Inspection Reports for
Juniper Village at Devon
445 N Valley Forge Rd, Devon, PA 19333, United States, PA, 19333
Back to Facility Profile44 Reports
Inspection Report — May 21, 2026
Follow-Up
Date: May 21, 2026
Visit Reason
The inspection was a partial, announced follow-up visit triggered by a complaint and incident review to verify correction of previous deficiencies.
Complaint Details
The inspection was complaint-related, triggered by allegations of resident abuse and incident reporting failures. The allegations were substantiated with multiple violations found.
Findings
Multiple deficiencies were identified including failure to report suspected resident abuse, incomplete medical evaluations, unsecured medications, and confidentiality breaches. The facility submitted plans of correction which were accepted and implemented by July 21, 2026.
Citations (14)
2600.15a Resident abuse incidents were not immediately reported to the local area agency on aging as required by law.
2600.16c The home failed to submit required incident reports to the Department within 24 hours for abuse incidents.
2600.17 Resident assignment sheets with confidential information were left unlocked and accessible outside the memory care office.
2600.121a The emergency exit gate keypad in the memory care courtyard was not functioning, blocking egress.
2600.141a Resident medical evaluations lacked required components including general physical exam and ability to self-administer medications.
2600.183b Medications and syringes were found unlocked, unattended, and accessible in a resident bathroom.
2600.183d Discontinued medications were found in a resident's bathroom without removal.
2600.190a Staff person administered medications without completing the required Department-approved medication administration course.
2600.225c Resident assessments lacked psychological diagnosis and behavioral needs, despite exhibited signs of agitation and aggression.
2600.231b Resident medical evaluation was not completed within 60 days prior to admission to the secured dementia care unit.
2600.231c Resident cognitive preadmission screening was not completed within 72 hours prior to admission to the secured dementia care unit.
2600.231e No documentation that the resident or designated person objected to admission or transfer to the secured dementia care unit.
2600.234a Resident's initial support plan was not completed within 72 hours of admission to the secured dementia care unit.
2600.251c Resident medical evaluation form was not completed on the Department’s current standardized form for personal care homes.
Report Facts
Residents Served: 55
Residents Served in Secured Dementia Care Unit: 15
Current Hospice Residents: 6
Residents Age 60 or Older: 55
Residents with Mobility Need: 15
Residents with Physical Disability: 2
Total Daily Staff: 70
Waking Staff: 53
Inspection Report — Apr 30, 2026
Monitoring
Date: Apr 30, 2026
Visit Reason
The visit was an unannounced partial inspection conducted as a monitoring review of THE DEVON SENIOR LIVING facility.
Findings
The submitted plan of correction was determined to be fully implemented. Deficiencies involved issues with the secured dementia care unit's emergency exit magnetic lock and medication management including discontinued and unavailable medications.
Citations (4)
Furniture and Equipment: The home's emergency exit in the secured dementia care unit's outdoor courtyard was not functioning properly due to a magnetic lock that did not unlock when the fire panel alarm was activated.
Unobstructed Egress: The magnetic lock on the emergency exit in the secured dementia care unit courtyard was not unlocking and blocked egress despite the fire panel alarm activation.
Prescription Current: A discontinued medication was found in the home's medication cart for an individual resident, violating the requirement that only current prescriptions be kept in the home.
Implement Storage Procedures: A prescribed medication was not available in the home as required for safe storage and access by trained staff.
Report Facts
Residents Served: 58
Secured Dementia Care Unit Residents Served: 15
Hospice Current Residents: 5
Inspection Report — Jan 8, 2026
Complaint Investigation
Date: Jan 8, 2026
Visit Reason
The inspection was conducted as a complaint investigation with an unannounced partial inspection to review compliance and verify the submitted plan of correction.
Complaint Details
The inspection was complaint-driven as indicated by the reason 'Complaint' and involved verification of a plan of correction submitted by the facility.
Findings
The inspection found multiple regulatory violations including resident confinement without ability to exit their room, unsecured poisonous materials accessible to residents, unauthorized locking devices on egress doors, failure to post current menus, and presence of medications without current orders. Plans of correction were accepted and implemented with ongoing monitoring.
Citations (5)
42b Abuse: A resident was confined to their room with the door locked and unable to exit independently, violating care plan requirements for unlocked doors while the resident is in the room.
82c Locking Poisonous Materials: Poisonous materials including Zinc Oxide paste, Voltaren, and mouthwash were found unlocked and accessible to residents not assessed as safe to use them.
121b Locking Device Approval: A resident room door in the Secured Dementia Care Unit had a lock that could only be opened with a key, preventing immediate egress without written approval or variance.
162c Menus Posted: The home's menus for several weeks were not posted; menus displayed were outdated from December 2025.
183d Prescription Current: Medications were found in resident rooms without current orders for those medications.
Report Facts
Residents Served: 56
Secured Dementia Care Unit Residents Served: 13
Hospice Current Residents: 6
Residents Age 60 or Older: 56
Residents with Mobility Need: 19
Residents with Physical Disability: 2
Inspection Report — Dec 4, 2025
Follow-Up
Date: Dec 4, 2025
Visit Reason
The inspection was a partial, unannounced follow-up visit triggered by an incident, conducted to verify the implementation of a previously submitted plan of correction.
Findings
The facility was found to have fully implemented the plan of correction related to abuse, treatment of residents, staff orientation, locking poisonous materials, and exterior hazards. Several violations were identified including verbal abuse by a staff member, inadequate fire safety orientation for a new staff member, unlocked poisonous materials accessible to residents, and exterior hazards such as broken flowerpot, water pooling, and ice patches. Corrective actions were taken and ongoing monitoring was established.
Citations (5)
42b Abuse: Staff member B verbally abused residents, including shouting and yelling, causing fear in residents. Staff member B was suspended and no longer employed.
42c Treatment of Residents: Staff member B restricted residents from watching TV and turned off lights, treating residents without dignity and respect.
65a Fire Safety Orientation: The facility could not verify that a new staff member received required fire safety and emergency preparedness orientation on their first day.
82c Locking Poisonous Materials: An unlocked housekeeping cart containing poisonous cleaners was found accessible in the memory care unit, posing a safety risk to residents.
100a Exterior Hazards: Broken flowerpot, large pool of water, and ice patch were found on exterior grounds posing safety hazards.
Report Facts
Residents Served: 58
Memory Care Residents Served: 15
Current Hospice Residents: 5
Residents Age 60 or Older: 58
Residents Diagnosed with Mental Illness: 4
Residents Diagnosed with Intellectual Disability: 1
Residents with Mobility Need: 19
Residents with Physical Disability: 1
Inspection Report — Nov 10, 2025
Monitoring
Date: Nov 10, 2025
Visit Reason
The visit was a partial, unannounced monitoring inspection to verify the implementation of a previously submitted plan of correction.
Findings
The submitted plan of correction was determined to be fully implemented. The facility demonstrated compliance with medication storage and management procedures following the identified deficiency.
Citations (1)
Regulation 185.a required the facility to develop and implement procedures for safe storage and use of medications. A prescribed as-needed medication was not available in the home on the inspection date.
Report Facts
Residents Served: 61
Secured Dementia Care Unit Residents Served: 17
Hospice Current Residents: 6
Notice — Sep 9, 2025
Date: Sep 9, 2025
Visit Reason
This document serves to notify the facility that a waiver request to waive the requirement for direct care staff to have a high school diploma, GED, or active registry status was granted due to education obtained outside the United States.
Findings
The waiver is granted under specific conditions including documentation of equivalent education and annual review during inspections to ensure compliance. Failure to comply may result in termination of the waiver or other licensing actions.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Theresa Hartman | Bureau Director, Human Services Licensing | Signed the waiver approval letter. |
Inspection Report — Sep 4, 2025
Follow-Up
Date: Sep 4, 2025
Visit Reason
The inspection was a partial, unannounced follow-up visit triggered by an incident to verify the implementation of a previously submitted plan of correction.
Findings
The facility was found to have fully implemented the plan of correction related to multiple violations including abuse, direct care staff qualifications, transportation safety, additional resident assessments, and support plan signatures. Continued compliance and ongoing monitoring were emphasized.
Citations (5)
Regulation 42b, Abuse: A resident was not secured with a seat belt during transport, resulting in injury from a fall in the vehicle. Staff Person A was suspended and terminated for failing to ensure resident safety and lacking direct care qualifications.
Regulation 54a, Direct Care Staff: Staff Person A did not have a high school diploma, GED, or active nurse aide registry status as required.
Regulation 171b1, Providing Transportation: Resident was not secured with a seatbelt while the vehicle was in motion during transport by staff person A.
Regulation 225c, Additional Assessment: Resident assessment was not completed within 5 days of a significant change in condition after hospital discharge.
Regulation 227g, Support Plan Signatures: Resident and assessor did not sign the support plan developed after a significant change in condition.
Report Facts
Residents Served: 58
Secured Dementia Care Unit Residents Served: 15
Residents Age 60 or Older: 58
Residents with Mobility Need: 18
Inspection Report — Aug 11, 2025
Follow-Up
Date: Aug 11, 2025
Visit Reason
The inspection was a full, unannounced renewal and incident review conducted on 08/11/2025 and 08/12/2025 to verify correction of previous deficiencies and ensure ongoing compliance.
Findings
The facility had multiple deficiencies related to resident confidentiality, contract signatures, quality management, abuse, staff qualifications and training, sanitary conditions, medication management, emergency preparedness, and documentation. All cited deficiencies had plans of correction accepted and were implemented by 11/19/2025.
Citations (39)
Resident records and medication logs were left unlocked, unattended, and accessible at the nurses' station and medication cart.
A resident-home contract was not signed by the resident as required.
The home did not have a quality management plan at the time of inspection.
A resident with dementia eloped from the secured dementia care unit and was found with a head injury.
Two direct care staff did not have a high school diploma, GED, or active registry status on the Pennsylvania nurse aide registry.
Two staff persons did not receive required orientation on fire safety and emergency preparedness topics on their first day of work.
A direct care staff person received only 3 hours of annual training in 2024, less than the required 12 hours.
Direct care staff person did not receive required training on medication administration, dementia care, infection control, personal care, safe management, and care for residents with mental illness during 2024.
The home's record of training for a staff person did not include length of training for some required topics.
The home did not have a staff training plan for 2025 at the time of inspection.
An enabler bar was not securely attached to a resident's bed.
Poisonous materials including shampoo and body wash were unlocked and accessible to residents not assessed as capable of safe use.
Sanitary conditions were not maintained, including spilled condiment in refrigerator, substance resembling blood or feces in spa room, and no method to dry hands in a bathroom.
Trash was scattered outside the home near the dining room exit, including cardboard boxes and cigarette butts.
A first aid kit in the secured dementia care unit did not include a breathing shield.
Beds for two residents lacked clean sheets, blankets, or pillowcases.
A bed in a resident's bedroom did not have an operable lamp or source of light at bedside.
A bathroom in a resident's bedroom had no soap dispenser.
No thermometer was present in the freezer on the 3rd floor lounge.
Outdated and unlabeled cans of cranberry sauce and biscuits were found in a refrigerator on the 3rd floor.
The home's emergency procedures were not posted in a conspicuous and public place.
The home lacked documentation of written notification to the local fire department of the home's address, bedroom locations, and evacuation assistance needs.
A fire extinguisher in the laundry room near room 201 had not been inspected by a fire safety expert.
Fire drill records lacked routes used to evacuate and specific times of drills.
A menu change was made without providing notice to residents in advance of the meal.
A resident self-administering medications was unable to recognize, distinguish, or indicate medication details.
Medications for residents were found unlocked, unattended, and accessible in the nurse's station.
A discontinued medication was found in a resident's medication cart.
A syringe prescribed for a resident was missing the cap and contained liquid.
Medication administration records lacked documentation of glucometer readings and medication availability.
Medication administration records for a resident did not indicate dosage for a prescribed medication.
Medication administration records did not include initials of staff administering medications on specific dates and times.
A resident's initial assessment did not document the need for an enabler despite the resident requiring one.
A resident's assessment did not reflect a significant change requiring assistance to self-administer medication.
A resident admitted to the secured dementia care unit lacked documentation that the resident and designated person did not object to admission.
The home did not have a manufacturer statement verifying locks will release upon fire alarm activation, power failure, or lock release device operation.
Directions for operating the home's locking mechanism were not conspicuously posted near the main exit of the secured dementia care unit.
A direct care staff person working in the secured dementia care unit had only 3 hours of required dementia care training in 2024.
A resident record did not include color of hair and color of eyes.
Report Facts
Residents Served: 42
Secured Dementia Care Unit Residents Served: 16
Hospice Current Residents: 5
Resident Age 60 or Older: 42
Residents with Mobility Need: 22
Residents with Physical Disability: 1
Total Daily Staff: 64
Waking Staff: 48
Inspection Report — Aug 4, 2025
Monitoring
Date: Aug 4, 2025
Visit Reason
The inspection was a partial, unannounced monitoring visit conducted to review compliance with regulations and verify the implementation of a previously submitted plan of correction.
Findings
The facility was found to have multiple deficiencies including failure to post required licenses and influenza information, incomplete criminal background checks, inadequate direct care staffing hours for residents with mobility needs, incomplete staff training, missing medical evaluation information, incomplete preadmission screening forms, and missing posted instructions for key-locking devices. Plans of correction were accepted and implemented with ongoing compliance monitoring scheduled.
Citations (14)
The home's copy of 55 Pa.Code Chapter 2600 was not posted in a conspicuous and public place.
The home did not have an influenza poster posted as required by the Influenza Awareness Act.
Criminal background check for a staff member was not completed prior to hire.
Direct care staffing hours were below the required minimum for residents with mobility needs on specific dates.
Less than 75% of required personal care service hours were provided during waking hours on specific dates.
A staff person did not complete required orientation training within 40 scheduled working hours.
A direct care staff person received 0 hours of annual training in the previous training year.
A staff person did not receive required training in the Older Adult Protective Services Act during the training year.
Two fire extinguishers had not been inspected by a fire safety expert since October 2023.
Resident medical evaluation did not include an answer regarding the Mobility Needs Assessment.
Resident's preadmission screening form was not completed as required prior to admission.
Resident's written cognitive preadmission screening was not completed as required prior to admission to the secured dementia care unit.
Directions for operating key-locking devices were not conspicuously posted near exits in the secured dementia care unit.
Direct care staff person working in the secured dementia care unit had 0 hours of dementia care training during the previous training year.
Report Facts
Residents served: 60
Residents with mobility needs: 17
Required direct care hours: 94
Provided direct care hours: 74
Provided direct care hours: 77.5
Percentage of required hours during waking hours: 60
Percentage of required hours during waking hours: 59
Total daily staff: 77
Waking staff: 58
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff member A | Named in criminal background check and training deficiencies | |
| Staff person B | Named in orientation training deficiency | |
| Staff person C | Named in annual training content deficiency | |
| Healthcare Director | Named in multiple findings related to staffing, medical evaluations, and training | |
| Maintenance Director | Named in fire extinguisher inspection and key-locking device findings | |
| Administrator | Named in multiple corrective actions and training | |
| Business Office Manager | Named in training compliance monitoring | |
| Memory Care Manager | Named in key-locking device compliance monitoring | |
| Regional Operations Director | Named in auditing associate files for compliance | |
| Regional Healthcare Specialist | Named in auditing medical evaluations and preadmission screens |
Notice — Jul 24, 2025
Date: Jul 24, 2025
Visit Reason
This document serves to notify the facility that a waiver request to waive the high school diploma or GED requirement for a direct care staff person has been granted due to education obtained outside the United States.
Findings
The waiver is granted under specific conditions including documentation of equivalent education and annual review during inspections to ensure compliance. Failure to comply may result in termination of the waiver or other licensing actions.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Theresa Hartman | Bureau Director, Human Services Licensing | Signed the waiver approval letter. |
Inspection Report — Jun 2, 2025
Complaint Investigation
Date: Jun 2, 2025
Visit Reason
The inspection was conducted as a complaint investigation, unannounced, to review compliance with regulations following a reported incident involving a resident injury and other related concerns.
Complaint Details
The visit was complaint-related, triggered by an incident where a resident sustained a laceration during a transfer. The complaint involved allegations of abuse and neglect related to improper care and failure to report the incident.
Findings
The facility was found to have multiple deficiencies including failure to timely report an incident, improper handling of a resident transfer leading to injury, lack of a criminal background check for a staff member, unqualified direct care staff, and incomplete staff contact lists. Plans of correction were submitted and fully implemented by the report date.
Citations (5)
Failure to submit an incident report to the Department within 24 hours after a resident was taken to the hospital for a laceration requiring six sutures.
Staff did not follow the home's policy for refusal of care and proper transfer procedures, resulting in a resident's left foot being caught under a wheelchair causing a bloody laceration.
The home did not have a Pennsylvania State Police criminal background check for a staff person at the time of inspection.
Direct care staff person did not have a high school diploma, GED, or active registry status on the Pennsylvania nurse aide registry and no waiver was applied for.
Staff persons were missing from the facility's staff contact list.
Report Facts
Residents Served: 52
Secured Dementia Care Unit Residents Served: 16
Current Hospice Residents: 4
Residents Age 60 or Older: 52
Residents Diagnosed with Mental Illness: 3
Residents with Mobility Need: 25
Residents with Physical Disability: 1
Inspection Report — Aug 27, 2024
Follow-Up
Date: Aug 27, 2024
Visit Reason
The inspection was conducted as a full, unannounced review for renewal and complaint reasons at THE DEVON SENIOR LIVING facility.
Complaint Details
The inspection included complaint investigation as part of the renewal review. The plan of correction was fully implemented as of the follow-up review.
Findings
The report details multiple deficiencies related to contract signatures, staff qualifications and training, resident rights, medication management, facility maintenance, and resident assessments. The submitted plan of correction was found to be fully implemented as of the follow-up review.
Citations (28)
Resident-home contract for resident #1 was not signed by the resident.
Resident #1's record lacked a signed statement acknowledging receipt of resident rights and complaint procedures.
Direct care staff person A lacked required qualifications initially.
Direct care staff persons B and C did not complete required training on reporting of reportable incidents and conditions within 40 hours.
Direct care staff person A received only 11.5 hours of annual training in 2023, less than the required 12 hours.
Staff persons A and D did not receive fire safety training by a fire safety expert during 2023.
Training records for staff persons D and E did not include length of each course.
Procedures for bedside mobility devices lacked periodic assessment for installation, maintenance, and appropriateness.
Damage to walls and fixtures in resident #1's room was not fully repaired at time of inspection.
Damaged furniture in resident #1's room including bathroom vanity, TV, and lamp.
Bedroom #13 occupied by 2 residents had only 1 chair.
Resident #1 did not have an operable lamp at bedside.
Use of a common towel was observed in shared bathroom of room 13.
Unlabeled and undated food items found in kitchen storage areas.
Fire extinguisher in 13 passenger van lacked inspection tag.
Resident #1's initial medical evaluation was incomplete, missing health status information.
Resident #2's annual medical evaluation was incomplete; resident #3 and #4 had incomplete or missing evaluations.
Menus in secured dementia care unit were outdated and not posted for current weeks.
Resident #5's medication record did not reflect correct dosage as verified by physician.
Resident #6's insulin pens were not marked with date opened, making expiration determination impossible.
Blood glucose readings for resident #6 and #7 were not properly documented; medication for resident #8 was unavailable.
Resident #9's controlled substance was not stored under double lock as required.
Resident #1's medication record lacked diagnosis or purpose for prescribed medication; resident #9's medication instructions differed between package and MAR.
Medication administration records for residents #1, #6, and #10 lacked initials of administering staff.
Resident #1 was not educated on right to refuse medication if medication error suspected.
Resident #1's assessment did not include recent aggressive behaviors and property destruction.
Resident #3 and #11 had incomplete or improperly completed support plans, including missing device use details and signatures.
Direct care staff persons A and D lacked required 6 hours of annual dementia care training in 2023.
Report Facts
Residents Served: 48
Residents Served in Secured Dementia Care Unit: 16
Current Hospice Residents: 3
Total Daily Staff: 72
Waking Staff: 54
Deficiency Count: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director | Executive Director | Named in multiple findings related to contract audits, training oversight, and plan of correction implementation. |
| Business Office Manager | Business Office Manager | Involved in auditing resident contracts and staff training files. |
| Director of Resident Care | Director of Resident Care | Responsible for training, audits of medical evaluations, medication management, and support plans. |
| Maintenance Director | Maintenance Director | Responsible for fire extinguisher inspections and facility maintenance audits. |
| Culinary Director | Culinary Director | Responsible for food safety, menu posting, and kitchen audits. |
| Director of Resident Services | Director of Resident Services | Responsible for support plan completion and signature audits. |
Inspection Report — Jul 18, 2024
Complaint Investigation
Date: Jul 18, 2024
Visit Reason
The inspection was conducted as a complaint investigation with a partial, unannounced review of the facility on 07/18/2024, followed by off-site reviews on 08/01/2024 and 08/13/2024.
Complaint Details
The inspection was complaint-related as indicated by the reason 'Complaint' and the partial unannounced inspection on 07/18/2024.
Findings
The submitted plan of correction was determined to be fully implemented. Two deficiencies were noted: a non-operable battery in a portable smoke detector in the visitor's bathroom and insufficient dementia care training for a direct care staff person in the secured dementia care unit.
Citations (2)
The portable smoke detector in the 1st floor visitor's bathroom did not have an operable battery installed.
Direct care staff person A, who works in the Secure Dementia Care Unit, had only 1 hour of training in dementia care during the 2023 training year, less than the required 6 hours.
Report Facts
Residents Served: 50
Residents in Secured Dementia Care Unit: 15
Staff Training Hours Required: 6
Staff Training Hours Completed: 1
Total Daily Staff: 76
Waking Staff: 57
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Direct care staff person A | Direct Care Staff | Named in the deficiency related to insufficient dementia care training. |
| Director of Resident Services | Completed dementia training for resident services team members as part of plan of correction. | |
| Executive Director | Responsible for auditing team member training for 2024. | |
| Business Office Manager | Responsible for auditing team member training for 2024. | |
| Maintenance Director | Conducted survey of portable smoke detectors and scheduled monthly surveys as part of plan of correction. |
Inspection Report — Feb 16, 2024
Follow-Up
Date: Feb 16, 2024
Visit Reason
The inspection visit on 02/16/2024 was a partial, unannounced follow-up to review the submitted plan of correction related to an incident.
Findings
The submitted plan of correction was determined to be fully implemented. Deficiencies included failure to secure medical care after a flooding incident and missing resident signatures on contracts, both of which were addressed with corrective actions and staff re-education.
Citations (2)
The resident-home contract was not signed by the resident.
Failure to secure medical care for residents after a flooding incident that caused injury.
Report Facts
Residents Served: 52
Secured Dementia Care Unit Residents Served: 15
Hospice Current Residents: 5
Residents with Mobility Need: 26
Residents 60 Years or Older: 52
Residents Diagnosed with Mental Illness: 1
Residents Diagnosed with Intellectual Disability: 2
Inspection Report — Jan 29, 2024
Follow-Up
Date: Jan 29, 2024
Visit Reason
The inspection visit on 01/29/2024 was a partial, unannounced follow-up inspection triggered by a complaint and incident, to verify the implementation of a previously submitted plan of correction.
Complaint Details
The inspection was complaint-related and included incident review. The plan of correction was accepted and fully implemented by 03/08/2024.
Findings
The submitted plan of correction was determined to be fully implemented as of the follow-up date. Deficiencies related to incomplete medical evaluations and resident record content were corrected, including audits and ongoing monitoring plans to ensure compliance.
Citations (2)
Resident medical evaluation did not include medical information pertinent to diagnosis and treatment in case of an emergency, medication regimen, contraindicated medications, medication side effects, and body positioning and movement stimulation.
Resident record did not include race, height, weight, color of hair, color of eyes, or a record of incident reports for the individual resident.
Report Facts
Residents Served: 51
Residents in Dementia Unit: 15
Hospice Residents: 4
Residents with Mobility Need: 27
Residents 60 Years or Older: 51
Residents Diagnosed with Intellectual Disability: 2
Total Daily Staff: 78
Waking Staff: 59
Inspection Report — Jul 27, 2023
Renewal
Date: Jul 27, 2023
Visit Reason
The inspection was a renewal and provisional licensing inspection conducted to determine compliance with 55 Pa. Code Chapter 2600 relating to Personal Care Homes.
Findings
The facility was found to be generally in compliance but had multiple deficiencies including missing influenza awareness poster, unsecured poisonous materials accessible to residents, sanitary condition issues, hot water temperature exceeding limits, improper food storage and labeling, medication storage and administration errors, and missing emergency procedure submissions. Plans of correction were submitted and accepted with evidence of completion provided.
Citations (16)
2600.18 Influenza Awareness Act: An influenza awareness poster was not present in the home on 7/27/23.
2600.82c Locking Poisonous Materials: Poisonous materials including hand soap, cleaners, toothpastes, mouthwash, and deodorants were unlocked and accessible to residents not assessed as safe to use them.
2600.85a Sanitary Conditions: Debris and unclean items were found under the kitchen sink and a foam cup with spilled liquid was found in the freezer on 7/27/23.
2600.89b Hot Water Temperature: Hot water temperature in room 13 measured 132°F, exceeding the 120°F limit.
2600.103c Food Protected: Two cups of uncovered chocolate ice cream were stored in the ice cream freezer on 7/27/23.
2600.103d Storing Food Off Floor: Eight 5-gallon water bottles were stored on the floor in the storage room on 7/27/23.
2600.103e Left Overs: Unlabeled and undated leftover food items including cake, drinks, and salad dressing were found in various kitchen refrigerators and freezers.
2600.103g Storing Food: A bag of Panko breadcrumbs and pieces of vanilla cake were opened and unsealed in dry storage and kitchen fridge.
2600.105g Lint Removal and Duct Cleaning: Approximately 1-inch accumulation of lint was found in lint traps of two commercial dryers.
2600.107c Food/Water 3 Day Supply: Emergency food supply was insufficient for 40 residents on 7/27/23.
2600.107d Procedure Emergency Management Agency Submission: Written emergency procedures had not been submitted to the local emergency management agency since 2021.
2600.144d Smoking Outside: Two employees were smoking outside the designated smoking area on 7/27/23.
2600.183e Storing Medications: A loose pill was found in the medication cart on 7/28/23, indicating improper medication storage.
2600.185a Implement Storage Procedures: Medications administered to residents on 7/27/23 were not signed off on the narcotics declining inventory log.
2600.233c Key-Locking Devices: Directions for operating the locking mechanism were not conspicuously posted near the main door to the Secure Dementia Care Unit.
2600.234b Support Plan Needs Elements: Resident 5's support plan did not address diagnoses of cognitive impairment, heroin dependence, and anxiety.
Report Facts
Residents served: 40
Residents served in Secure Dementia Care Unit: 13
Current Hospice Residents: 2
Hot water temperature: 132
Unlabeled leftover food items: 6
Unlabeled leftover food items: 2
Unlabeled leftover food items: 1
Water bottles stored on floor: 8
Lint accumulation: 1
Emergency food supply boxes: 9
Instant Nonfat Dry milk boxes: 6
Large cans of tuna: 2
Boxes of raisins: 22
Large cans of applesauce: 3
Large cans of corn beef hash: 5
Cans of condensed milk: 8
Cans of medium-sliced beets: 3
Inspection Report — May 12, 2023
Monitoring
Date: May 12, 2023
Visit Reason
The inspection was a provisional, unannounced monitoring visit to review compliance and the implementation of a previously submitted plan of correction.
Findings
The inspection identified multiple deficiencies related to medication storage, discontinued medications, storage procedures, following prescriber's orders, support plan documentation, medical evaluations, and admission procedures for the secured dementia care unit. All deficiencies had plans of correction submitted and were marked as implemented by August 8, 2023.
Citations (9)
Medications in the cart lacked 'opened on' dates, violating storage requirements.
Discontinued narcotic medication was not destroyed according to policy and regulations.
Resident's glucometer was not calibrated to the correct date and time.
Resident #3 and #4 were administered medications not following prescriber's orders.
Resident #5's support plan did not include dietary needs despite doctor's order for mechanical soft diet.
Resident #1's medical evaluation did not indicate need for secured dementia care unit placement.
No documentation that residents #1 and #6 and their designated persons had not objected to admission to the secured dementia care unit.
Resident #6's initial support plan was completed late, beyond 72 hours of admission to secured dementia care unit.
Resident #6's support plan was not revised to reflect agitation and aggression exhibited after admission.
Report Facts
Residents Served: 40
Residents Served in Secured Dementia Care Unit: 15
Current Hospice Residents: 3
Residents Age 60 or Older: 39
Residents Diagnosed with Intellectual Disability: 2
Residents with Mobility Need: 17
Inspection Report — Dec 12, 2022
Enforcement
Date: Dec 12, 2022
Visit Reason
The inspection visits occurred on June 9, 27, and 28, 2022; September 8 and 9, 2022; and November 30 and December 12, 2022, to assess compliance with 55 Pa. Code Chapter 2600 relating to Personal Care Homes. The Department issued a first provisional license based on an acceptable plan to correct violations found during these inspections.
Findings
Violations of 55 Pa. Code Chapter 2600 were found during multiple inspections, leading to revocation of the prior certificate of compliance and issuance of a first provisional license. The Department intends to assess fines for specific violations unless corrected by the mandated correction date.
Report Facts
Fine Per Resident Per Day: 5
Calculated Fine Per Day: 195
Mandated Correction Date: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jamie Buchenauer | Deputy Secretary | Signed enforcement letter and final decision notice |
Inspection Report — Nov 30, 2022
Enforcement
Date: Nov 30, 2022
Visit Reason
The inspection was conducted as a result of complaint and monitoring concerns, including multiple visits on June 9, 27, 28, September 8, 9, and November 30 and December 12, 2022, to assess compliance with Pennsylvania Department of Human Services regulations for Personal Care Homes.
Complaint Details
The inspection was complaint-related and included monitoring. Specific substantiation status is not stated.
Findings
Multiple violations were found related to medication administration, storage, labeling, and documentation, as well as sanitary conditions and prescription adherence. The facility was issued a first provisional license with a requirement to correct all violations by specified dates, or face fines and possible license revocation.
Citations (10)
Instances of shared glucometers between residents with inconsistent or missing glucose log readings.
Staff persons who had not completed Department-approved medication administration courses administered medications improperly.
Discontinued prescriptions remained on medication carts.
Loose pills found in multiple medication carts.
Original containers for prescription medications lacked proper pharmacy labels.
Improper storage procedures for medications and medical equipment by trained staff.
Failure to document medication administration times properly.
Failure to follow prescriber's orders for insulin and other medications, including missed doses and incorrect dosages.
Staff persons without completed diabetes patient education programs administered insulin injections.
Medication administration training records lacked documentation of course completion for certain staff.
Report Facts
Fine Per Resident Per Day: 5
Calculated Fine Per Day: 195
Mandated Correction Date: 5
Residents Served: 39
Secured Dementia Care Unit Residents Served: 12
Hospice Current Residents: 5
Inspection Report — Oct 20, 2022
Monitoring
Date: Oct 20, 2022
Visit Reason
The inspection was a monitoring visit conducted by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing, to assess compliance at THE DEVON SENIOR LIVING facility.
Findings
No regulatory citations or deficiencies were identified during the inspection. The facility was found to be in compliance with licensing requirements.
Report Facts
Resident Support Staff: 0
Total Daily Staff: 49
Waking Staff: 37
Residents Served: 35
Secured Dementia Care Unit Residents Served: 11
Hospice Current Residents: 3
Residents Age 60 or Older: 35
Residents with Mobility Need: 14
Inspection Report — Sep 8, 2022
Renewal
Date: Sep 8, 2022
Visit Reason
The inspection was a renewal inspection conducted to assess compliance with licensing requirements for The Devon Senior Living facility.
Findings
The inspection identified multiple violations including failure to report a medication error, lack of dignity and respect in resident treatment, missing documentation for fire department notification, incomplete annual medical evaluations for residents, improper medication storage procedures, incomplete medication administration records, and failure to follow prescriber's orders. Plans of correction were submitted with some implemented and others not yet implemented as of the report date.
Citations (7)
Failure to report medication error to the Department within 24 hours.
Failure to treat resident with dignity and respect; staff spoke loudly and created an unwanted spectacle.
No documentation of written notification to local fire department regarding home address, bedroom locations, and evacuation assistance.
Residents #3 and #4 did not have completed annual medical evaluations for 2022.
Medication (Polyethylene Glycol 3350) was not available in the home as prescribed.
Medication administration records for resident #1 did not include initials of staff administering medications on specified dates.
Resident #1 was not administered prescribed medications on 9/8/22 due to medication unavailability.
Report Facts
Fine Per Resident Per Day: 5
Calculated Fine Per Day: 195
Mandated Correction Date: 5
Inspection Report — Jun 9, 2022
Enforcement
Date: Jun 9, 2022
Visit Reason
The inspection was conducted as a partial, unannounced incident investigation related to violations found during multiple licensing inspections on June 9, 27, and 28, 2022, September 8 and 9, 2022, and November 30 and December 12, 2022.
Findings
The facility was found to have multiple violations related to resident care, including a fatal choking incident involving resident #1 who was served food inconsistent with their prescribed mechanical soft diet. The Department revoked the facility's certificate of compliance and issued a first provisional license. Fines are proposed for violations unless corrected by the mandated dates.
Citations (6)
Resident #1 was served food inconsistent with prescribed mechanical soft diet, leading to choking and death due to asphyxiation.
Failure to update resident #1's medical evaluation after choking incident and death.
Failure to meet resident #1's special dietary needs as prescribed by physician.
Failure to provide dietary alternative for resident #1 during dinner.
Failure to follow prescriber's orders for resident #1's diet, resulting in death.
Failure to revise resident #1's support plan within 30 days of assessment and changes in medical needs.
Report Facts
Fine Per Resident Per Day: 5
Calculated Fine Per Day: 195
Residents Served: 36
Secured Dementia Care Unit Residents Served: 11
Residents 60 Years or Older: 35
Residents Diagnosed with Intellectual Disability: 1
Residents with Mobility Need: 9
Inspection Report — Mar 14, 2022
Complaint Investigation
Date: Mar 14, 2022
Visit Reason
The inspection was conducted as a complaint investigation during an unannounced partial inspection on 03/14/2022.
Complaint Details
The inspection was complaint-related, but no deficiencies or substantiated issues were found.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Residents Served: 35
Secured Dementia Care Unit Residents Served: 8
Hospice Residents: 4
Residents 60 Years or Older: 34
Residents Diagnosed with Intellectual Disability: 1
Residents with Mobility Need: 11
Inspection Report — Dec 9, 2021
Renewal
Date: Dec 9, 2021
Visit Reason
The inspection was conducted as a renewal and incident investigation at THE DEVON SENIOR LIVING facility.
Findings
The inspection identified multiple deficiencies including failure to post the current license inspection summary, incomplete staff access records during an incident investigation, sanitary and safety violations, improper food storage and labeling, medication labeling and storage issues, incomplete staff orientations and training, and missing documentation for support plan signatures. All deficiencies had plans of correction implemented or directed.
Citations (18)
The home's most recent License Inspection Summary was not posted in a conspicuous and public place.
Incomplete staff schedule provided to Department agent during incident investigation.
The home does not have contact information for all substitute staff.
Ancillary staff person did not have a general orientation to specific job functions.
No sanitary method of hand drying in the bathroom in resident room.
Hot water temperature in resident room bathrooms exceeded 120°F.
Resident did not have access to a source of light that can be turned on/off at bedside.
No soap dispenser in the bathroom in resident room.
Food not protected from contamination; uncovered food items found in refrigerators.
Leftover food items were unlabeled and undated in multiple refrigerators and storage areas.
No thermometer in the Unit 6 freezer in the main kitchen.
Pharmacy label for resident's medication did not include correct instructions for administration.
Resident's medication administration record did not match prescribed instructions.
Residents participated in support plan development but did not sign the support plans.
Multiple substitute personnel did not receive orientation on fire safety and emergency preparedness topics.
Staff person did not complete required orientation on reporting of reportable incidents and conditions within 40 hours.
Direct care staff person provided unsupervised ADL services without completing required training.
Medications prescribed to residents were not available in the home.
Report Facts
Residents Served: 39
Staff Members During Investigation: 15
Staff Members Named in Schedule: 9
Total Daily Staff: 50
Waking Staff: 38
Hot Water Temperature: 123.9
Hot Water Temperature: 122.1
Notice — Sep 7, 2021
Date: Sep 7, 2021
Visit Reason
This document serves as a renewal notification and license issuance for The Devon Senior Living 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 — Feb 8, 2021
Renewal
Date: Feb 8, 2021
Visit Reason
The inspection was conducted as a renewal visit to review compliance with licensing regulations at The Devon Senior Living facility.
Findings
The inspection identified multiple deficiencies including improper placement of carbon monoxide detectors, incomplete criminal background checks, staff lacking required qualifications and orientations, unsafe storage of poisonous materials, sanitary issues, snow and ice obstructions blocking emergency exits, medication management errors, and missing or outdated medical evaluations and support plans. All deficiencies were corrected or plans of correction accepted with follow-up monitoring.
Citations (17)
Carbon monoxide detectors were improperly placed less than 15 feet from fossil fuel burning devices.
Criminal history background check for staff person A was requested more than one year prior to date of hire.
Direct care staff persons A and B lacked high school diplomas, GEDs, or active registry status on the Pennsylvania nurse aide registry.
Staff persons A and B did not receive required fire safety and emergency preparedness orientation on their first day.
Staff persons A and B did not complete required orientation on resident rights, emergency medical plan, mandatory abuse reporting, and reportable incidents within 40 scheduled working hours.
Staff persons A and B provided unsupervised ADL services without completing Department-approved direct care training and competency test.
A bottle of purple liquid hand soap labeled as poisonous was unlocked and accessible to residents.
Sticky dried brown substance present on medication cart tray.
Snow and ice obstructed emergency exit walkways and doors, blocking egress.
Expired medication (Ketoconazole Shampoo) present on medication cart.
Sample prescription medication (Alendronate Sodium) not labeled with resident's name or instructions.
Resident #3's glucometer reading did not match glucose log; resident #4's medication missing and glucometer not calibrated.
Resident #4's Ammonium Lactate Lotion was documented as administered but was not available.
Resident #4 missed multiple prescribed medications on specified dates.
Resident #1's medical evaluation was outdated at time of admission to secured dementia care unit.
Directions for operating key-locking devices at secured unit doors were not conspicuously posted.
Resident #1's initial support plan was completed after admission to secured dementia care unit.
Report Facts
Residents Served: 47
Memory Care Residents Served: 12
Staff Total Daily: 64
Waking Staff: 48
Snow Accumulation: 3
Inspection Report — Jan 13, 2021
Follow-Up
Date: Jan 13, 2021
Visit Reason
The inspection was a partial, unannounced follow-up visit conducted due to an incident, to verify the implementation of a previously submitted plan of correction.
Findings
The submitted plan of correction related to a resident rights violation was fully implemented. The employee involved was suspended pending investigation and subsequently terminated. The facility committed to ongoing education on resident rights.
Citations (1)
Staff member told a resident to stop saying who they voted for, implying voters for Donald Trump are racist, causing the resident to feel uncomfortable.
Report Facts
Residents Served: 48
Residents Served in Dementia Unit: 13
Hospice Residents: 5
Resident Mobility Need: 17
Residents 60 Years or Older: 48
Residents Diagnosed with Intellectual Disability: 1
Inspection Report — Oct 29, 2020
Complaint Investigation
Date: Oct 29, 2020
Visit Reason
The inspection was conducted as a complaint investigation with an unannounced partial inspection on 10/29/2020.
Complaint Details
The inspection was triggered by a complaint. The submitted plan of correction was accepted and fully implemented as of 12/28/2020.
Findings
The submitted plan of correction was found to be fully implemented. Deficiencies included missing temperature documentation in medical evaluations and incomplete medication administration records lacking staff initials.
Citations (2)
2600.141.a Medical evaluation did not include the resident's temperature. An audit completed on 12/18/2020 confirmed compliance thereafter.
2600.187.b Medication administration records for Resident #1 lacked staff initials for Metformin and Quetiapine doses administered on 10/24/2020.
Report Facts
Residents Served: 48
Memory Care Residents Served: 15
Hospice Residents: 6
Residents Age 60 or Older: 48
Residents with Mobility Need: 18
Residents with Physical Disability: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Natasha Braswell | Lead Inspector | Lead inspector for the 10/29/2020 complaint investigation |
| Mia Johnson | Lead Reviewer | Lead reviewer for plan of correction submissions and document review |
Notice — Oct 2, 2020
Date: Oct 2, 2020
Visit Reason
This document serves as a license renewal notification and certificate of compliance for The Devon Senior Living Personal Care Home. It informs the facility that a regular license is issued and that an onsite inspection will be conducted within the next twelve months as required by regulation.
Findings
No inspection findings are reported in this document. It confirms the issuance of a regular license and advises that future inspections will be conducted to ensure compliance.
Report Facts
Inspection Report — Jul 29, 2020
Complaint Investigation
Date: Jul 29, 2020
Visit Reason
The inspection was conducted as a complaint investigation following allegations of abuse and staffing concerns at The Devon Senior Living.
Complaint Details
The visit was complaint-related, investigating allegations of abuse and inadequate staffing. The complaint was substantiated with findings of mechanical restraint and staffing deficiencies.
Findings
The investigation found that a staff member used a mechanical restraint by tying a scarf around a resident's waist and securing it to a wheelchair. Additionally, staffing levels were insufficient to meet resident needs during an anxiety episode, and direct care staff lacked required qualifications and training.
Citations (5)
42b - Abuse: Staff Member A tied a scarf around Resident #1's waist and secured it to a wheelchair, restraining the resident and violating abuse prevention regulations.
54a - Direct Care Staff: Direct care staff person A lacked a high school diploma, GED, or active Pennsylvania nurse aide registry status as required.
60a - Staff/Support Plan: Resident #1 did not receive comfort during anxiety as required, and Staff Member A was left alone with 13 residents with dementia for 1.5 hours, failing to meet staffing needs.
65d - Initial Direct Care Training: Direct care staff person A provided unsupervised ADL services without completing and passing the required Department-approved direct care training course.
202 - Prohibitions: Mechanical restraint use by Staff Member A tying a scarf around Resident #1's waist and securing it to a wheelchair was prohibited.
Report Facts
Residents Served: 48
Residents Served in Dementia Unit: 15
Hospice Current Residents: 6
Staff Left Alone with Residents: 13
Duration of Staffing Deficiency: 1.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff Member A | Named in findings related to abuse, mechanical restraint, staffing, and training violations |
Inspection Report — Jan 14, 2020
Follow-Up
Date: Jan 14, 2020
Visit Reason
The visit was a partial, unannounced inspection conducted due to an incident reported at the facility.
Complaint Details
The inspection was triggered by an incident involving improper restraint of a resident by staff tying a plastic bag to prevent the resident from leaving their bedroom.
Findings
The submitted plan of correction related to abuse, restraints, and obstructed egress violations was fully implemented. The facility demonstrated compliance with required corrective actions.
Citations (3)
42b Abuse regulation 2600. A resident was subjected to restraint by tying a plastic bag to the bedroom door and hallway rail to prevent leaving the room.
42p Restraints regulation 2600. A resident was restrained by tying a plastic bag to the bedroom door and hallway rail to prevent leaving the room.
121a Unobstructed Egress regulation 2600. Stairways, hallways, doorways, and egress routes were blocked by a plastic bag tied to a resident's bedroom door and hallway rail.
Report Facts
Residents Served: 66
Memory Care Residents Served: 6
Current Hospice Residents: 6
Residents Age 60 or Older: 66
Residents Diagnosed with Mental Illness: 2
Residents with Mobility Need: 18
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tiffanie Small | Executive Director | Signed plan of correction documents related to abuse and restraint violations |
Notice — Jul 25, 2019
Date: Jul 25, 2019
Visit Reason
The document serves as a renewal notification and license issuance for The Devon Senior Living 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 a licensing certificate and renewal letter without compliance or deficiency details.
Report Facts
Inspection Report — Jun 26, 2019
Renewal
Date: Jun 26, 2019
Visit Reason
The inspection was conducted as an annual renewal inspection of The Devon Senior Living facility to assess compliance with 55 Pa. Code Ch. 2600 relating to Personal Care Homes.
Findings
Multiple violations were found related to housekeeping/maintenance, sanitary conditions, trash receptacles, lighting, emergency telephone numbers, toilet paper provision, lint removal and duct cleaning, and medication storage procedures. Plans of correction were partially implemented with adequate progress noted as of December 2, 2019.
Citations (8)
60c - Housekeeping/Maintenance: The home had only one housekeeper and a supervisor fulfilling housekeeping duties, resulting in basic housekeeping tasks not being completed due to lack of staff.
85a - Sanitary Conditions: Medication carts were unclean with medication residue, no paper towels were found in room 122 bathroom, and strong urine odors and gloves left by staff were found in multiple rooms.
85d - Trash Receptacles: A full, uncovered, unattended trash can was found in the activities room bathroom.
87 - Lighting: Missing light bulbs were found in the 1st and 2nd floors stairwell in the Terrace tower.
91 - Telephone Numbers: Emergency telephone numbers for nearest hospital and fire department were missing in the kitchenette area and room 18.
102h - Toilet Paper: No toilet paper was available for the toilets in bathrooms of rooms 12 and 122.
105g - Lint Removal and Duct Cleaning: Accumulation of lint was found inside dryer traps on the 2nd and 3rd floors, though no clothes were in the dryer at the time.
185a - Implement Storage Procedures: The glucometer for resident #1 was not calibrated to the correct month.
Report Facts
Residents Served: 66
Dementia Unit Residents Served: 11
Hospice Current Residents: 6
Housekeeping Staffing: 1
Total Daily Staff: 84
Waking Staff: 63
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Robert Angel | Executive Director | Named in multiple plans of correction and signature on violation report |
Inspection Report — May 15, 2019
Complaint Investigation
Date: May 15, 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 at The Devon Senior Living.
Complaint Details
The inspection was complaint-driven as indicated by the reason 'Complaint' and the unannounced notice. Specific deficiencies related to medical evaluations, service descriptions, and support plans were identified.
Findings
Violations were found related to incomplete medical evaluations, inadequate written description of services, and insufficient support plan revisions. The facility was required to correct these deficiencies and implement plans of correction.
Citations (4)
2600.141a. The resident's medical evaluation did not include weight under the General Physical Examination section. Resident R1 was discharged prior to the inspection and the DME was not corrected.
2600.141b1. Resident #1's most recent medical evaluation was completed on 2-14-18, with the previous one on 2-14-17, indicating a failure to complete annual medical evaluations.
2600.223a. The home's written description of services does not include skilled care involving detailed services for pressure wounds. Resident R1 developed a pressure wound requiring third party agency services.
2600.234d. The support plan for resident #1 was completed on 2/14/19 but did not address changes in medical status or detail required wound care by a third party agency.
Report Facts
Residents Served: 73
Secured Dementia Care Unit Residents Served: 13
Hospice Current Residents: 3
Residents Age 60 or Older: 60
Residents Diagnosed with Mental Illness: 2
Residents with Mobility Need: 21
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kenneth Williams | Administrator | Named as facility administrator in violation report |
| Robert Angel | Executive Director | Named in plan of correction approvals and responsible for corrective actions |
Inspection Report — Mar 26, 2019
Complaint Investigation
Date: Mar 26, 2019
Visit Reason
The inspection was conducted as a complaint investigation at The Devon Senior Living facility on March 26, 2019.
Complaint Details
The inspection was triggered by a complaint. The report does not state substantiation status.
Findings
Multiple violations of 55 Pa. Code Chapter 2600 were found, including issues with sanitary conditions, trash receptacles, support plan documentation, preadmission screening, and key-locking device signage. Corrective actions were planned or partially implemented for all violations.
Citations (5)
55 Pa.Code §2600.85(a) - Sanitary conditions were not maintained; a strong smell of urine was noted in room 19 and used toilet paper was found on the rim of the toilet in room 14.
55 Pa.Code §2600.85(d) - Trash cans in bathrooms of rooms 13 and 14 lacked lids and trash was placed in an uncovered bedside wash basin on the bathroom floor of room 14.
55 Pa.Code §2600.227(g) - Resident #1 participated in support plan development but did not sign the support plan dated 09/25/18 and 01/30/19.
55 Pa.Code §2600.231(c) - Resident #1 was admitted to the secured dementia unit on 01/29/19 without a completed cognitive preadmission screening within 72 hours prior to admission.
55 Pa.Code §2600.233(c) - Directions for operating the home's locking mechanism were not conspicuously posted near the exit door by the living room in the secured dementia care unit.
Report Facts
Number of Residents Served: 73
Number of Residents Served in Secured Dementia Care Unit: 13
Number of Current Hospice Residents: 3
Number of Hospice Residents in Past Year: 18
Residents with Mental Illness: 2
Residents with Mobility Need: 21
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kenneth Williams | Administrator | Named as facility administrator on page 2. |
| Dean Gray | Department representative on-site during inspection on 03/26/2019. |
Inspection Report — Feb 13, 2019
Complaint Investigation
Date: Feb 13, 2019
Visit Reason
The inspection was conducted as a result of an incident complaint reported at The Devon Senior Living facility on February 13, 2019.
Complaint Details
The visit was triggered by an incident complaint involving resident-to-resident abuse. Resident #1 reported being hit by resident #2, and the incident was witnessed by resident #3. The complaint was substantiated by the findings.
Findings
Violations of 55 Pa. Code Chapter 2600 related to resident neglect and incomplete medical evaluations were found. The facility was cited for failure to prevent resident abuse and for missing required medical evaluation documentation.
Citations (2)
55 Pa.Code §2600.42(b) - A resident was physically abused when resident #2 hit resident #1 in the head with her cane. Staff failed to intervene or supervise during the incident.
55 Pa.Code §2600.141(a)(2) - Medical evaluations for residents #1 and #2 did not include immunization history or license number of the medical professional as required.
Report Facts
Number of Residents Served: 73
Number of Current Hospice Residents: 5
Number of Residents Served in Secured Dementia Care Unit: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kenneth Williams | Executive Director | Named as the legal entity representative and involved in plan of correction |
| Natasha Braswell | Department representative on-site during inspection |
Inspection Report — Nov 27, 2018
Routine
Date: Nov 27, 2018
Visit Reason
The Department's Bureau of Human Services Licensing representatives conducted an inspection of The Devon Senior Living facility on November 27, 2018.
Findings
No regulatory citations with 55 Pa. Code Ch. 2600 (relating to Personal Care Homes) were identified as a result of this inspection.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shawn Parker | Human Services Licensing Supervisor | Signed the inspection report letter. |
Inspection Report — Sep 6, 2018
Complaint Investigation
Date: Sep 6, 2018
Visit Reason
The inspection was conducted as a complaint investigation of The Devon Senior Living facility on September 6, 2018.
Complaint Details
The complaint investigation found substantiated violations related to failure to report a resident fall incident within 24 hours as required by regulation.
Findings
Violations of 55 Pa. Code Chapter 2600 related to Personal Care Homes were found, including failure to report a resident's fall and injury to the Department within the required timeframe. A plan of correction involving re-education of staff and monitoring of incident reporting was implemented.
Citations (1)
Regulation 55 Pa.Code §2900 2600.16(c) requires reporting incidents to the Department within 24 hours. The facility failed to report a resident's fall and resulting hip fracture to the Department in a timely manner.
Report Facts
Number of Residents Served: 73
Total Daily Staff: 93
Waking Staff: 70
Number of Current Hospice Residents: 7
Number of Hospice Residents in Past Year: 16
Number of Residents Served in Secured Dementia Care Unit: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ken Williams | Administrator | Named as facility administrator in relation to the inspection and plan of correction |
| Denise Gillespie | Department representative on-site during inspection |
Inspection Report — Jul 26, 2018
Renewal
Date: Jul 26, 2018
Visit Reason
The document is a renewal license issued in response to a July 18, 2018 renewal application to operate The Devon Senior Living Personal Care Home. 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 notification and confirmation of regulatory requirements for future inspections.
Report Facts
Inspection Report — May 18, 2018
Annual Inspection
Date: May 18, 2018
Visit Reason
Annual inspection of The Devon Senior Living facility conducted by the Pennsylvania Department of Human Services Bureau of Human Services Licensing to assess compliance with 55 Pa. Code Chapter 2600 relating to Personal Care Homes.
Findings
Multiple violations of state regulations were identified, including issues with incident reporting, documentation, sanitary conditions, safety hazards, emergency procedures, medication administration, and resident rights. Plans of correction were submitted and partially implemented with adequate progress noted.
Citations (19)
55 Pa.Code §2500: The home failed to report incidents to the Department's personal care home regional office within 24 hours as required.
55 Pa.Code §2600.10(a): The most recent inspection of the hot water boiler was outdated and lacked proper certification documentation.
55 Pa.Code §2600.25(b): Residency contracts for residents #4, #5, and #6 were not signed by the residents.
55 Pa.Code §2600.11(a): Statements signed by residents acknowledging receipt of resident rights and complaint procedures were missing for residents #5, #8, and #7.
55 Pa.Code §2600.85(a): No paper towels were available in the 1st floor bathroom next to the elevator at 9:35 am on 04/18/2018.
55 Pa.Code §2600.63(a): Carpet near the 1st floor elevator was split and frayed at the seam, creating a potential hazard.
55 Pa.Code §2600.90(g)(3): The kitchen first aid kit did not include a working thermometer.
55 Pa.Code §2600.102(h): No toilet paper was available in the 1st floor bathroom near the elevator at 11:45 am on 04/18/2018.
55 Pa.Code §2600.103(g): Vanilla ice cream in the freezer was opened and unsealed.
55 Pa.Code §2600.137(e): The home lacked written emergency procedures including confidentiality of medical information and contact information for residents' designated persons.
55 Pa.Code §2600.121(a): A rope blocked the stairs to the exit located at the chapel.
55 Pa.Code §2600.130(g): A dirty smoke detector was found and was repaired within 48 hours.
55 Pa.Code §2600.130(h): The home's emergency procedures did not indicate procedures when smoke detectors or fire alarms are inoperable.
55 Pa.Code §2600.141(b)(1): Resident #3's last medical evaluation was completed on 03/12/2017, requiring timely updates.
55 Pa.Code §2600.187(a): Staff person A did not sign the master medication signature sheet for April 2018.
55 Pa.Code §2600.191: Residents #2, #4, #5, #3, and #7 were not administered medications as prescribed, with documentation errors noted.
55 Pa.Code §2600.227(a): Resident #8 was admitted without a completed support plan.
55 Pa.Code §2600.227(g): Resident #6 participated in support plan development but did not sign the plan.
55 Pa.Code §2600.233(c): The posted code for the SDU locking mechanism was incorrect and the hole punch for the zip tie covered part of the code.
Report Facts
Number of Residents Served: 75
Number of Violations: 19
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kenneth Williams | Executive Director | Named as legal entity representative signing plans of correction |
Notice — Aug 2, 2017
Date: Aug 2, 2017
Visit Reason
This document serves as a renewal notification and license issuance for The Devon Senior Living Personal Care Home following receipt of a renewal application dated August 1, 2017.
Findings
The Department of Human Services confirms issuance of a regular license for the facility with a maximum capacity of 84 persons. The Department will conduct an onsite annual inspection within the next twelve months as required by regulation.
Report Facts
Inspection Report — Apr 28, 2017
Complaint Investigation
Date: Apr 28, 2017
Visit Reason
The inspection was conducted as a complaint investigation triggered by an incident at The Devon Senior Living.
Complaint Details
The visit was complaint-related due to an incident of suspected abuse. The abuse allegation was substantiated by the finding that the home failed to timely report to the local area agency on aging.
Findings
Two violations were found: failure to immediately report suspected abuse to the local area agency on aging, and failure to provide assistance with instrumental activities of daily living as indicated in the resident's assessment and support plan.
Citations (2)
REGULATION 65 Pa.Code §2600.15(a): The home did not report suspected abuse of a resident to the local area agency on aging until 4/24/17, which was not timely.
REGULATION 65 Pa.Code §2600.23(b): The resident's assessment and support plan required assistance with safe transfer, but staff failed to follow interventions, causing physical bruising to the resident.
Report Facts
Number of Residents Served: 84
Number of Current Hospice Residents: 7
Number of Hospice Residents in past year: 18
Number of Residents 60 Years or Older: 84
Number of Residents with Mental Illness: 2
Number of Residents with Mobility Need: 25
Number of Residents with Physical Disability: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie McDuffy | Administrator | Named in facility header |
| Ken Williams | Executive Director | Signed plan of correction for violations |
Inspection Report — Dec 13, 2016
Annual Inspection
Date: Dec 13, 2016
Visit Reason
The inspection was conducted as part of the Department of Human Services' annual licensing inspections on December 13, 2016, December 14, 2016, and March 28, 2017, including renewal and complaint reasons.
Findings
Violations related to Personal Care Homes regulations under 55 Pa.Code Chapter 2600 were found, including improper sharing of glucometers, inaccurate medication administration records, incomplete pre-admission screening, and incomplete resident assessments. Plans of correction were submitted and partially implemented as of April 2017.
Citations (6)
Regulation 55 Pa.Code §2600.85(a): The home shared a glucometer between residents, confirmed by analysis of readings, violating sanitary conditions requirements.
Regulation 55 Pa.Code §2600.187(b): The medication administration record for Resident #2 incorrectly documented the blood sugar reading as 248 when the actual glucometer reading was 245.
Regulation 55 Pa.Code §2600.224(a): Pre-admission screening forms for two residents did not include determinations that the home could meet their service needs.
Regulation 55 Pa.Code §2600.225(c): Resident #5's most recent assessment was completed on 10/21/2016, with the previous on 8/25/2015, lacking timely annual assessments.
Regulation 55 Pa.Code §2600.187(a)(13) and (a)(14): Resident #1 and #2 had incomplete or missing blood glucose testing documentation and medication administration records on specified dates.
Regulation 55 Pa.Code §2600.187(d): The home failed to follow prescriber directions for Resident #2's blood glucose testing, with no test performed on 3/16/17 and no recorded measurements.
Report Facts
Number of Residents Served: 78
Number of Residents Served: 79
Total Daily Staff: 101
Walking Staff: 76
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kenneth Williams | Executive Director | Named as Administrator and Legal Entity Representative signing plans of correction. |
Inspection Report — Jul 26, 2016
Renewal
Date: Jul 26, 2016
Visit Reason
The document is a renewal license issued to The Devon Senior Living to operate a Personal Care Home. The Department received a renewal application on July 26, 2016, and will conduct an onsite inspection within the next twelve months as required by regulation.
Findings
No inspection findings are reported in this document. It serves as a license renewal certificate and notification of upcoming annual inspection requirements.
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