background checks, staff training, fire safety, sanitation, medication administration, and facility maintenance. Plans of correction were submitted and partially implemented with adequate progress noted.
Citations (17)
2600.17 Resident records were unlocked, unattended, and accessible in the activity room, compromising resident confidentiality.
2600.51 Criminal history background checks were not requested for direct care staff person A until after employment began.
2600.65(a) Direct care staff persons A and B started work without receiving required training on fire safety and emergency preparedness.
2600.65(b) Direct care staff persons A and B did not receive training on topics required by regulation 2600.65b.
2600.65(g) Direct care staff person C did not receive fire safety training conducted by a fire safety expert during the 2016 training year.
2600.82(c) Poisonous materials were unlocked and accessible in the activity room and housekeeping areas, posing a safety hazard to residents.
2600.85(a) Strong odor of urine was present near room #117, indicating unsanitary conditions.
2600.88(a) Vinyl flooring in the kitchen was separated from the floor, creating a tripping hazard.
2600.95 The bottom surface and inside panel of the kitchen cabinet were crumbling and in disrepair.
2600.96(a) First aid kits lacked required items such as thermometers, scissors, breathing shields, and eye coverings.
2600.131(c) A fire extinguisher was not installed in the kitchen as required by regulation.
2600.132(a) The home did not conduct a fire drill during December 2016 as required.
2600.183(f) Discontinued medications were not properly removed from the medication cart for resident #5.
2600.184(a) Prescription medication containers were not properly labeled with resident name, medication, dosage, and administration instructions.
2600.187(b) Resident #10's assessment did not indicate food allergies; resident #11's assessment did not reflect home health care services provided.
2600.227(a) Resident #11's support plan was not developed or implemented within 30 days of admission as required.
2600.227(d) Resident #5's support plan did not indicate hospice services being provided.
Report Facts
Number of Residents Served: 33
Number of Current Hospice Residents: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Delisa Longdon | Executive Director | Named in relation to multiple findings and plans of correction throughout the report. |
Inspection Report — Dec 21, 2016
Routine
Date: Dec 21, 2016
Visit Reason
The Department of Human Services licensing representatives conducted an inspection of the facility.
Findings
No regulatory violations were identified as a result of this inspection.
Inspection Report — Dec 7, 2016
Complaint Investigation
Date: Dec 7, 2016
Visit Reason
The inspection was conducted as a complaint investigation triggered by an incident at the facility.
Complaint Details
The visit was complaint-related due to an incident involving a resident choking on improperly prepared food. The complaint was substantiated by findings of noncompliance with dietary regulations.
Findings
The inspection found violations related to the management of a resident's special dietary needs, specifically a mechanical soft diet that was not properly followed, resulting in choking and hospitalization. Plans of correction were submitted to address these deficiencies.
Citations (2)
Regulation 55 Pa.Code §2600.161(d) requires documentation of a resident's special dietary needs. Resident #1 was prescribed a mechanical soft diet, but was served inappropriate food causing choking and hospitalization.
Regulation 55 Pa.Code §2600.225(c) requires additional resident assessments. Resident #1's assessment was not updated to reflect the prescribed mechanical soft diet until after the incident.
Report Facts
Number of Residents Served: 37
Number of Current Hospice Residents: 6
Number of Residents Who Are 60 Years of Age or Older: 37
Number of Residents Who Have Mental Illness: 3
Number of Residents Who Have a Mobility Need: 22
Total Daily Staff: 59
Waking Staff: 44
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sarah Kitchner | Executive Director | Named in relation to the dietary violation and plan of correction |
| Donald Knee | Inspector conducting the violation report | |
| Ashley Roser | Inspector present on-site during inspection | |
| Brent Sutherland | Acting Human Services Licensing Supervisor | Signed the cover letter regarding the inspection |
Inspection Report — Apr 11, 2016
Renewal
Date: Apr 11, 2016
Visit Reason
The inspection was a renewal licensing inspection conducted by the Pennsylvania Department of Human Services on April 11, 2016, to assess compliance with 55 Pa.Code Ch. 2600 regulations for Personal Care Homes.
Findings
Multiple violations were found related to staff training in required topics, fire safety, older adult protective services, falls and accident prevention, trash receptacle coverage, posting of emergency telephone numbers, fire drill record keeping, and completeness of medical evaluations. Plans of correction were partially implemented as of the report date.
Citations (6)
Regulation 2600.65(f): Direct care staff did not complete required training topics during the 2015 training year including infection control, hygiene, immobility prevention, and care for residents with mental health or mental retardation.
Regulation 2600.65(g): Direct care and ancillary staff did not complete required annual training in fire safety, Older Adult Protective Services Act, and falls and accident prevention during the 2015 training year.
Regulation 2600.85(d): Trash in kitchens and bathrooms was not kept in covered receptacles; a small trash can in the common shower room was uncovered and half full of garbage.
Regulation 2600.91: Required telephone numbers for emergency services were not posted on or by the telephone in room #138.
Regulation 2600.132(c): The fire drill record did not include the time of the drill, only the date and duration were recorded.
Regulation 2600.141(a)(2): Resident #1's medical evaluation did not include pulse rate, blood pressure, or temperature; these sections were left blank.
Report Facts
Number of Residents Served: 38
Number of Current Hospice Residents: 4
Number of Hospice Residents in Past Year: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sarah Kitcher | Executive Director | Named as Administrator and Executive Director in the report and responsible for posting telephone numbers and other compliance areas. |
Inspection Report — Jan 11, 2016
Renewal
Date: Jan 11, 2016
Visit Reason
The document is a renewal application and license issuance for Lowrie Place Personal Care Home, confirming the facility's renewal to operate under Title 55, PA Code, Chapter 2600.
Findings
No inspection findings are reported in this document. It confirms the issuance of a regular license and states that an onsite inspection will be conducted within the next twelve months.
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