Inspection Reports for
The Addison of Woodbourne Place

The facility was found to be in compliance with 55 Pa. Code Chapter 2600 relating to Personal Care Homes. Several deficiencies were identified related to contract signatures, annual training content, sanitary conditions, first aid kit contents, medication records, labeling of OTC medications, and support plan documentation. All deficiencies had plans of correction implemented by January 14, 2025.

The facility was found to have implemented all required corrections including contract signatures, annual fire safety training, sanitary conditions, first aid kit completeness, medication record accuracy, labeling of OTC medications, and support plan updates related to medical/dental care. Continued compliance must be maintained.

The inspection found multiple deficiencies including failure to report an incident within 24 hours, lack of staff trained in first aid/CPR on duty during certain shifts, unsecured combustible materials accessible to residents, failure to post weekly menus in a conspicuous place, and medication record inaccuracies including discontinued medications still listed and missing staff initials on medication administration records. The submitted plan of correction was determined to be fully implemented.

The waiver allows a specified employee to serve as direct care staff based on a credential evaluation of education obtained outside the United States, subject to documentation and annual review during inspections.

The facility was found to be in substantial compliance with the regulations, but the licensing inspector was unable to complete a full inspection due to the new legal entity. Citations were found and must be corrected by specified dates. A provisional license was issued based on substantial but not complete compliance.

The facility was found to have multiple regulatory violations including failure to post required telephone numbers, direct care staff qualification issues, unsecured bedside mobility devices, unsanitary medication handling practices, missing emergency telephone numbers, outdated emergency procedures, incomplete menu postings, improper calibration of medical equipment, and incomplete resident support plans. All deficiencies had plans of correction accepted and were implemented by April 11, 2024.

The visit was complaint-related due to an incident where Resident #1, diagnosed with Alzheimer's and dementia, left the facility unnoticed and was fatally injured. The complaint was substantiated by findings of neglect and failure to follow required procedures.

The facility was found to have multiple violations related to resident abuse, failure to complete pre-admission screening, use of non-standardized forms, and incomplete resident records. A resident with dementia left the facility unnoticed and was fatally injured. The facility lacked proper documentation and screening prior to admission.

The inspection identified multiple deficiencies including unsigned resident contracts, lack of operable bedside lamps, food safety violations related to uncovered and unlabeled food, incomplete medical evaluations, discontinued medications kept in the medication cart, inaccurate controlled substance logs, unavailable prescribed medications, and incomplete resident support plans. All deficiencies had plans of correction submitted and were determined to be fully implemented by the time of the report.

The inspection was complaint-driven, with a partial unannounced inspection conducted on 01/31/2022 and follow-up documentation submissions on 02/22/2022 and 03/07/2022. The plan of correction was accepted and fully implemented.

Multiple deficiencies were identified including issues with criminal background checks, direct care staff qualifications, medication storage and administration, medication documentation, and resident assessments. Plans of correction were accepted and implemented with ongoing monitoring and audits scheduled.

The inspection identified multiple deficiencies related to staffing, physical site conditions, medication management, and resident records. Corrective actions and education were implemented with follow-up audits scheduled to ensure ongoing compliance.

The Department issued a regular license in response to the renewal application and advised that an onsite annual inspection will be conducted within the next twelve months to ensure compliance with applicable regulations.

The inspection was complaint-driven and included a follow-up on the plan of correction submission. The plan of correction was determined to be fully implemented as of June 6, 2022.

Two deficiencies were identified: one involving a direct care staff member lacking required educational qualifications or registry status, and another involving a resident's support plan not being revised to reflect changes in mobility needs. Both deficiencies had plans of correction implemented and fully accepted.

The inspection was complaint-driven, triggered by allegations of resident abuse involving staff. The complaint was substantiated with multiple violations found related to abuse reporting, supervision, incident reporting, and resident rights.

The inspection found multiple deficiencies including failure to immediately report suspected resident abuse, failure to develop a supervision plan or suspend staff involved in abuse allegations, failure to submit incident reports timely, inadequate resident relocation assistance, incomplete staff orientation training, hazardous resident equipment, hot water temperature exceeding limits, unsafe furniture, and lack of placement planning for residents needing higher levels of care. Plans of correction were accepted for all deficiencies.

The inspection identified deficiencies related to failure to report suspected resident abuse timely, missing resident contract signatures, inadequate safeguarding of resident money, and presence of discontinued medication in the medication cart. Plans of correction were submitted and partially implemented.

No inspection findings are reported in this document. It confirms issuance of a regular license and advises that the Department will conduct an inspection within the next year to ensure compliance.

The inspection was complaint-driven, unannounced, and focused on multiple allegations including medication errors, resident rights violations, staff qualifications, and record confidentiality. The complaint was substantiated with multiple violations found.

Multiple violations were found related to medical evaluations, medication management, medication records, medication administration documentation, prescription currency, prohibitions on chemical restraints, resident dignity and respect, staff qualifications, orientation, training, resident assessments, support plans, and record confidentiality. Plans of correction were partially implemented with ongoing audits and staff education.

Inspection was complaint-driven as stated under Inspection Reason. Specific complaints involved medication administration errors and expired medications.

Violations were found related to medication administration, including improper administration of suppositories, expired medications in the medication cart, and incomplete medication records. Plans of correction were partially implemented as of the report date.

The inspection identified multiple violations related to staffing qualifications, housekeeping, training, medication administration, sanitation, and documentation. Plans of correction were submitted with partial implementation noted as of July 24, 2019.

No inspection findings are reported in this document. It is an administrative renewal notice confirming license issuance and outlining future inspection requirements.

The inspection was triggered by an incident complaint involving staff-resident interaction. The complaint was substantiated as violations were found.

Violations of 55 Pa. Code Chapter 2600 were found related to resident dignity and respect, staff training documentation, and resident support plans. A plan of correction was submitted addressing staff training, resident rights, and ongoing monitoring.

No inspection findings are reported in this document. It serves as a license renewal confirmation and notification of future inspection requirements.

Multiple violations of 55 Pa.Code Chapter 2600 were found, including issues with bedroom lighting, incomplete medical evaluations, medication administration records, medication administration documentation, and preadmission screening forms. Plans of correction were submitted with partial implementation progress noted.

No inspection findings are reported in this document. It confirms the issuance of a regular license following the renewal application and outlines the requirement for a future annual inspection.

The waiver request is denied as not needed because documentation confirms the education exceeds the criteria for a high school diploma. The facility must keep a copy of the educational documentation.

No inspection findings are reported in this document. It only confirms the license renewal and outlines the requirement for a future annual inspection.

The inspection found multiple violations related to facility maintenance, food storage and labeling, medication storage and administration, and resident assessments. Plans of correction were submitted with partial implementation status noted.