Inspection Reports for
The Addison of McCullough Place
500 Cheney Oak Dr, Johnstown, PA 15905, United States, PA, 15905
Back to Facility Profile20 Reports
Inspection Report — Apr 9, 2026
Complaint Investigation
Date: Apr 9, 2026
Visit Reason
The inspection was conducted as a complaint investigation with an unannounced partial inspection on 04/09/2026.
Complaint Details
The inspection was complaint-related and the submitted plan of correction was determined to be fully implemented.
Findings
The facility was found to have delayed administration of prescribed medication to a resident. The submitted plan of correction was fully implemented and compliance was confirmed.
Citations (1)
2600.187.d requires the home to follow prescriber's directions. A resident was prescribed medication for 7 days but did not receive the first dose until after delivery to the home.
Report Facts
Residents Served: 36
Current Residents in Hospice: 5
Residents Age 60 or Older: 36
Residents Diagnosed with Mental Illness: 1
Residents with Mobility Need: 10
Residents with Physical Disability: 1
Inspection Report — Mar 4, 2026
Renewal
Date: Mar 4, 2026
Visit Reason
The inspection was an unannounced full renewal inspection with an incident review conducted on 03/04/2026 to verify compliance and plan of correction implementation.
Findings
The facility was found to have multiple deficiencies including breaches of resident record confidentiality, improper treatment of residents, privacy violations related to audio/video monitoring, expired vehicle inspection documentation, and inconsistent resident dietary assessments. All deficiencies had plans of correction accepted and were implemented by 03/30/2026.
Citations (5)
2600.17 Resident records were left unattended on a medication cart accessible to anyone, violating confidentiality requirements.
2600.42c A resident was treated without dignity and respect, including rough transfers and inappropriate verbal communication by staff.
2600.42s A resident placed a camera with audio and video recording in their room; audio was disabled after family intervention to comply with privacy rights.
2600.171c The home's van had an expired inspection sticker and was immediately taken for inspection and returned.
2600.225c Resident dietary assessments were inconsistent, listing both mechanical soft and regular liberalized diets.
Report Facts
Residents Served: 39
Current Hospice Residents: 5
Inspection Report — Sep 10, 2024
Renewal
Date: Sep 10, 2024
Visit Reason
The inspection was conducted as a renewal review of the facility's compliance with licensing regulations.
Findings
The facility was found to have multiple deficiencies related to record confidentiality, evacuation times, medication storage and management, and resident record content. All deficiencies had plans of correction accepted and were implemented by 11/21/2024.
Citations (5)
Resident records containing privacy coding documents were unlocked, unattended, and accessible in a conspicuous area.
The home's maximum safe evacuation time was exceeded during drills on 4/26/24 and 6/27/24.
Prescription medications and syringes were found unlocked, unattended, and accessible in a resident's bathroom cabinet.
Expired medications were found in the home's medication cart for residents.
Resident #3's record did not include a death certificate despite the resident dying in the home.
Report Facts
Residents Served: 39
Total Daily Staff: 51
Waking Staff: 38
Current Residents in Hospice: 11
Residents Age 60 or Older: 39
Residents with Mental Illness: 1
Residents with Mobility Need: 12
Inspection Report — Apr 30, 2024
Date: Apr 30, 2024
Visit Reason
The inspection was a partial, announced licensing inspection conducted on 04/30/2024 for the purpose of a new inspection at the facility.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Total Daily Staff: 47
Waking Staff: 35
Residents Served: 36
Current Residents in Hospice: 10
Residents Diagnosed with Mental Illness: 2
Residents with Mobility Need: 11
Inspection Report — Apr 30, 2024
Re-Inspection
Date: Apr 30, 2024
Visit Reason
The inspection was conducted as a licensing inspection of a newly licensed personal care home facility. A re-inspection will be conducted within 3 months of the license effective date to ensure full compliance.
Findings
The facility was found to be in substantial compliance with applicable regulations, and no regulatory citations or deficiencies were identified during the inspection.
Report Facts
Residents Served: 36
Current Residents in Hospice: 10
Residents Diagnosed with Mental Illness: 2
Residents with Mobility Need: 11
Total Daily Staff: 47
Waking Staff: 35
Inspection Report — May 31, 2023
Follow-Up
Date: May 31, 2023
Visit Reason
The inspection visit occurred as a follow-up to review the submitted plan of correction after an incident at the facility.
Findings
The facility was found to have fully implemented the submitted plan of correction related to a violation where a staff member did not treat a resident with dignity and respect. The staff member was placed on administrative leave and subsequently terminated, and re-education and auditing measures were implemented to ensure compliance.
Citations (1)
Staff Person A did not treat Resident #1 with dignity and respect by telling the resident not to use their call light because the staff did not have time to respond.
Report Facts
Residents Served: 33
Current Residents in Hospice: 7
Residents Age 60 or Older: 33
Residents Diagnosed with Mental Illness: 1
Residents with Mobility Need: 16
Inspection Report — Mar 1, 2023
Renewal
Date: Mar 1, 2023
Visit Reason
The inspection was conducted as a renewal visit with an incident noted, to assess compliance with licensing regulations and verify the implementation of a submitted plan of correction.
Findings
The inspection identified deficiencies related to unsecured poisonous materials, outdated food items, and improper storage of medications. The facility submitted and implemented a plan of correction addressing these issues, including staff re-education, audits, and disposal of hazardous items.
Citations (3)
Poisonous materials such as disinfecting wipes, bleach powder, mouthwash, and hand sanitizer were found unsecured and accessible to residents who are unable to safely use or avoid poisonous materials.
Multiple dented cans of food were found in the kitchen pantry, which is against regulations prohibiting use of outdated or spoiled food or dented cans.
Resident's Eucerin Cream container was cracked and leaking, indicating improper storage of medications.
Report Facts
Residents Served: 38
Staffing Hours: 41
Waking Staff: 31
Dented Cans: 3
Residents with Mobility Need: 3
Hospice Residents: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director | Executive Director (ED) | Named in plan of correction for locking poisonous materials, discarding dented cans, and re-educating staff |
| Care Service Manager | Care Service Manager (CSM) | Conducted audits and re-educated staff on medication storage requirements |
| Regional Director of Care Services | Regional Director of Care Services (RDCS) | Re-educated Executive Director and staff on regulatory requirements |
Inspection Report — May 3, 2022
Renewal
Date: May 3, 2022
Visit Reason
The inspection was a full, unannounced renewal inspection conducted on 05/03/2022 and 05/04/2022 to review compliance with licensing regulations.
Findings
The inspection identified multiple deficiencies related to contract signatures, annual medical evaluations, medication storage and labeling, medication administration, and support plan signatures. Plans of correction were accepted and implemented with audits and education scheduled to ensure ongoing compliance.
Citations (8)
Resident #4's resident-home contract was not signed by the resident.
Resident #2’s most recent medical evaluation did not include the Medical Professional License Number.
Two tubes of medication were unlocked, unattended, and accessible in Resident #3's bathroom, who cannot self-administer medications.
Resident #5's medication label did not match the prescribed dosage and instructions.
Medications for Residents #1, #3, #4, #5, and #6 were not available in the home as prescribed.
Resident #4 and Resident #5's medication administration records did not include prescribed medications.
The home did not follow prescriber's orders for multiple residents due to unavailable medications.
Residents #4 and #5 participated in support plan development but did not sign the plan, and the home did not document refusal or inability to sign.
Report Facts
Residents Served: 42
Current Hospice Residents: 11
Residents with Mobility Need: 21
Residents 60 Years or Older: 42
Total Daily Staff: 63
Waking Staff: 47
Notice — Jun 30, 2021
Date: Jun 30, 2021
Visit Reason
The document serves as a renewal notification and issuance of a regular license for McCullough Place Personal Care Home, 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 an administrative notice confirming license renewal and outlining future inspection requirements.
Report Facts
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary, Office of Long-term Living | Signed the renewal notification letter |
Inspection Report — Jun 9, 2021
Renewal
Date: Jun 9, 2021
Visit Reason
The inspection was conducted as a licensing inspection by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing.
Findings
No regulatory citations were identified as a result of this inspection.
Notice — May 5, 2020
Date: May 5, 2020
Visit Reason
This document serves as a renewal notification and license issuance for McCullough Place Personal Care Home. It informs the facility that an onsite inspection will be conducted within the next twelve months as required by state regulations.
Findings
No inspection findings are reported in this document. It confirms the issuance of a regular license following the renewal application.
Report Facts
Inspection Report — Oct 1, 2019
Renewal
Date: Oct 1, 2019
Visit Reason
The inspection was a renewal visit conducted by the Pennsylvania Department of Human Services, Bureau of Human Services Licensing, Office of Long-term Living, to review compliance at McCullough Place.
Findings
The submitted plan of correction was found to be fully implemented and in compliance. Two violations were cited related to an expired rabies vaccination for a resident's dog and an expired medication in the home's PM medication cart.
Citations (2)
109b - Rabies Vaccination: A dog belonging to Resident 1 had an expired rabies vaccination as of 8/21/19.
183d - Prescription Current: A partially used box of Ipratropium Bromide 0.5mg solution belonging to Resident 2 was present with an expiration date of June 2019.
Report Facts
Residents Served: 41
Current Hospice Residents: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stacy Murphy | Executive Director | Signed plan of correction for violations |
Notice — Apr 17, 2019
Date: Apr 17, 2019
Visit Reason
This document is a renewal application acknowledgment and license issuance for McCullough Place, a Personal Care Home, confirming the facility's licensed 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 serves as a license renewal confirmation and notification of future inspection requirements.
Inspection Report — Oct 10, 2018
Annual Inspection
Date: Oct 10, 2018
Visit Reason
The inspection was conducted as a result of the Department's Bureau of Human Services Licensing annual inspection and included renewal and complaint reasons.
Findings
Violations related to medication labeling, medication administration records, and support plan signatures were found. Plans of correction were submitted and partially or fully implemented as of late November 2018.
Citations (3)
55 Pa.Code §2600.184(a) - The prescription medication Clobetasol Propionate Ointment 0.05% for Resident #1 did not have a pharmacy label including required information.
55 Pa.Code §2600.187(a) - The October 2018 medication administration record did not include the prescription medication Clobetasol Propionate Ointment 0.05% for Resident #1.
55 Pa.Code §2600.227(g) - The initial support plan dated 5/5/17 for Resident #2 was not signed by the home.
Report Facts
Number of Residents Served: 40
Total Daily Staff: 53
Waking Staff: 40
Number of Current Hospice Residents: 2
Number of Hospice Residents in past year: 8
Number of Residents Age 60 or Older: 40
Number of Residents with Mental Illness: 1
Number of Residents with Mobility Need: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stacy Murphy | Administrator | Named as Administrator and signed plan of correction documents |
| Douglas Hoover | Department representative conducting inspection |
Notice — Jul 10, 2018
Date: Jul 10, 2018
Visit Reason
The document serves as a renewal notification for the license to operate McCullough Place Personal Care Home and informs that an onsite inspection will be conducted within the next twelve months as required by state regulations.
Findings
No inspection findings are reported in this document. It confirms issuance of a regular license following the renewal application.
Inspection Report — Oct 13, 2017
Annual Inspection
Date: Oct 13, 2017
Visit Reason
The Department of Human Services conducted an annual licensing inspection of McCullough Place on October 13, 2017.
Findings
The facility was found to be in compliance with 55 Pa.Code Chapter 2600 relating to Personal Care Homes.
Notice — Oct 13, 2017
Date: Oct 13, 2017
Visit Reason
Issuance of a revised license due to recent adjustment of the use of physical space at the facility, resulting in a revised licensed capacity.
Findings
The document includes a revised license certificate granting operation of McCullough Place as a Personal Care Home with a maximum capacity of 55 residents. A self-inspection tool with regulatory requirements is included but no violations or deficiencies are noted.
Report Facts
Inspection Date: Oct 13, 2017
Notice — Jul 11, 2017
Date: Jul 11, 2017
Visit Reason
The document is a renewal notice confirming the issuance of a regular license for McCullough Place Personal Care Home following the renewal application submitted on July 11, 2017.
Findings
The Department advises that an onsite annual inspection will be conducted within the next twelve months to ensure compliance with Title 55, PA Code, Chapter 2600. Enforcement actions will be taken if noncompliance is found during the inspection.
Report Facts
Inspection Report — Oct 18, 2016
Annual Inspection
Date: Oct 18, 2016
Visit Reason
The inspection was conducted as an annual licensing inspection of the facility.
Findings
The facility was found to be in compliance with 55 Pa.Code Chapter 2600 relating to Personal Care Homes.
Notice — Jul 7, 2016
Date: Jul 7, 2016
Visit Reason
This document serves as a renewal notification and license issuance for McCullough Place Personal Care Home following receipt of the renewal application dated July 6, 2016.
Findings
No inspection findings are reported in this document. It states that an onsite inspection will be conducted within the next twelve months as required by regulation.
Report Facts
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