Inspection Reports for
The Birches at Harleysville
691 MAIN STREET,, HARLEYSVILLE, PA, 19438
Back to Facility Profile40 Reports
Inspection Report — Apr 22, 2026
Monitoring
Date: Apr 22, 2026
Visit Reason
The inspection was an unannounced partial review conducted as a monitoring visit to verify the implementation of a previously submitted plan of correction.
Findings
The facility was found to have fully implemented the submitted plan of correction. Several deficiencies were noted related to criminal background checks, training records, locking of poisonous materials, medication storage and security, and calibration of medical equipment, all with corrective actions accepted and implemented.
Citations (6)
51 - Criminal Background Check: The facility failed to complete a criminal background check for a staff person as required by regulations.
65i - Training Record: The home's record of direct care staff training lacked required details including location, course title, and length for all trainings completed by a staff person.
82c - Locking Poisonous Materials: Poisonous materials including Crest and Equate toothpaste were unlocked, unattended, and accessible to residents not assessed capable of safe use.
183b - Meds and Syringes Locked: Prescription and OTC medications were found unlocked, unattended, and accessible in a resident's room.
183e - Storing Medications: Medications were stored improperly with missing open or expiration dates and damaged packaging on medication carts.
185a - Implement Storage Procedures: A glucometer for a resident was not calibrated with the correct time, showing an incorrect reading.
Report Facts
Residents Served: 80
Secured Dementia Care Unit Residents Served: 32
Hospice Current Residents: 12
Residents Age 60 or Older: 79
Residents with Mobility Need: 46
Residents with Physical Disability: 4
Total Daily Staff: 126
Waking Staff: 95
Notice — Apr 13, 2026
Date: Apr 13, 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 was 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 — Mar 2, 2026
Date: Mar 2, 2026
Visit Reason
The document serves to notify the facility that a waiver request to 55 PA.Code § 2600.54(a)(2) regarding direct care staff qualifications has been granted due to education received outside the United States.
Findings
The waiver is granted with conditions requiring documentation of education equivalency to be maintained and made available upon request. The Department will review this waiver annually during inspections to ensure compliance.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Theresa Hartman | Bureau Director, Human Services Licensing | Signed the waiver approval letter. |
Notice — Feb 26, 2026
Date: Feb 26, 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 based on education equivalency evaluated by a credential evaluator. 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. |
Notice — Feb 13, 2026
Date: Feb 13, 2026
Visit Reason
This document serves to grant a waiver for a direct care staff member at The Birches at Harleysville who obtained their education outside the United States, waiving the requirement for a U.S. high school diploma or equivalent.
Findings
The waiver is granted under specified conditions including documentation retention and annual review during inspections. Noncompliance with conditions may result in waiver termination or other licensing actions.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Theresa Hartman | Bureau Director, Human Services Licensing | Signed the waiver approval letter. |
Inspection Report — Feb 3, 2026
Renewal
Date: Feb 3, 2026
Visit Reason
The inspection was conducted as a renewal visit with additional reasons including complaint and incident review.
Findings
The inspection identified multiple deficiencies including failure to report suspected abuse timely, missing criminal background checks for staff, improper medication storage and administration errors, and incomplete medical evaluations. Corrective actions were accepted and implemented with ongoing quality assurance plans.
Citations (21)
15a - Resident Abuse Report: The facility failed to immediately report suspected abuse of a resident missing $100 to the local area agency on aging.
16c - Written Incident Report: The facility did not submit an incident report to the Department regarding the resident's missing money.
42b - Abuse: Residents reported missing money; the facility failed to ensure safety and proper handling of cash and tips.
51 - Criminal Background Check: Two staff members did not have criminal background checks through the PA Patch system.
54a - Direct Care Staff: A direct care staff person lacked a high school diploma, GED, or active registry status on the Pennsylvania nurse aide registry.
82c - Locking Poisonous Materials: Poisonous materials were unlocked and accessible to residents not assessed as capable of safe use.
100b - Removal Snow/Obstructions: The home failed to maintain a cleared path to an emergency exit due to ice and snow accumulation.
101j7 - Lighting/Operable Lamp: A resident did not have access to a bedside lamp or source of lighting that can be turned on/off at bedside.
105g - Lint Removal and Duct Cleaning: Lint accumulated in the lint trap of the main laundry room dryer.
141a 1-10 Medical Evaluation Information: Medical evaluations for several residents did not include the license number of the provider.
141b1 - Annual Medical Evaluation: Annual medical evaluations for several residents lacked the provider's license number.
162c - Menus Posted: Menus for the week following 2/1/2026 were not posted in multiple care units.
183b - Meds and Syringes Locked: Multiple medications were unlocked, unattended, and accessible in resident rooms.
183d - Prescription Current: A prescribed medication was in the medication cart but not on current orders.
183e - Storing Medications: Several medications were expired, unlabeled with open dates, broken, or improperly stored.
184a - Resident's Meds Labeled: A medication ointment lacked a pharmacy label including the resident's name.
185a - Implement Storage Procedures: Glucometer times were incorrect and medication administration documentation lacked AM/PM indication.
185b - Medication Procedures: The facility failed to account for missing controlled substance medication upon resident's return.
187b - Date/Time of Medication Admin.: Medication administration records lacked initials of staff administering medications on multiple occasions.
187d - Follow Prescriber's Orders: Residents were administered incorrect doses of prescribed insulin medications.
251b - Record Entries Legible: A resident's medication sign out sheet was written over and not legible.
Report Facts
Residents Served: 72
Residents in Secured Dementia Care Unit: 30
Current Residents in Hospice: 6
Residents Age 60 or Older: 71
Residents with Mobility Need: 42
Residents with Physical Disability: 5
Inspection Report — Oct 23, 2025
Follow-Up
Date: Oct 23, 2025
Visit Reason
The inspection was a partial, unannounced follow-up visit to verify the implementation of a previously submitted plan of correction related to an incident.
Findings
The facility was found to have fully implemented the plan of correction related to resident assistance with activities of daily living and resident-to-resident abuse. Continued compliance and ongoing quality assurance measures were required.
Citations (2)
23a Activities of Daily Living Assistance: A resident requiring assistance with ambulation and transferring did not receive required supervision and assistance, being pushed in a wheelchair by another resident without staff supervision.
42b Abuse: A resident was bitten on the finger by another resident, resulting in hospital treatment and prescribed antibiotics. The facility intervened and transferred the aggressive resident to memory care.
Report Facts
Residents Served: 74
Secured Dementia Care Unit Residents Served: 31
Hospice Current Residents: 7
Residents Age 60 or Older: 73
Residents with Mobility Need: 42
Residents with Physical Disability: 4
Inspection Report — Jul 29, 2025
Plan of Correction
Date: Jul 29, 2025
Visit Reason
The inspection was conducted as a follow-up review of the submitted plan of correction related to a violation concerning resident consent documentation for admission to the secured dementia care unit.
Findings
The plan of correction was determined to be fully implemented. The violation involved a resident who initially objected in writing to admission to the secured dementia care unit, but corrective actions were taken including obtaining consent and reviewing all resident contracts in the secured dementia unit.
Citations (1)
Resident record lacked documentation that the resident and designated person had not objected to admission to the secured dementia care unit.
Report Facts
Residents Served: 85
Secured Dementia Care Unit Residents Served: 31
Hospice Residents: 7
Residents 60 Years or Older: 74
Residents with Mobility Need: 41
Residents with Physical Disability: 4
Inspection Report — Apr 4, 2024
Complaint Investigation
Date: Apr 4, 2024
Visit Reason
The inspection was conducted as a complaint and incident investigation at THE BIRCHES AT HARLEYSVILLE on 04/04/2024.
Complaint Details
The inspection was complaint-driven and incident-related, with a follow-up type of Plan of Correction (POC) submission scheduled.
Findings
The inspection found deficiencies related to unsecured poisonous materials accessible to residents and unlabeled over-the-counter medications belonging to a resident. The submitted plan of correction was determined to be fully implemented.
Citations (2)
Unsecured poisonous materials such as antiperspirants, hand sanitizers, mouthwash, and skin protectant ointment were accessible to residents who were not assessed as capable of safely using or avoiding them.
A jar of over-the-counter medication belonging to a resident was found unlabeled in the resident's bathroom cabinet.
Report Facts
Residents Served: 78
Secured Dementia Care Unit Residents Served: 23
Hospice Residents: 11
Resident Support Staff Total Daily Staff: 126
Waking Staff: 95
Inspection Report — Feb 28, 2024
Renewal
Date: Feb 28, 2024
Visit Reason
The inspection was conducted as a renewal inspection of THE BIRCHES AT HARLEYSVILLE facility on 02/28/2024 and 02/29/2024 to review compliance with licensing requirements.
Findings
The inspection identified multiple deficiencies including unsecured enabler bars, unlocked poisonous materials, combustible materials accessible to residents, expired medications in the medication cart, unlocked medication cart, improperly calibrated glucometers, failure to follow prescriber's orders, and incomplete preadmission screening forms. Plans of correction were accepted and implemented with ongoing quality assurance actions.
Citations (8)
Resident 1 and Resident 2 had enabler bars not secured to the bed frame per manufacturer's instructions.
Purell Hand Sanitizer was unlocked, unattended, and accessible to residents in memory care.
A can of butane was unlocked, unattended, and accessible to residents in the garden house memory care area.
Expired medications for Resident 3 and Resident 4 were found in the home's medication cart.
Medication cart was left unlocked in the garden house memory care area.
Resident 5 and Resident 6's glucometers were not calibrated properly.
Resident 7 was administered medication prior to the prescribed time.
Resident 10's preadmission screening form was completed after admission.
Report Facts
Residents Served: 80
Secured Dementia Care Unit Residents Served: 34
Hospice Current Residents: 11
Residents Who Have Mobility Need: 48
Residents Who Are 60 Years of Age or Older: 80
Residents Diagnosed with Mental Illness: 1
Residents Diagnosed with Physical Disability: 1
Inspection Report — Dec 21, 2023
Complaint Investigation
Date: Dec 21, 2023
Visit Reason
The inspection was conducted as a complaint and incident investigation at THE BIRCHES AT HARLEYSVILLE facility on 12/21/2023.
Complaint Details
The inspection was complaint-related, but no deficiencies were found and no follow-up was required.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Residents Served: 80
Secured Dementia Care Unit Residents Served: 34
Hospice Current Residents: 11
Resident Support Staff: 0
Total Daily Staff: 123
Waking Staff: 92
Residents 60 Years or Older: 77
Residents Diagnosed with Mental Illness: 1
Residents with Mobility Need: 43
Residents with Physical Disability: 1
Inspection Report — Aug 9, 2023
Complaint Investigation
Date: Aug 9, 2023
Visit Reason
The inspection was conducted as a complaint investigation with unannounced partial review visits on 08/09/2023, 08/10/2023, and 08/29/2023 to assess compliance with regulatory requirements.
Complaint Details
The inspection was complaint-driven, with the reason explicitly stated as 'Complaint'. The submitted plan of correction was reviewed and accepted, with follow-up dates scheduled for verification.
Findings
The submitted plan of correction was found to be fully implemented following the complaint investigation. Deficiencies involved support plan documentation issues, including a resident not signing the support plan and a delay in completing the initial support plan within the required timeframe.
Citations (2)
Resident 1 participated in the development of the support plan but did not sign the support plan.
Resident 1's initial support plan was not completed within 72 hours of admission to the secured dementia care unit.
Report Facts
Residents Served: 78
Secured Dementia Care Unit Residents Served: 33
Hospice Residents: 10
Residents Age 60 or Older: 77
Residents with Mobility Need: 36
Residents with Physical Disability: 3
Residents Diagnosed with Mental Illness: 1
Inspection Report — Mar 22, 2023
Renewal
Date: Mar 22, 2023
Visit Reason
The inspection was conducted as a renewal visit to review compliance with licensing requirements at THE BIRCHES AT HARLEYSVILLE.
Findings
The facility was found to have several deficiencies including missing eye coverings in the first aid kit, improper freezer temperatures, routine scheduling of fire drills on Fridays, and failure to follow prescriber's medication orders for a resident. Plans of correction were accepted and implemented with ongoing monitoring and staff training.
Citations (5)
The first aid kit in Daybreak did not include eye coverings.
The temperature in the Daybreak Freezer was 15 degrees Fahrenheit, above the required 0°F for frozen food.
The temperature in the main kitchen ice cream freezer was 6 degrees Fahrenheit, above the required 0°F for frozen food.
The home routinely holds fire drills on Fridays, not on different days and times as required.
Two medication errors where prescriber's orders were not followed for Resident 1's sliding scale insulin administration.
Report Facts
Freezer Temperature: 15
Freezer Temperature: 6
Fire Drills Dates: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Resident Care Director | Responsible for ensuring first aid kits compliance, reporting medication errors, conducting staff training, and ongoing audits. | |
| Dining Services Director | Responsible for freezer temperature compliance and staff training on food storage. | |
| Environmental Services Director | Responsible for scheduling and conducting fire drills per state requirements. | |
| Two Medication Technicians | Did not follow prescriber's orders for Resident 1's medication administration. |
Inspection Report — Oct 17, 2022
Complaint Investigation
Date: Oct 17, 2022
Visit Reason
The inspection was conducted as a complaint investigation following concerns related to an incident involving a resident who was injured after rolling down the parking lot in a wheelchair and the home's failure to report the incident to the Department.
Complaint Details
The complaint investigation was substantiated as the home did not report the incident involving resident #1 to the Department as required. The home followed up with the hospital and determined no serious injury occurred, but initially failed to report the incident.
Findings
The home failed to report a resident incident to the Department within the required 24-hour timeframe. The resident sustained injuries and was hospitalized. The home subsequently implemented corrective actions including staff training and ongoing monitoring to ensure compliance with reporting requirements.
Citations (1)
Failure to report a resident incident to the Department within 24 hours as required.
Report Facts
Residents Served: 74
Secured Dementia Care Unit Residents Served: 28
Hospice Current Residents: 5
Residents with Mobility Need: 36
Residents 60 Years or Older: 74
Residents Diagnosed with Mental Illness: 2
Residents with Physical Disability: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Resident Care Director | Made the written report to the Department on 10/17/22 following the inspection and involved in ongoing monitoring and training | |
| Executive Director | Completed training on 10/18/22, responsible for reviewing concerns at QA meetings, and provided training following inspection | |
| Daybreak Director | Involved in ongoing monitoring of residents sent to hospital and training | |
| Representative Eberhart | Made the home's Executive Director aware of the need to report the incident during inspection |
Inspection Report — Jun 23, 2022
Date: Jun 23, 2022
Visit Reason
The inspection was conducted as a licensing inspection by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing on 06/23/2022.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Residents Served: 63
Secured Dementia Care Unit Residents Served: 17
Hospice Current Residents: 4
Resident Support Staff: 0
Total Daily Staff: 90
Waking Staff: 68
Residents Age 60 or Older: 62
Residents with Mobility Need: 27
Residents with Physical Disability: 27
Residents Diagnosed with Mental Illness: 2
Inspection Report — May 13, 2022
Monitoring
Date: May 13, 2022
Visit Reason
The inspection was an unannounced partial monitoring visit conducted to review ongoing compliance and follow-up on previous issues.
Findings
The inspection identified a medication administration error involving an incorrect dose of Morphine given to Resident #1. The facility promptly reported the incident, notified the physician and POA, and implemented corrective actions including staff training and ongoing medication cart audits to ensure compliance.
Citations (1)
Resident #1 was administered an incorrect dose of Morphine, receiving 0.5 ml (10mg) instead of the prescribed 0.25 ml (5mg) prior to care.
Report Facts
Residents Served: 66
SDCU Residents Served: 20
Current Hospice Residents: 4
Total Daily Staff: 95
Waking Staff: 71
Residents Age 60 or Older: 65
Residents with Mobility Need: 29
Residents with Physical Disability: 29
Residents Diagnosed with Mental Illness: 1
Residents Diagnosed with Intellectual Disability: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jamie Buchenauer | Deputy Secretary | Signed the letter approving revised license capacity |
Inspection Report — Apr 22, 2022
Plan of Correction
Date: Apr 22, 2022
Visit Reason
The inspection was a follow-up review of the submitted plan of correction related to a prior incident at the facility.
Findings
The submitted plan of correction was determined to be fully implemented, with continued compliance required. The main deficiency involved a resident's medical evaluation lacking certain required medical diagnosis information, which was addressed through documentation and procedural updates.
Citations (1)
Resident #1's medical evaluation did not include a medical diagnosis including physical or mental disabilities of the resident, or medical information pertinent to diagnosis and treatment in case of an emergency.
Report Facts
Residents Served: 63
Secured Dementia Care Unit Residents Served: 20
Hospice Residents: 4
Total Daily Staff: 94
Waking Staff: 71
Residents 60 Years or Older: 62
Residents with Mobility Need: 31
Residents with Physical Disability: 31
Residents Diagnosed with Mental Illness: 1
Inspection Report — Apr 6, 2022
Follow-Up
Date: Apr 6, 2022
Visit Reason
The inspection was a partial, unannounced visit conducted due to an incident on 04/06/2022, with a follow-up type of Plan of Correction (POC) submission.
Findings
The facility was found to have a medication administration deficiency where Resident #1 was not administered Levothyroxine as prescribed from 3/1/22 through 3/29/22. The plan of correction was accepted and included staff training and system monitoring to prevent recurrence.
Citations (1)
Resident #1 was prescribed Levothyroxine 137 mcg daily but was not administered the medication from 3/1/22 through 3/29/22.
Report Facts
Residents Served: 64
Medication Omission Duration (days): 29
Total Daily Staff: 96
Waking Staff: 72
Secured Dementia Care Unit Residents Served: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Claire Mendez | Signed the letter regarding plan of correction acceptance | |
| Resident Care Director | Named in medication omission finding and corrective actions |
Inspection Report — Mar 23, 2022
Renewal
Date: Mar 23, 2022
Visit Reason
The inspection was conducted as a partial, unannounced visit for relicensing to open a second memory care neighborhood and to review compliance with licensing requirements.
Findings
The inspection identified deficiencies related to life safety and physical plant issues, including obstructed egress due to a manual keypad locking mechanism on the memory care gate, lack of written approval for the locking device, exit doors equipped with manual keypad mechanisms, combustible materials stored near heat sources, and doors not locked with an electronic or magnetic locking system. Plans of correction were accepted and implemented with completion dates by 05/11/2022.
Citations (5)
Memory care gate had a manual keypad mechanism blocking egress from the home's exit route to the parking lot.
Gate at memory care used as egress route was equipped with manual keypad locking mechanism without written approval or variance.
Exit door at the memory care gate was equipped with a manual keypad mechanism.
A bottle of Kwik paint stripper with flammable caution instruction was stored inside the boiler room.
Doors opening into the parking lot were not locked with an electronic or magnetic locking system.
Report Facts
Residents Served: 65
Secured Dementia Care Unit Residents Served: 22
Hospice Residents: 5
Total Daily Staff: 100
Waking Staff: 75
Inspection Report — Jan 12, 2022
Follow-Up
Date: Jan 12, 2022
Visit Reason
The inspection was a follow-up review conducted by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing, to verify that the submitted plan of correction was fully implemented following prior deficiencies.
Findings
The facility was found to have implemented the plan of correction fully. Previous deficiencies included failure to report an incident timely, resident-to-resident abuse, incomplete criminal background checks for staff, failure to implement positive interventions for aggressive behavior, and incomplete support plan documentation. Ongoing monitoring and corrective actions were described to maintain compliance.
Citations (5)
Failure to report a resident fall incident to the Department within 24 hours as required.
Resident #1 physically assaulted resident #2 without proper safety precautions in place.
Criminal background check for staff person A was not completed until several months after hire.
Failure to implement positive interventions to modify or eliminate aggressive behavior of resident #1.
Support plan for resident #1 did not address behavioral and psychological concerns impacting safety.
Report Facts
Residents Served: 77
Residents Served in Dementia Unit: 21
Total Daily Staff: 107
Waking Staff: 80
Number of Residents 60 Years or Older: 53
Residents with Mobility Need: 30
Residents with Physical Disability: 30
Number of Incidents of Aggressive Behavior by Resident #1: 4
Inspection Report — Dec 28, 2021
Renewal
Date: Dec 28, 2021
Visit Reason
The inspection was conducted as a renewal inspection of the facility license.
Findings
The inspection identified multiple deficiencies including missing resident signatures on contracts and support plans, incomplete staff orientation and training documentation, obstructed egress due to a locked patio gate, medication administration errors, and lack of resident education on the right to refuse medication. Plans of correction were accepted and documented as implemented.
Citations (9)
Resident-home 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.
Staff person A did not receive timely orientation on fire safety and emergency preparedness topics on her date of hire.
Staff person A did not complete timely training within 40 scheduled work hours on resident rights, emergency medical plan, mandatory reporting of abuse and neglect, and reporting of reportable incidents.
Garden Walk Ground Patio gated fence had a push button lock with no code to exit, blocking egress.
Resident 2 was not administered prescribed medication on 12/15/21 at 8:00 am; medication was signed off but remained in blister pack and not signed on narcotic count sheet.
Resident 3 was not administered prescribed medication on 12/10/21 at 7:00 am.
Resident 1 was not educated on the right to question or refuse medication if a medication error is suspected; no signed documentation was provided.
Resident 4 participated in the development of the support plan but did not sign the support plan.
Report Facts
Residents Served: 52
Residents Served in Dementia Unit: 21
Hospice Residents: 6
Total Daily Staff: 81
Waking Staff: 61
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff person A | Named in deficiencies related to incomplete orientation and training documentation. | |
| Staff person B | Named in medication administration errors and removal from medication administration duties. | |
| Marketing Director | Homes Marketing Director | Responsible for contract review and resident education; involved in deficiencies related to resident contract signatures and education. |
| Executive Director | Homes Executive Director | Provided training and oversight related to contract review and resident education. |
| Resident Care Director | Homes Resident Care Director | Involved in medication administration oversight and training. |
| Memory Care Director | Homes Memory Care Director | Involved in medication administration oversight and support plan review. |
| Maintenance Director | Homes Maintenance Director | Installed push button lock on patio gate causing egress obstruction. |
| Business Office Manager | Homes Business Office Manager | Conducted internal audits of employee files and orientation documentation. |
Inspection Report — Nov 8, 2021
Complaint Investigation
Date: Nov 8, 2021
Visit Reason
The inspection was conducted as a complaint investigation to review compliance with licensing requirements and address specific allegations related to staff qualifications, resident care, and documentation.
Complaint Details
The inspection was complaint-driven, with substantiation implied by the findings of multiple deficiencies related to staff qualifications, resident care, and documentation.
Findings
The inspection identified multiple deficiencies including staff lacking required documentation and training, residents being denied access to bedrooms, inadequate assistance with eating and toileting, incomplete resident support plans, and missing preadmission screenings. Plans of correction were accepted and follow-up training and audits were implemented.
Citations (10)
Direct care staff persons A and B did not have a high school diploma, GED, or active registry status on the Pennsylvania nurse aide registry.
Staff person A completed an online FA/CPR training by a source not certified by a hospital or recognized health care organization.
Staff persons A and B did not receive or document required initial fire safety orientation on their first day.
Staff persons A and B did not complete training within 40 hours on emergency medical plan, mandatory reporting of abuse and neglect, and reporting of reportable incidents.
Residents in rooms 24, 26, 28, 30, 32, 35, 36, 37, and 39 were denied access to their bedrooms by staff locking the doors.
Resident #3 was not properly assisted with eating and drinking as required by their care plan.
Medication administration training record for staff person C lacked verification of passing initial training and timely completion of annual practicum.
Resident #1's support plan did not document how incontinence care needs would be met.
Resident #2's written cognitive preadmission screening was not completed within 72 hours prior to admission to the secured dementia care unit.
Resident #1 experienced delays in toileting assistance, with call bell logs showing waits up to 41 minutes.
Report Facts
Residents Served: 48
Residents Served in Secured Dementia Care Unit: 19
Current Hospice Residents: 5
Staffing Hours - Total Daily Staff: 72
Staffing Hours - Waking Staff: 54
Residents Waiting Time for Assistance: 41
Inspection Report — Apr 23, 2021
Complaint Investigation
Date: Apr 23, 2021
Visit Reason
The inspection was conducted as a complaint and incident investigation with an unannounced partial inspection.
Complaint Details
The inspection was triggered by complaints and incidents involving resident care and staff conduct. The allegations included failure to assist with healthcare appointments, disrespectful treatment of residents, and privacy violations. Staff Member A was suspended and terminated following the investigation. Resident #3 is deceased and Resident #2 and #4 moved to other communities.
Findings
The inspection found deficiencies related to failure to assist a resident with healthcare appointments, inappropriate staff language and behavior towards residents, and violation of resident privacy during care. Plans of correction were submitted and fully implemented.
Citations (3)
Resident #1 did not receive assistance attending podiatrist appointments as required.
Staff Member A used inappropriate language and jokes with residents, including threatening language and profanity.
Staff Member A was present and facetiming a family member in Resident #4's room while the resident was receiving care, violating privacy.
Report Facts
Residents Served: 51
Secured Dementia Care Unit Residents Served: 18
Hospice Current Residents: 6
Residents Age 60 or Older: 51
Residents Diagnosed with Mental Illness: 1
Residents Diagnosed with Intellectual Disability: 1
Residents with Mobility Need: 29
Residents with Physical Disability: 1
Notice — Mar 19, 2021
Date: Mar 19, 2021
Visit Reason
The document serves as a renewal notification and license issuance for the Personal Care Home 'Birches at Arbour Square' following receipt of the renewal application dated December 9, 2020.
Findings
The Department issued a regular license in response to the renewal application and advised that an annual onsite inspection will be conducted within the next twelve months to ensure compliance with applicable regulations.
Report Facts
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary | Signed the renewal notification letter. |
Inspection Report — Mar 2, 2021
Renewal
Date: Mar 2, 2021
Visit Reason
The inspection was an unannounced renewal inspection conducted on 03/02/2021 and 03/03/2021 to review compliance with licensing requirements.
Findings
The inspection identified multiple deficiencies including unlocked narcotics sign-out books, improperly labeled poisonous materials, unlocked poisonous materials in the secured dementia care unit, sanitary condition issues, fire extinguisher inspection overdue, medication administration errors, incomplete medical evaluations, missing documentation on medication procedures, and incomplete resident assessments and support plans. All deficiencies had plans of correction accepted and were reported as implemented or in progress.
Citations (13)
Unlocked narcotics sign-out books were unattended and accessible on med carts.
Spray bottles marked as air-freshener were not stored in original labeled containers.
Multiple spray bottles including Febreze air-freshener and disinfectants were found unlocked in the SDCU closet, posing a risk to residents.
Toilet bowl in resident bathroom was ringed with black mold and strong odor of urine was present in hallways and resident rooms.
Fire extinguisher in the home's van had not been inspected since December 2019.
Resident #1's medical evaluation was not completed annually as required.
Medication administration error where nurse administered wrong dose of Vimpat due to failure to check label.
Controlled substance sign-out sheet for resident #3's Oxycodone did not document receipt and destruction properly.
Medication administration record for resident #4 lacked initials of staff administering Morphine Sulfate doses.
Resident #5's preadmission screening form did not include determination that resident's needs could be met by the home.
Resident #5's initial assessment was not completed within 15 days of admission.
Resident #6's support plan was blank in the medical/dental needs section despite known medical conditions.
Resident #7 was admitted to the secured dementia care unit without a medical evaluation completed within 60 days prior to admission.
Report Facts
Residents Served: 63
Secured Dementia Care Unit Residents Served: 23
Residents with Mobility Need: 34
Residents Age 60 or Older: 63
Residents Diagnosed with Mental Illness: 3
Residents Diagnosed with Intellectual Disability: 1
Residents with Physical Disability: 1
Inspection Report — Feb 4, 2021
Complaint Investigation
Date: Feb 4, 2021
Visit Reason
The inspection was a complaint investigation conducted due to allegations of abuse, neglect, and noncompliance with regulatory requirements at the facility.
Complaint Details
The complaint investigation was substantiated with findings of abuse, neglect, privacy violations, inadequate staff training, and medication errors.
Findings
The investigation found multiple violations including delayed abuse reporting, resident neglect, improper medication administration, inadequate staff training, unsanitary conditions, and failure to follow prescriber's orders. The facility submitted plans of correction which were accepted and implemented.
Citations (15)
Delayed reporting of suspected resident abuse to the local area agency on aging.
Failure to report an incident to the Department within 24 hours as required.
Staff person was not given proper respirator mask while providing care to a quarantined resident exposed to COVID-19.
Resident abuse including intimidation, physical abuse, neglect, and failure to respond timely to call bells.
Violation of resident privacy by electronic dissemination of photos without consent.
Administrator failed to adequately manage the home, resulting in neglect and unmet resident needs.
Direct care staff received insufficient annual training hours and lacked training in required topics including dementia care.
Unsanitary conditions including feces odor, dirty walls, and improper medication administration.
Uncovered trash receptacles in dining area of memory care unit.
Outdated or unlabeled food items stored in memory care unit refrigerator.
Residents in memory care unit lacked access to meals after meal times.
Expired medication found in medication cart.
Medication cart left unlocked and unattended during narcotics audit.
Resident administered medication prescribed for another resident.
Failure to follow prescriber's orders for vital sign checks before medication administration.
Report Facts
Inspection dates: 4
Residents served: 70
Residents served in dementia unit: 24
Hospice residents: 7
Staff total daily: 103
Waking staff: 77
Training hours received: 1.5
Medication cart unattended duration: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff Person B | Agency Personnel Member | Named in resident abuse and delayed reporting findings; banned from building. |
| Staff Person D | Med Tech | Observed asleep during shift; terminated for privacy violation. |
| Staff Person E | Administrator / Executive Director | Failed to manage facility properly; resigned following investigation. |
| Staff Person F | Direct Care Staff | Received insufficient training in 2019; works in Secure Dementia Care Unit. |
Inspection Report — Nov 19, 2020
Renewal
Date: Nov 19, 2020
Visit Reason
The inspection was a full, unannounced renewal inspection conducted on 11/19/2020 to review compliance with licensing requirements.
Findings
The inspection identified multiple deficiencies including incomplete criminal background checks, missing staff orientations and trainings, unlocked poisonous materials accessible to residents, incomplete medical evaluations, medication administration errors, and incomplete resident assessments. Plans of correction were accepted and documented with completion dates by 12/31/2020.
Citations (18)
Criminal background check for a medication technician was not completed until nearly two years after hire.
A staff member did not receive required orientation in fire safety and emergency preparedness on the first day of work.
A staff member did not complete orientation on resident rights, emergency medical plan, abuse reporting, and incident reporting within 40 scheduled working hours.
A staff member did not receive annual training in fire safety, emergency preparedness, resident rights, protective services act, and accident prevention during the 2019 training year.
Crest toothpaste with a poison warning label was unlocked and accessible to residents in a secured dementia care unit where not all residents were assessed capable of safely using poisons.
Stained ceiling tiles were observed inside the door of the Daybreak secured dementia care unit.
Two residents' medical evaluations did not include their medication lists as required.
Resident #3's most recent medical evaluation was completed on 11/19/19, exceeding the annual requirement.
Resident #4 was administered half the prescribed dose of Lorazepam on two occasions.
A discontinued medication (Vitamin D 50,000 IU) was found in a medication cart after discontinuation.
Resident #6's Humalog insulin pen was kept beyond the 28-day discard period after opening.
Resident #7 was administered Lorazepam three times in one day, but the third administration was not recorded on the medication administration record.
Resident #4 was administered half doses of Lorazepam instead of the prescribed full dose on two occasions.
Resident #7 was administered Lorazepam three times in one day, exceeding the prescribed twice daily dose.
The medication error involving Resident #7 was not reported to the department as required.
Resident #2's initial assessment was not completed within 15 days of admission.
Resident #8's additional assessment was completed after a significant change in condition had occurred.
Resident #9 was unable to sign the support plan and the home did not document a notation of inability or refusal to sign.
Report Facts
Residents Served: 61
Residents Served in Secured Dementia Care Unit: 22
Hospice Current Residents: 7
Residents Age 60 or Older: 61
Residents Diagnosed with Mental Illness: 2
Residents Diagnosed with Intellectual Disability: 1
Residents with Mobility Need: 31
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff Member A | Medication Technician | Named in criminal background check deficiency |
| Staff Person B | Named in multiple orientation and training deficiencies | |
| Staff Member C | Administered medication error dose not recorded on MAR | |
| Shawn Brandt | Executive Director | Named as responsible for training and corrective actions |
Inspection Report — Dec 11, 2019
Renewal
Date: Dec 11, 2019
Visit Reason
The document is a renewal application and license issuance for the Personal Care Home 'Birches at Arbour Square' pursuant to Title 55, PA Code, Chapter 2600. The Department will conduct an onsite inspection within the next twelve months as part of the annual inspection requirement.
Findings
No inspection findings are reported in this document. It serves as a license renewal confirmation and notice of upcoming inspection requirements.
Report Facts
Inspection Report — Nov 21, 2019
Follow-Up
Date: Nov 21, 2019
Visit Reason
The inspection was a follow-up review to verify that the previously submitted plan of correction was fully implemented following an incident.
Findings
The submitted plan of correction was determined to be fully implemented. Continued compliance must be maintained.
Citations (3)
Staff person A, hired on 09/19/19, did not have a criminal background check completed until 09/20/19.
Direct care staff person B, hired on 10/10/19, did not complete and pass the Department-approved direct care training course and competency test.
Resident #1's support plan did not identify the individual responsible for addressing the resident's needs, including care provided by the resident's boyfriend/POA starting the week of 10/20/19.
Report Facts
Residents Served: 67
Secured Dementia Care Unit Residents Served: 24
Current Hospice Residents: 5
Current Hospice Residents Total: 22
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Elijah Brisbone | Executive Director | Named in plan of correction and training oversight |
Inspection Report — Nov 4, 2019
Follow-Up
Date: Nov 4, 2019
Visit Reason
The inspection was conducted as a follow-up to verify the implementation of a previously submitted plan of correction related to a complaint.
Complaint Details
The inspection was triggered by a complaint and plan of correction verification. The plan of correction was approved and found implemented.
Findings
The submitted plan of correction was found to be fully implemented. The facility demonstrated compliance with the required corrections.
Citations (2)
2600.187d: Resident #1 was prescribed a lidocaine patch to be applied daily but did not receive it from 9/4/19 to 9/9/19.
2600.227g: Resident #1 participated in the development of the support plan on 8/19/19 but did not sign or refuse to sign the plan.
Report Facts
Residents Served: 70
Secured Dementia Care Unit Residents Served: 23
Current Hospice Residents: 5
Residents Age 60 or Older: 70
Residents Diagnosed with Mental Illness: 2
Residents with Mobility Need: 31
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Elijah Brisbone | Executive Director | Named in plan of correction signatures and facility administration |
Inspection Report — Sep 18, 2019
Complaint Investigation
Date: Sep 18, 2019
Visit Reason
The inspection was conducted as a result of an incident, as indicated by the reason 'Incident' on the inspection report. The visit was unannounced and partial in scope.
Complaint Details
The inspection was complaint-related due to an incident, but no substantiation status is explicitly stated in the report.
Findings
Multiple violations of 55 Pa. Code Ch. 2600 related to personal care home regulations were found, including staff credentialing, orientation, training, and medication record deficiencies. Plans of correction were submitted and partially implemented as of March 23, 2020.
Citations (6)
2600.54a Direct care staff person A lacks a high school diploma, GED, or active registry status on the Pennsylvania nurse aide registry.
2600.62 The home failed to maintain a current list of names, addresses, and telephone numbers of substitute personnel.
2600.65a Staff person A did not receive orientation on evacuation procedures, fire drills, emergency evacuation, smoking safety, fire extinguishers, smoke detectors, and emergency services.
2600.65b Staff person A completed 40 scheduled work hours but did not complete training on resident rights, emergency medical plan, mandatory abuse reporting, and reporting of incidents.
2600.65d Staff person A began providing unsupervised ADL services without a certificate of passing the Department-approved direct care training course and competency test.
2600.187a Resident #1's medication administration record lacks diagnoses for prescribed Atorvastatin 10 mg and Mirtazapine 7.5 mg.
Report Facts
Residents Served: 64
Secured Dementia Care Unit Residents Served: 21
Hospice Current Residents: 6
Total Daily Staff: 92
Waking Staff: 69
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Elijah Brisbone | Executive Director | Named as administrator and legal entity representative signing plans of correction |
Inspection Report — Aug 22, 2019
Complaint Investigation
Date: Aug 22, 2019
Visit Reason
The inspection was conducted as a complaint and incident investigation at Birches at Arbour Square to assess compliance with 55 Pa. Code Ch. 2600 relating to Personal Care Homes.
Complaint Details
The inspection was complaint-driven and incident-related. The complaint involved allegations of verbal abuse and neglect. The Department substantiated neglect and abuse, resulting in staff suspensions and terminations.
Findings
Multiple violations related to abuse, neglect, and inadequate staffing were found. The facility failed to report incidents timely and did not provide adequate care to residents, resulting in staff suspensions and terminations.
Citations (5)
2600.16.c The home failed to report an allegation of verbal abuse and a resident found on the floor in a timely manner to the Department.
2600.42.b Overnight staff neglected duties by failing to assist residents who fell or were left on the floor and by moving an emergency button out of reach.
2600.42.b Residents #1, #2, and #3 did not receive care identified in their plans; responsible caregivers were suspended and terminated after investigation.
2600.42.c A staff member was overheard making inappropriate remarks to residents, leading to suspension and a performance improvement plan.
2600.60.a Staffing was inadequate on July 16, 2019, resulting in delayed care and unmet resident needs; agency staffing and recruitment efforts were initiated.
Report Facts
Residents Served: 69
Secured Dementia Care Unit Residents Served: 23
Current Hospice Residents: 7
Resident with Mobility Need: 29
Resident Age 60 or Older: 68
Residents Diagnosed with Mental Illness: 1
Residents with Physical Disability: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Katie McConnell | Administrator | Named as facility administrator in report header |
| Mia Johnson | Human Services Licensing Supervisor | Signed the inspection report and plan of correction |
| Dean Gray | Department representative conducting on-site inspection | |
| Elijah Basham | PCHA | Signed multiple plans of correction |
Inspection Report — Aug 8, 2019
Complaint Investigation
Date: Aug 8, 2019
Visit Reason
The inspection was conducted as a complaint investigation at Birches at Arbour Square on August 8, 2019.
Complaint Details
The inspection was complaint-driven and unannounced. The violations were substantiated as described in the violation report.
Findings
The inspection found violations related to staffing shortages, failure to provide substitute coverage, and lack of written procedures for timely meal delivery in the memory care unit. Plans of correction were partially implemented with ongoing efforts to improve staffing and meal delivery.
Citations (3)
2600 60b. The home was understaffed on 8/1/19 due to call-outs and failed to provide additional staff to meet residents' needs. Untrained personnel provided care in violation of Pennsylvania state requirements.
2600 61. The home failed to provide substitute coverage on 8/8/19 in the memory care unit, leaving residents unattended for direct care and medication services.
2600 223b. The home lacked written procedures for timely delivery and management of meals in the memory care unit, resulting in occasional late noon meals during the visit.
Report Facts
Residents Served: 69
Residents Served in Dementia Unit: 23
Current Hospice Residents: 7
Total Daily Staff: 98
Waking Staff: 74
Residents with Mobility Need: 29
Residents 60 Years or Older: 69
Residents with Physical Disability: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Johnathan Gardner | Administrator | Named as facility administrator in the report. |
| Natasha Braswell | Department Representative | On-site inspector for the complaint investigation. |
| Elijah Brisbone | Executive Director | Named in relation to plan of correction approval and correspondence. |
Inspection Report — Mar 19, 2019
Renewal
Date: Mar 19, 2019
Visit Reason
The inspection was a renewal visit conducted by the Department’s Bureau of Human Services Licensing on March 19 and 20, 2019 to assess compliance with 55 Pa. Code Ch. 2600 relating to Personal Care Homes.
Findings
The inspection identified violations including a missing trash can lid in the dining room, hazardous objects in the garden patio, and staff lacking proper credentials for medication administration. Plans of correction were submitted and partially implemented with adequate progress noted.
Citations (3)
85a Sanitary Conditions: On 3-20-19 at 2:30pm, the trash can in the dining room was missing a lid.
100a Exterior - Free of Hazards: Two electric bed frames and a broken refrigerator door were found in the garden patio.
190a Completion Medication Course: On 3-19-19, staff persons A, B, and C did not have proper credentials to administer medication and were not in compliance with the annual medication administration policy.
Report Facts
Residents Served: 69
Secured Dementia Care Unit Residents Served: 23
Hospice Current Residents: 7
Residents Age 60 or Older: 69
Residents with Mobility Need: 29
Residents with Physical Disability: 1
Total Daily Staff: 98
Waking Staff: 74
Inspection Report — Mar 18, 2019
Routine
Date: Mar 18, 2019
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 — Dec 14, 2018
Renewal
Date: Dec 14, 2018
Visit Reason
The document is a renewal application response and license issuance for the Personal Care Home 'Birches at Arbour Square'. The Department advises that an annual onsite inspection will be conducted within the next twelve months as required by regulation.
Findings
No inspection findings are reported in this document. It serves as a license renewal confirmation and notification of upcoming annual inspection requirements.
Report Facts
Inspection Report — May 3, 2018
Date: May 3, 2018
Visit Reason
The inspection was conducted as a partial inspection triggered by an incident.
Findings
The facility was found to have violations related to the staff training plan, specifically lacking training that promotes cultural sensitivity to the older adult population served.
Citations (1)
55 Pa.Code §2600.66(b) - The home's staff training plan does not include training that promotes cultural sensitivity to the older adult population being served.
Report Facts
Number of Residents Served: 68
Number of Residents Served in Secured Dementia Care Unit: 21
Number of Current Hospice Residents: 8
Number of Hospice Residents in Past Year: 23
Number of Residents with a Mobility Need: 29
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tracy C. Aungst | Administrator | Named as legal entity representative and signed plan of correction. |
| Patricia Adams | Regional Licensing Director | Signed the cover letter regarding the inspection results. |
| Natasha Braswell | Department representative on-site during inspection. |
Inspection Report — Dec 19, 2017
Routine
Date: Dec 19, 2017
Visit Reason
The Department of Human Services licensing representatives conducted an inspection of the facility on December 19, 2017.
Findings
No regulatory violations were identified as a result of this inspection.
Inspection Report — Jul 20, 2017
Annual Inspection
Date: Jul 20, 2017
Visit Reason
The inspection was conducted as part of the Department of Human Services' Personal Care Homes annual licensing inspections on July 20 and July 21, 2017, for Birches at Arbour Square.
Findings
Several violations of 55 Pa.Code Chapter 2600 were found related to staff training documentation, sanitation during medication administration, medication storage, medication record keeping, and resident support plan signatures. Plans of correction were submitted and partially implemented with adequate progress noted.
Citations (5)
2600.65(d) - The home was unable to provide documentation that Direct Care Staff person A, hired 05/08/17, successfully completed the Department-approved direct care training and competency test.
2600.85(a) - During medication pass observation on 07/20/17, staff person B did not clean the work area before administering medications.
2600.183(b) - Prescription medications, OTC medications, CAM and syringes were not kept in a locked area or container; Resident #1's hydrocortisone cream was unlocked and accessible in their room on 07/21/17.
2600.187(a) - Resident #2's medication administration record lacked documentation of glucose testing for specified dates and times, inconsistent with sliding scale orders.
2600.227(a) - Resident #3 did not sign the support plan dated 03/09/17, despite participation in its development.
Report Facts
Number of Residents Served: 78
Number of Residents Served in Secured Dementia Care Unit: 24
Number of Current Hospice Residents: 16
Number of Hospice Residents in past year: 22
Total Daily Staff: 102
Waking Staff: 77
Number of Residents Age 60 or Older: 78
Number of Residents with Mobility Need: 24
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Denise M. Langman | Interim Executive Director | Named as Legal Entity Representative signing plans of correction |
| Dean Gray | Department of Human Services inspector conducting the inspection | |
| Natasha Braswell | Department of Human Services inspector conducting the inspection |
Inspection Report — December 15, 2017
Renewal
Date: December 15, 2017
Visit Reason
The document is a renewal application and license issuance for the Personal Care Home 'Birches at Arbour Square'. The Department will conduct an onsite inspection within the next twelve months as part of the annual inspection requirement.
Findings
No inspection findings are reported in this document. It serves as a license renewal confirmation and notification of future inspection requirements.
Report Facts
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