Citations (last 5 years)
Citations (over 5 years)
26.2 citations/year
Citations are regulatory findings recorded during state inspections.
457% worse than Pennsylvania average
Pennsylvania average: 4.7 citations/yearCitations per year
80
60
40
20
0
Occupancy
Latest occupancy rate
59% occupied
Based on a May 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Census: 66
Capacity: 112
Citations: 0
Date: May 9, 2025
Visit Reason
The inspection was conducted as a licensing inspection by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing, with the reason noted as 'Incident'.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
License Capacity: 112
Residents Served: 66
Secured Dementia Care Unit Capacity: 18
Secured Dementia Care Unit Residents Served: 16
Hospice Current Residents: 10
Residents Age 60 or Older: 66
Residents with Mental Illness: 1
Residents with Mobility Need: 30
Inspection Report
Complaint Investigation
Census: 66
Capacity: 112
Citations: 0
Date: Apr 16, 2025
Visit Reason
The inspection was conducted as a complaint investigation at THE PINES OF MT. LEBANON facility on 04/16/2025.
Complaint Details
The inspection was triggered by a complaint, but no deficiencies or citations were found, indicating no substantiated issues.
Findings
No regulatory citations or deficiencies were identified as a result of this complaint investigation inspection.
Report Facts
Residents Served: 66
License Capacity: 112
Secured Dementia Care Unit Capacity: 18
Secured Dementia Care Unit Residents Served: 17
Hospice Current Residents: 13
Residents Age 60 or Older: 66
Residents with Mobility Need: 33
Residents with Physical Disability: 1
Inspection Report
Complaint Investigation
Census: 51
Capacity: 112
Citations: 0
Date: Sep 17, 2024
Visit Reason
The inspection was conducted as a complaint investigation during an unannounced partial licensing inspection of the facility.
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
License Capacity: 112
Residents Served: 51
Secured Dementia Care Unit Capacity: 19
Secured Dementia Care Unit Residents Served: 9
Hospice Current Residents: 6
Resident Age 60 or Older: 51
Residents with Mobility Need: 16
Residents with Physical Disability: 1
Total Daily Staff: 67
Waking Staff: 50
Inspection Report
Renewal
Census: 54
Capacity: 112
Citations: 25
Date: Mar 18, 2024
Visit Reason
The inspection was conducted as part of a renewal and provisional exit conference to assess compliance with 55 Pa. Code Ch. 2600 relating to Personal Care Homes.
Complaint Details
The April 2024 and July 2024 inspections were complaint-related, investigating incidents including abuse of resident #2 by staff, failure to assist resident #1 with transfers, and other regulatory violations. The abuse allegation was substantiated by APS following investigation.
Findings
The facility was found to be in compliance overall but had multiple deficiencies including failure to post current license inspection summaries, confidentiality breaches of resident records, lack of influenza posters, inadequate first aid/CPR trained staff, insufficient annual training for direct care staff, heat source safety issues, ventilation problems in bathrooms, improper food storage, missing emergency procedures postings, inadequate fire alarm signaling for hearing impaired residents, medication packaging violations, outdated service descriptions, incomplete preadmission screenings, unsigned support plans, delayed medical evaluations, missing directions for key-locking devices, incomplete resident records logs, and abuse incidents.
Citations (25)
Failure to post current license inspection summaries in a public and conspicuous place.
Resident records were unlocked, unattended and accessible, violating confidentiality requirements.
No influenza poster posted in a public place as required by the Influenza Awareness Act.
Insufficient number of staff trained in first aid and certified in obstructed airway techniques and CPR present during shifts.
Direct care staff did not receive required annual training hours related to job duties.
Direct care staff did not receive required training on specified topics including medication self-administration, dementia care, infection control, and others.
Direct care staff did not receive required annual training on fire safety by a fire safety expert.
Heat sources exceeding 120°F accessible to residents were not equipped with protective guards or insulation.
Bathrooms without operable outside windows lacked exhaust fans for ventilation.
Food and emergency water stored on the floor in kitchen storage room.
No thermometer present in special needs kitchen drink refrigerator.
Food stored in open and unsealed containers in walk-in freezer and cooler.
Emergency preparedness plans not posted in a conspicuous and public place.
Residents with hearing impairment lacked approved signaling devices in common areas to alert fire alarms.
Medications repackaged into small bags not in original labeled containers.
Written description of services inaccurately indicated transportation was provided when it was not.
Preadmission screening forms incomplete, unsigned, or missing for several residents.
Resident support plan not signed by resident and lacked documentation of refusal or inability to sign.
Medical evaluation for secured dementia care unit resident completed after admission date.
No directions posted for operating key-locking devices at secured dementia care unit exit door.
Resident records destruction log missing birthdates and admission dates.
Resident #1 not assisted with transfers due to inoperable Hoyer lift.
Resident #2 subjected to inappropriate and non-consensual kissing by staff, causing fear and distress.
Poisonous materials left unlocked and accessible in secured dementia care unit storage room.
Sanitary conditions not maintained; red sticky substance found on freezer drawer bottom.
Report Facts
License Capacity: 112
Residents Served: 54
Residents Served: 51
Residents Served: 50
Capacity of Secure Dementia Care Unit: 18
Residents Served in Secure Dementia Care Unit: 8
Residents Served in Secure Dementia Care Unit: 5
Residents Served in Secure Dementia Care Unit: 7
Total Daily Staff: 70
Waking Staff: 53
Total Daily Staff: 67
Waking Staff: 50
Total Daily Staff: 66
Waking Staff: 50
Gallons of Emergency Water Stored on Floor: 137
Open Hot Dogs: 7
Open Box of Corn Kernels: 30
Open Bag of Cookie Pieces: 0.5
Open Bag of Sugar: 25
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ashley Roser | Lead Inspector | Lead inspector for multiple inspections including March 18, 2024 and April 18, 2024. |
| Eric Ambrose | SMD | Responsible for conducting fire safety training and monitoring compliance. |
| Staff person A | Involved in abuse incident with resident #2; suspended and terminated. |
Inspection Report
Follow-Up
Census: 49
Capacity: 112
Citations: 4
Date: Jan 18, 2024
Visit Reason
The inspection was a partial, unannounced follow-up visit to verify the implementation of a previously submitted plan of correction related to medication storage, labeling, changes, and administration documentation.
Findings
The facility was found to have repeat violations regarding medication storage, labeling, changes in medication orders, and documentation of medication administration. The submitted plan of correction was determined to be fully implemented as of the follow-up inspection.
Citations (4)
Medication eye drops were opened, undated, and filled beyond the manufacturer's 28-day discard requirement.
Several residents' prescription medications lacked pharmacy labels on the original containers.
Medication changes were not properly documented in writing; a medication was omitted without a discontinuation order.
Medications were administered by staff but not documented in the medication administration record (MAR) with no exceptions noted.
Report Facts
License Capacity: 112
Residents Served: 49
Memory Care Capacity: 18
Memory Care Residents Served: 8
Hospice Residents: 12
Residents with Mobility Need: 16
Residents with Physical Disability: 1
Total Daily Staff: 65
Waking Staff: 49
Inspection Report
Complaint Investigation
Census: 66
Capacity: 112
Citations: 27
Date: Aug 14, 2023
Visit Reason
The inspection was conducted due to complaints, provisional license issues, and incidents at The Pines of Mt. Lebanon facility.
Complaint Details
The visit was complaint-related involving allegations of abuse, neglect, medication errors, and failure to comply with regulations. Some abuse allegations were substantiated, and investigations were conducted. The facility failed to report abuse and incidents timely to the Department and Area Office of Aging.
Findings
Multiple violations were found including confidentiality breaches, resident elopement, medication administration errors, incomplete medical evaluations and assessments, failure to report and investigate abuse allegations properly, and deficiencies in resident support plans and signatures.
Citations (27)
Resident records were left unlocked and accessible, breaching confidentiality.
Resident #5 left the home unattended without staff hearing the wander guard alarm.
Exit doors were not labeled with exit signs.
Resident #5's annual medical evaluation was outdated.
Discontinued medications were still present in the home.
Medication administration times were not properly documented.
Resident #6's initial assessment was incomplete and no assessment was completed for resident #7.
Resident #5 left the home unattended and unsupervised, causing safety concerns.
Resident #7's support plan was not completed within 30 days of admission.
Resident #6's medical evaluation did not indicate need for secured dementia care unit.
Medications were not current or properly labeled, including insulin and other prescriptions.
Medications were not administered at prescribed times.
Allegations of abuse were not reported to the Area Office of Aging or Department as required.
Staff person involved in abuse allegations was not immediately suspended.
Residents and designated persons were not notified of abuse allegations.
Incidents of abuse were not reported to the Department timely.
Resident #7 waited excessive time for toileting assistance and fell without timely help.
Residents were neglected and verbally abused by staff.
Medication carts were left unlocked and accessible.
Discontinued medications were not removed timely from medication carts.
Resident support plans were not signed by required individuals.
Medical evaluations were incomplete or missing required information.
Glucometers were not set to correct date and time.
Medication administration records did not document insulin units administered.
Resident assessments were incomplete or missing diagnoses.
Resident support plans were incomplete or missing required signatures.
Resident #2 was transferred without required assistance causing pain.
Report Facts
License Capacity: 112
Residents Served: 66
Secured Dementia Care Unit Capacity: 18
Residents Served in Secured Dementia Care Unit: 14
Staffing Hours: 86
Waking Staff: 65
Fine Amount Per Violation: 310
Number of Violations Listed for Fine: 11
Resident Wait Time for Toileting Assistance: 72
Resident Wait Time for Toileting Assistance: 73
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff person A | Named in multiple abuse and medication administration findings. | |
| Juliet Marsala | Deputy Secretary | Signed enforcement and licensing letters. |
Inspection Report
Renewal
Census: 57
Capacity: 112
Citations: 32
Date: Mar 27, 2023
Visit Reason
The inspection was conducted as a renewal and complaint investigation of The Pines of Mt. Lebanon facility to assess compliance with Pennsylvania Department of Human Services regulations.
Findings
Multiple violations were found related to resident confidentiality, contract completion, staff training, sanitary conditions, emergency preparedness, medication management, fire safety, and record keeping. Many corrective actions were directed with specified completion dates, but several were noted as not implemented as of July 24, 2023.
Citations (32)
Resident privacy coding document containing names of multiple residents was posted in a public area.
Resident-home contracts were not completed timely for certain residents.
Telephone number of the Department’s personal care home regional office was not posted in a conspicuous and public place.
Staff trained in first aid and CPR were not present at all times as required.
Direct care staff did not receive required annual training hours.
Direct care staff did not receive required training in infection control, personal care needs, and safe management techniques.
Sanitary conditions were not maintained; freezer in secure dementia care unit kitchen had large splatters of sherbet and vanilla ice cream.
Emergency telephone numbers for nearest hospital, police, fire department, etc. were not posted in the secure dementia care unit kitchen.
No operable lamp or other source of lighting that can be turned on/off at bedside for residents #1 and #2.
No grab bar, hand rail or assist bar in unlocked employee bathroom in main hallway.
Food was stored uncovered in the freezer in the secure dementia care unit kitchen.
Outdated or unlabeled food was found in the freezer in the secure dementia care unit kitchen.
Residents #5 and #6 unable to hear fire alarm system; no approved signaling device installed.
Unannounced fire drills were not held monthly as required.
Fire drill records did not indicate time or exact evacuation times for multiple drills.
Fire drill during sleeping hours was not conducted as required.
Fire drills were not held on different days and times as required.
Residents #2 and #7 medical evaluations lacked required clinical details and documentation.
Discontinued medications were found in medication carts for resident #4 and #8.
Medication labels did not match prescribed dosages for residents #2 and #4.
Blood sugar readings did not match documented medication administration records for resident #2.
Certain prescribed medications for resident #4 were not available in the home.
Resident #4's medication administration record indicated incorrect dosing for acetaminophen and oxycodone.
Resident #4's medication administration record was not updated with correct prescriptions.
Resident #2 was prescribed multiple medications that were not administered on 3/11/23.
Resident #8's prescribed medications were not available in the home on 3/27/23.
No preadmission screening was completed for residents #4 and #8.
Resident #4 and #5 initial assessments were incomplete or missing required diagnoses and medical information.
Resident #8's medical evaluation was not completed within 60 days prior to admission as required.
Resident #8 did not have a completed cognitive preadmission screening within 72 hours prior to admission.
Key-locking devices and directions for operating the home's locking mechanism were not posted near the door leading from the secure dementia care unit courtyard.
Multiple resident records were destroyed in 2023 without including required resident identifying information.
Report Facts
Residents served: 57
License capacity: 112
Staff total daily: 80
Waking staff: 60
Census at inspection: 57
Fine per day: 285
Fine per resident per day: 5
Inspection Report
Complaint Investigation
Census: 62
Capacity: 112
Citations: 3
Date: Jan 4, 2023
Visit Reason
The inspection was conducted as a complaint investigation with unannounced partial inspections on January 4, 5, and 19, 2023, to assess compliance with regulations related to Personal Care Homes.
Complaint Details
The inspection was complaint-driven, focusing on incidents involving smoke alarms, sprinkler leaks, and multiple medication errors involving residents #1, #2, #4, and #5. The complaint was substantiated with findings of unreported incidents and medication administration issues.
Findings
Multiple violations were found including failure to report incidents and medication errors, incomplete medication administration records, and failure to follow prescriber's orders. A provisional license was issued due to failure to submit or comply with an acceptable plan of correction. Several deficiencies remained not implemented as of July 24, 2023.
Citations (3)
Failure to report incidents such as smoke detection and sprinkler leaks to the Department within 24 hours.
Medication administration records did not include initials of staff administering medications for multiple residents.
Failure to follow prescriber's orders with numerous medications not administered to residents on multiple dates.
Report Facts
License Capacity: 112
Residents Served: 62
Fine per day: 285
Staffing: 72
Waking Staff: 54
Inspection Report
Complaint Investigation
Census: 52
Capacity: 112
Citations: 5
Date: Oct 17, 2022
Visit Reason
The inspection was conducted as a complaint investigation with unannounced partial inspections on October 13, 14, and 17, 2022, to review compliance and the submitted plan of correction.
Complaint Details
The inspection was complaint-driven, with a review of submitted plans of correction which were found not implemented as of June 14, 2023.
Findings
Multiple deficiencies were found including unsanitary conditions with feces smeared in resident bathrooms, multiple stains on bedroom carpets, incomplete annual medical evaluations, missing posted menus for the week, and incomplete medication administration records for a resident.
Citations (5)
Sanitary conditions not maintained; feces smeared on toilet seats and floors in multiple resident bathrooms.
Multiple stains on carpeting in bedrooms 127 and 201.
Annual medical evaluation for resident #1 was incomplete and missing medication list.
Menus were not posted for the week of 10/16/22 – 10/22/22.
Medication administration records for resident #2 were not initialed at required times for multiple medications.
Report Facts
License Capacity: 112
Residents Served: 52
Secured Dementia Care Unit Capacity: 17
Secured Dementia Care Unit Residents Served: 7
Hospice Current Residents: 9
Residents Diagnosed with Mental Illness: 2
Residents with Mobility Need: 10
Residents 60 Years or Older: 52
Residents with Physical Disability: 3
Inspection Report
Complaint Investigation
Census: 34
Capacity: 112
Citations: 3
Date: May 19, 2022
Visit Reason
The inspection was conducted as a complaint investigation with unannounced partial inspections on 05/19/2022 and 05/31/2022, followed by a plan of correction submission and review.
Complaint Details
The inspection was complaint-driven, with a follow-up plan of correction submission and review. The complaint involved medication administration and adherence to prescriber's orders.
Findings
The facility was found to have deficiencies related to medication administration documentation and failure to follow prescriber's orders for blood glucose monitoring and insulin administration. A plan of correction was submitted and determined to be fully implemented.
Citations (3)
Medication administration record did not include initials of staff who administered medication to resident #1 at specified times.
Resident #2's blood glucose checks were not performed as prescribed, and insulin doses were inconsistently administered or documented.
Resident #3's blood glucose was not checked as prescribed.
Report Facts
License Capacity: 112
Residents Served: 34
Staffing Hours: 51
Waking Staff: 38
Secured Dementia Care Unit Capacity: 18
Residents Served in SDCU: 6
Hospice Residents: 7
Residents 60 Years or Older: 334
Residents with Mobility Need: 17
Residents with Physical Disability: 1
Inspection Report
Renewal
Census: 33
Capacity: 112
Citations: 7
Date: Feb 23, 2022
Visit Reason
The inspection was conducted as a renewal licensing inspection of THE PINES OF MT. LEBANON facility on 02/23/2022 through 02/25/2022.
Findings
The inspection identified multiple deficiencies including missing influenza awareness posters, entrapment hazards due to uncovered bedrails, unsecured poisonous materials accessible to residents, incomplete medical evaluations, medication record errors, unsigned resident contracts, and failure to follow prescriber's medication orders. Plans of correction were accepted and documented as implemented.
Citations (7)
Influenza awareness poster was not posted in a public and conspicuous place as required by the Influenza Awareness Act.
Bedrails on both sides of resident #2's bed were uncovered, posing an entrapment hazard.
An 8 ounce tube of Colgate toothpaste with poison control warning was unlocked and accessible in a secured dementia unit bathroom, posing a risk to residents not assessed as capable of safely using poisons.
Medical evaluation for resident #1 did not include cognitive function or health status.
Medication prescribed to resident #1 was not indicated on the medication administration record.
Resident-home contract for resident #1 was not signed by the resident.
Resident #4 was not administered prescribed medications on multiple occasions due to medication unavailability in the home.
Report Facts
License Capacity: 112
Residents Served: 33
Secured Dementia Care Unit Capacity: 18
Secured Dementia Care Unit Residents Served: 9
Hospice Current Residents: 8
Resident Support Staff Hours: 33
Total Daily Staff: 84
Waking Staff: 63
Inspection Report
Complaint Investigation
Census: 36
Capacity: 112
Citations: 3
Date: Dec 13, 2021
Visit Reason
The inspection was conducted as a complaint and incident investigation with an unannounced partial inspection on 12/13/2021 and 12/14/2021.
Complaint Details
The inspection was complaint-driven, investigating incidents reported during the week of 12/6/21 involving staff person A's failure to assist residents as required. The complaint was substantiated with repeat violations noted.
Findings
The facility was found to have deficiencies related to incomplete training records, unsigned support plans for residents, and failure to provide assistance with activities of daily living as indicated in residents' support plans. Plans of correction were submitted and some were accepted and implemented.
Citations (3)
Lack of documentation for required training for staff person A.
Support plans for residents #2 and #3 were not signed by the assessor or the resident.
Staff person A failed to assist residents #1 and #2 with activities of daily living as indicated in their support plans, including refusal to assist resident #1 with bedpan use.
Report Facts
License Capacity: 112
Residents Served: 36
Secured Dementia Care Unit Capacity: 16
Residents Served in Dementia Unit: 9
Current Hospice Residents: 7
Resident Age 60 or Older: 35
Residents with Mental Illness: 2
Residents with Mobility Need: 18
Residents with Physical Disability: 1
Total Daily Staff: 54
Waking Staff: 41
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff person A | Named in findings related to lack of training documentation and failure to assist residents with activities of daily living. | |
| RWD | Responsible for conducting audits and education related to support plan compliance. |
Inspection Report
Renewal
Citations: 0
Date: Sep 27, 2021
Visit Reason
The inspection was conducted as a licensing inspection by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing.
Findings
No regulatory citations were identified as a result of this inspection.
Inspection Report
Renewal
Citations: 0
Date: Sep 8, 2021
Visit Reason
The inspection was conducted as a licensing inspection by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing.
Findings
No regulatory citations were identified as a result of this inspection.
Inspection Report
Complaint Investigation
Census: 39
Capacity: 112
Citations: 2
Date: Aug 27, 2021
Visit Reason
The inspection was conducted as a complaint investigation following a complaint received by the Pennsylvania Department of Human Services.
Complaint Details
The visit was complaint-related, triggered by concerns about resident safety and support plan adequacy. The plan of correction was accepted and fully implemented.
Findings
The facility was found to have deficiencies related to support plan revisions for residents, specifically failure to update support plans to reflect residents' safety risks and care needs. The submitted plan of correction was determined to be fully implemented.
Citations (2)
Resident #1’s support plan was not updated to indicate the resident’s lack of regard for safety while self-propelling a wheelchair or the care and services needed to prevent injuries.
Resident #2’s support plan did not indicate the high fall risk including the home’s care and services to protect the resident despite multiple unwitnessed falls.
Report Facts
License Capacity: 112
Residents Served: 39
Secured Dementia Care Unit Capacity: 18
Secured Dementia Care Unit Residents Served: 7
Hospice Residents: 5
Resident #2 Falls: 5
Inspection Report
Renewal
Capacity: 112
Citations: 0
Date: May 21, 2021
Visit Reason
The document is a renewal license issued in response to the facility's April 6, 2021 renewal application to operate the Personal Care Home. The Department advises that an onsite inspection will be conducted within the next twelve months as required by regulation.
Findings
The Department has issued a regular license for The Pines of Mt. Lebanon following the renewal application. No findings of noncompliance are stated in this document, but the Department notes that enforcement action will be taken if noncompliance is found during future inspections.
Report Facts
Maximum capacity: 112
Secure Dementia Care Unit capacity: 18
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary, Office of Long-term Living | Signed the renewal license letter |
Inspection Report
Complaint Investigation
Census: 40
Capacity: 112
Citations: 5
Date: May 18, 2021
Visit Reason
The inspection was a partial, unannounced complaint investigation conducted on 05/18/2021 and 05/20/2021 at The Pines of Mt. Lebanon.
Complaint Details
The inspection was triggered by a complaint, as indicated by the inspection reason 'Complaint' and the partial, unannounced nature of the visit.
Findings
The inspection found multiple deficiencies related to expired administrator license, medication storage and administration errors, inaccurate glucometer calibration and blood glucose recording, and failure to follow prescriber's orders for resident #1. Plans of correction were accepted and implemented with specified completion dates.
Citations (5)
The nursing home administrator license for Staff person A expired on 6/30/2020.
The glucometer belonging to resident #1 was not calibrated to the current date, and blood glucose readings were inaccurately recorded on the Medication Administration Record.
Resident #1's MAR was not initialed by staff who administered Lantus insulin on 5/7/2021 at 8:00 p.m.
Resident #1's insulin and other medications were administered late or withheld without proper documentation on multiple occasions.
The home failed to develop and implement procedures for safe storage, access, security, distribution and use of medications and medical equipment by trained staff.
Report Facts
License Capacity: 112
Residents Served: 40
Staffing Hours - Total Daily Staff: 62
Staffing Hours - Waking Staff: 47
Residents with Mobility Need: 22
Residents Age 60 or Older: 39
Residents Diagnosed with Mental Illness: 2
Residents Diagnosed with Physical Disability: 1
Residents Diagnosed with Intellectual Disability: 0
Inspection Report
Renewal
Census: 37
Capacity: 112
Citations: 11
Date: Apr 8, 2021
Visit Reason
The inspection was conducted as a renewal licensing inspection of THE PINES OF MT. LEBANON facility by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing on 04/08/2021 through 04/13/2021.
Findings
The inspection identified multiple deficiencies including failure to post required documents, unsecured resident records, lack of carbon monoxide detectors near hot water tanks, improper resident transfer assistance, unsigned resident contracts, failure to educate a resident on rights, unsanitary conditions, incomplete menu postings, unlocked medications, discontinued medications present, and inaccurate medication records. Plans of correction were accepted for all deficiencies with specified completion dates.
Citations (11)
Failure to post a copy of 55 Pa. Code Chapter 2600 in a conspicuous and public place in the home.
Resident records, including personal identifiable information, were unlocked, unattended, and accessible in unsecured areas.
No carbon monoxide detector installed in close proximity to the home's 3 hot water tanks as required by law.
Residents requiring two-person transfer assistance were transferred with only one staff member, contrary to their assessments and support plans.
Resident #7's contract was not signed by the resident.
Resident #7 was not educated on resident rights or the right to lodge complaints without retaliation.
Walls of the microwave in the secured dementia care unit were covered in dried food.
Menu for the upcoming week was not posted in a conspicuous and public place as required.
A box of over-the-counter medication was unlocked, unattended, and accessible in the Wellness room.
Discontinued medication (Montelukast Sod 10mg) was found in the medication cart.
Blood glucose readings for resident #9 were not accurately recorded on the medication administration record.
Report Facts
License Capacity: 112
Residents Served: 37
Secured Dementia Care Unit Capacity: 18
Secured Dementia Care Unit Residents Served: 9
Hospice Current Residents: 6
Staffing Hours - Total Daily Staff: 58
Staffing Hours - Waking Staff: 44
Inspection Report
Follow-Up
Census: 37
Capacity: 112
Citations: 4
Date: Mar 25, 2021
Visit Reason
The inspection was conducted as a follow-up to review the submitted plan of correction related to a resident abuse incident that occurred on 03/16/2021.
Complaint Details
The visit was complaint-related due to an incident on 03/16/2021 where direct care staff person D mocked resident #1 by making noises and using inappropriate language during incontinence care. The home delayed reporting the incident until 03/19/2021. The staff member was not immediately suspended and continued to work until later that evening and the following day. The staff member resigned during the investigation.
Findings
The facility was found to have fully implemented the submitted plan of correction addressing the failure to immediately report suspected resident abuse and failure to properly supervise the involved staff. The incident involved direct care staff mocking a resident and inappropriate language during care. The staff member involved resigned during the investigation.
Citations (4)
Failure to immediately report suspected abuse of a resident in accordance with regulations.
Failure to immediately develop and implement a plan of supervision or suspend the staff person involved in the alleged abuse incident.
Failure to report the incident or condition to the Department within 24 hours as required.
Failure to treat a resident with dignity and respect; direct care staff mocked the resident and used inappropriate language during care.
Report Facts
License Capacity: 112
Residents Served: 37
Secured Dementia Care Unit Capacity: 18
Secured Dementia Care Unit Residents Served: 10
Current Residents Receiving Hospice: 7
Residents Age 60 or Older: 40
Residents Diagnosed with Mental Illness: 2
Residents with Mobility Need: 22
Residents with Physical Disability: 1
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