Inspection Reports for
The Terrace At Chestnut Hill
495 E Abington Ave, Philadelphia, PA 19118, United States, PA, 19118
Back to Facility Profile42 Reports
Inspection Report — Dec 10, 2025
Renewal
Date: Dec 10, 2025
Visit Reason
The inspection was conducted as a renewal visit with an incident review at THE TERRACE AT CHESTNUT HILL.
Findings
The inspection found medication record discrepancies for residents self-administering medications and labeling errors on medication containers. The facility submitted a plan of correction which was accepted and fully implemented by the inspection date.
Citations (2)
Regulation 181f: Resident #1 and #2's medication records did not include current lists of medications, with discrepancies between listed and actual medications. The facility reconciled medications and educated residents and staff on medication accuracy.
Regulation 184a: Resident #3's medication container label had incorrect instructions that did not match the medication administration record. The order was verified and corrected with the pharmacy.
Report Facts
Residents Served: 85
Secured Dementia Care Unit Residents Served: 20
Hospice Current Residents: 6
Residents with Mobility Need: 27
Total Daily Staff: 112
Waking Staff: 84
Inspection Report — Dec 16, 2024
Renewal
Date: Dec 16, 2024
Visit Reason
The inspection was conducted as a renewal inspection of the facility license for THE TERRACE AT CHESTNUT HILL on 12/16/2024 and 12/17/2024.
Findings
The inspection identified several sanitary and safety deficiencies including unclean furniture, feces smeared on a bathroom toilet seat, strong urine odor in a memory care area, exposed trash can lids with food spills, multiple tripping hazards on the outdoor patio, and grease buildup on kitchen surfaces. Plans of correction were submitted and fully implemented by February 20, 2025.
Citations (7)
Couch in memory care #2 was unclean with food stains.
Arms of the blue floral print chair were soiled with stains.
Male common area bathroom toilet seat had feces smeared on it.
Strong smell of urine located on Memory Care #4 area of the home.
Lid of trash can was exposed with an unclean surface of food spills; plastic lids covering ice cream had stains of spilled ice cream.
Outdoor patio area had multiple tripping hazards including overturned table and umbrella stand with protruding parts.
Side of the oven between the cooktop and deep fryer was covered in grease and grime, posing a fire hazard.
Report Facts
Residents Served: 85
Memory Care Residents Served: 26
Hospice Residents: 9
Residents with Mobility Need: 31
Residents 60 Years or Older: 84
Total Daily Staff: 116
Waking Staff: 87
Inspection Report — Nov 20, 2024
Date: Nov 20, 2024
Visit Reason
The inspection was conducted as a partial, unannounced visit due to an incident at the facility.
Findings
No regulatory citations or deficiencies were identified during this inspection.
Report Facts
Resident Support Staff: 111
Waking Staff: 83
Residents Served: 86
Secured Dementia Care Unit Residents Served: 25
Hospice Current Residents: 8
Residents Age 60 or Older: 85
Residents with Mobility Need: 25
Inspection Report — Sep 27, 2024
Follow-Up
Date: Sep 27, 2024
Visit Reason
The inspection was a follow-up visit to verify the implementation of a previously submitted plan of correction related to a complaint and incident at the facility.
Complaint Details
The visit was complaint-related and incident-driven, involving a resident abuse incident witnessed on the elevator that resulted in injury and hospitalization.
Findings
The submitted plan of correction was determined to be fully implemented. The report details two deficiencies: one involving resident abuse resulting in a hip fracture, and another involving incomplete documentation in a resident's support plan for medical needs.
Citations (2)
Resident abuse incident where two residents were fighting on an elevator, resulting in one resident falling and sustaining a hip fracture.
Resident's support plan did not document how medical diagnoses would be met, constituting a repeated violation.
Report Facts
Residents Served: 83
Memory Care Residents Served: 25
Current Hospice Residents: 7
Residents Age 60 or Older: 83
Residents with Mobility Need: 34
Notice — Aug 30, 2024
Date: Aug 30, 2024
Visit Reason
The document serves as a waiver approval for a personal care home administrator to serve while completing the required 100-hour training and competency test.
Findings
The waiver allows the named individual to serve as administrator while enrolled in the required training course, with conditions including presence of a qualified administrator for at least 10 hours per week and expected compliance by January 31, 2025.
Report Facts
Training hours required: 100
Minimum qualified administrator presence: 10
Compliance deadline: 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Theresa Hartman | Bureau Director, Human Services Licensing | Signed the waiver approval letter |
Inspection Report — Jan 31, 2024
Follow-Up
Date: Jan 31, 2024
Visit Reason
The inspection was a partial, unannounced follow-up visit conducted on 01/31/2024 for incident and monitoring purposes to verify the implementation of a previously submitted plan of correction.
Findings
The submitted plan of correction was determined to be fully implemented. Deficiencies previously cited related to locking poisonous materials, lighting, furniture and equipment, leftover food labeling, and medication storage were addressed with corrective actions and staff in-service training.
Citations (5)
Unlabeled and undistinguishable bar of soap was unlocked, unattended, and accessible to residents in the Memory Care Room, with some residents not assessed as capable of safely using or avoiding poisonous materials.
The stairwell to exit 4 near a room was dark; the emergency light was not operable and the ceiling light fixture was not working.
The rubber seal at the bottom of the refrigerator in the Memory Care kitchenette was falling off.
An unlabeled, undated container of juice was found in the Memory Care kitchenette refrigerator.
Two loose pills were found in the Medication Cart serving the 2nd and 3rd floors; tape was found on the back of a blister pack for a resident's prescription tablet.
Report Facts
Residents Served: 70
Secured Dementia Care Unit Residents Served: 19
Hospice Residents: 8
Residents with Mobility Need: 51
Total Daily Staff: 121
Waking Staff: 91
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Memory Care Director | In-serviced on regulation 82C and responsible for twice weekly inspections of poisonous materials | |
| Maintenance Director | In-serviced on lighting and furniture/equipment compliance; responsible for weekly site walks and inspections | |
| Director of Wellness | In-serviced on medication storage; responsible for weekly audits of medication carts | |
| Medication Technicians | In-serviced on medication cart inspections and proper disposal of loose pills and taped blister packs | |
| Nursing Team | In-serviced on medication storage and disposal procedures |
Inspection Report — Oct 16, 2023
Renewal
Date: Oct 16, 2023
Visit Reason
The inspection was conducted as a renewal and incident review of THE TERRACE AT CHESTNUT HILL facility on 10/16/2023 and 10/17/2023.
Findings
The inspection identified multiple deficiencies including failure to report suspected resident abuse, medication errors, incomplete medical evaluations and assessments, improper storage of medications, inadequate documentation of support plans, and safety hazards such as blocked egress and water pressure issues. Plans of correction were accepted and implemented by 02/12/2024.
Citations (24)
Failure to immediately report suspected abuse of a resident involving a cut caused by a broken vase.
Failure to report medication errors involving insulin administration and blood sugar monitoring.
Resident abuse involving aggressive behavior and inadequate response to resident aggression.
Violation of resident privacy during medication administration in a common area.
Low water pressure in room 302.
Clogged toilet in second-floor women's bathroom.
No toilet paper available in first-floor women's bathroom.
Freezer temperature recorded at 14 degrees Fahrenheit, above required 0°F.
Blocked egress due to a thick fuzzy mat preventing door from opening fully.
Lack of documentation of written notification to local fire department regarding emergency evacuation.
Incomplete medical evaluations missing physical exam, immunization history, allergy information, and mobility assessments.
Failure to complete annual medical evaluations timely for several residents.
Improper storage of unopened insulin pen without date indicating time out of refrigeration.
Incorrect documentation of glucometer readings and missing medications on medication cart.
Failure to follow prescriber's orders for insulin administration based on blood sugar readings.
Failure to immediately report medication errors to resident, designated person, and prescriber.
Preadmission screening forms missing determination that resident needs can be met by the home.
Initial assessments not completed within 15 days of admission or missing key assessment elements.
Additional assessments missing or incomplete for eating, agitation, aggression, and diagnoses.
Support plans not completed timely or missing documentation of how resident needs will be met.
Resident without primary dementia diagnosis residing in secured dementia care unit unable to operate locking mechanism.
Admission support plan not developed within 72 hours of admission to secured dementia care unit.
Support plan missing identification of resident's physical, medical, social, cognitive, and safety needs.
Support plan missing documentation of resident's ability to self-administer medications or need for reminders.
Report Facts
Residents Served: 106
Secured Dementia Care Unit Residents Served: 32
Current Hospice Residents: 6
Residents with Mobility Need: 40
Residents Age 60 or Older: 106
Total Daily Staff: 146
Waking Staff: 110
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director | In-serviced staff on multiple deficiencies and oversaw plans of correction. | |
| Director of Wellness | In-serviced staff, conducted audits, and monitored compliance with medication administration and assessments. |
Inspection Report — Jun 13, 2023
Complaint Investigation
Date: Jun 13, 2023
Visit Reason
The inspection was conducted as a complaint and incident investigation with an unannounced partial inspection.
Complaint Details
The visit was complaint-related and included an incident investigation. The submitted plan of correction was fully implemented as of the last review dates.
Findings
The inspection found deficiencies related to annual medical evaluations, additional assessments lacking assessor information, and missing resident signatures on support plans. Plans of correction were accepted and implemented by July 14, 2023.
Citations (3)
Resident 1’s most recent medical evaluation was not completed as required annually.
The assessment for resident 2 did not indicate the assessor's name, title, signature, or date signed.
Resident 2 participated in the development of the support plan but did not sign the support plan.
Report Facts
Residents Served: 78
Secured Dementia Care Unit Residents Served: 29
Hospice Current Residents: 5
Residents 60 Years or Older: 78
Residents Diagnosed with Intellectual Disability: 3
Residents Diagnosed with Physical Disability: 12
Residents with Mobility Need: 41
Inspection Report — May 9, 2023
Date: May 9, 2023
Visit Reason
The inspection was conducted as a partial, unannounced visit due to an incident at the facility.
Findings
No regulatory citations or deficiencies were identified during the inspection.
Report Facts
Total Daily Staff: 120
Waking Staff: 90
Resident Support Staff: 0
Residents Served: 77
Secured Dementia Care Unit Residents Served: 29
Current Hospice Residents: 5
Residents Age 60 or Older: 77
Residents with Mobility Need: 43
Residents Receiving Supplemental Security Income: 0
Residents Diagnosed with Mental Illness: 0
Residents Diagnosed with Intellectual Disability: 0
Residents with Physical Disability: 0
Inspection Report — Feb 22, 2023
Follow-Up
Date: Feb 22, 2023
Visit Reason
The inspection visit on 02/22/2023 was a partial, unannounced follow-up to review the submitted plan of correction related to a prior incident.
Findings
The submitted plan of correction was determined to be fully implemented as of the review date. The report details a serious abuse incident involving a staff member who was terminated, as well as deficiencies related to direct care staff qualifications and training, all of which have been addressed with corrective actions and ongoing monitoring.
Citations (3)
Staff Member A verbally abused a resident and spit in the resident's face, resulting in immediate termination and police involvement.
Direct care staff person A did not have a high school diploma, GED, or active registry status on the Pennsylvania nurse aide registry.
Direct care staff person A provided unsupervised ADL services without completing and passing the Department-approved direct care training course and competency test.
Report Facts
Residents Served: 85
Secured Dementia Care Unit Residents Served: 33
Hospice Residents: 9
Residents 60 Years or Older: 82
Residents Diagnosed with Mental Illness: 3
Residents with Mobility Need: 54
Residents with Physical Disability: 1
Total Daily Staff: 139
Waking Staff: 104
Inspection Report — Jan 9, 2023
Complaint Investigation
Date: Jan 9, 2023
Visit Reason
The inspection was conducted as a complaint investigation with multiple on-site and off-site review dates to assess compliance and follow-up on a plan of correction submission.
Complaint Details
The visit was complaint-related, triggered by allegations of neglect and abuse, including failure to meet personal care needs of resident #2 during overnight shifts and staff sleeping on duty. The complaint was substantiated based on interviews and observations.
Findings
The inspection identified multiple deficiencies including failure to report incidents timely, neglect and abuse of residents, staff sleeping on duty, inadequate staff training, unsafe storage of poisonous materials, unsanitary conditions, communication system failures, incomplete medical evaluations, improper medication management, lack of written service procedures, incomplete resident assessments, and insufficient activities offered on memory care units.
Citations (20)
Failure to report an unwitnessed fall incident involving resident #1 to the Department within 24 hours.
Neglect and abuse of resident #2 during overnight shifts, including unmet toileting needs and sleeping staff.
Overnight staff sleeping while on duty despite requirement to be awake when 16 or more residents are present.
Staff training plan did not include Mechanical Hoyer Lift, Ostomy Care, and Urinary Catheter Care.
Poisonous materials (A&D Ointment and Prang Paint) were unlocked and accessible to residents in memory care unit.
Unsanitary conditions due to unlabeled towels and washcloths in shared living space.
Floors and ceilings in certain areas were unclean or in need of repair.
Lack of a communication system enabling staff to contact each other immediately in emergencies.
Broken and missing locks on cabinets in the 2nd floor memory care kitchen.
Medical evaluations for residents #2 and #5 were incomplete, missing vital signs and immunization history.
Menus were not posted timely and meal substitutions were not properly communicated to residents.
Resident #5 self-administers medications including insulin but lacked physician assessment for ability and reminders.
Discontinued medications were improperly stored on medication cart.
Glucagon Kit medication for resident #7 was not available in the home.
Written description of services and activities did not include scope, admission, and discharge criteria.
Lack of written procedures for delivery and management of services from admission to discharge, including ostomy and urinary catheter care.
Resident #2 and #5 had outdated assessments not completed annually or upon significant change.
Resident #8 did not sign the support plan despite participation in its development.
Direct care staff person D did not receive required annual dementia training for 2022.
Activities were not offered as scheduled on memory care units due to limited staff.
Report Facts
Residents present: 88
Memory care residents served: 34
Hospice residents: 6
Residents aged 60 or older: 86
Residents with mobility need: 21
Residents with mental illness: 3
Total daily staff: 109
Waking staff: 82
Inspection Report — Aug 15, 2022
Renewal
Date: Aug 15, 2022
Visit Reason
The inspection was a full, unannounced renewal inspection with an incident, conducted on 08/15/2022 and 08/16/2022 to assess compliance with licensing regulations and incident follow-up.
Findings
The facility had multiple deficiencies including failure to provide a current quality management plan, unsecured poisonous materials, unsanitary conditions in resident rooms and bathrooms, broken fixtures posing safety hazards, missing emergency telephone numbers, inoperable lamps, lack of toilet paper in bathrooms, improper refrigerator/freezer temperatures, insufficient emergency food supply, missing or outdated emergency management procedures, and medication storage and documentation issues. All deficiencies were corrected on-site or through submitted plans of correction with education and training provided to staff.
Citations (12)
The home did not provide the current or previous quality management plan.
Poisonous materials were found unsecured and accessible to residents on the Secure Dementia Unit.
Multiple bedrooms and bathrooms were found soiled, unclean, and smelling like feces.
Broken switch or nozzle in bathroom posing a safety hazard.
No emergency telephone numbers posted near telephones in resident bedrooms.
Lamps in resident bedrooms were not plugged in or operable.
Toilet paper was not provided for a toilet in a resident bathroom.
Walk-in freezer temperatures exceeded regulatory limits during inspection and prior logs.
The home did not maintain at least a 3-day supply of nonperishable food and drinking water.
The home did not provide current or previously approved written emergency procedures.
Medication audit revealed a medication on the med-cart without a current order for a resident.
Procedures for safe storage, access, security, distribution and use of medications and medical equipment were not properly implemented; missing medications and documentation errors were found.
Report Facts
Residents Served: 80
Secured Dementia Care Unit Residents Served: 34
Hospice Residents: 7
Residents 60 Years or Older: 77
Residents with Mobility Need: 51
Residents with Physical Disability: 3
Staffing Hours - Total Daily Staff: 131
Staffing Hours - Waking Staff: 98
Emergency Food Stock - Vanilla Pudding Cases: 4
Emergency Food Stock - Peaches Cases: 6
Emergency Food Stock - Apple Sauce Cases: 5
Emergency Food Stock - Mixed Vegetables Cases: 4
Emergency Food Stock - String Beans Cases: 1
Emergency Food Stock - 3 Bean Salad Cases: 3
Emergency Food Stock - Corn Cases: 3
Emergency Food Stock - Ravioli Cases: 3
Emergency Food Stock - Beef Stew Cases: 4
Emergency Food Stock - Cornbeef Hash Cases: 2
Emergency Food Stock - Pears Cases: 3
Emergency Food Stock - Pineapples Cases: 3
Emergency Food Stock - Fruit Cocktail Cases: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Bill Snow | Legal Entity Contact | Listed as contact for ABINGTON SENIOR CARE LLC |
| Director of Nursing | Named in relation to ensuring proper storage of poisonous materials and medication cart audits | |
| Memory Care Director | Named in relation to environmental rounds for poisonous materials | |
| Executive Director | Responsible for oversight of quality management meetings, emergency management plan submission, and corrective actions | |
| Facilities Engineer | Responsible for environmental rounds, emergency management plan submission, and facility maintenance | |
| Director of Sales & Marketing | Responsible for ensuring emergency telephone numbers are posted | |
| Medicine Technicians | Educated on medication matching and documentation policies | |
| Staff Person A | Mentioned in relation to quality management plan and emergency procedures knowledge | |
| Staff Person B | Terminated following medication investigation |
Inspection Report — Jun 14, 2022
Follow-Up
Date: Jun 14, 2022
Visit Reason
The inspection visit was conducted as a follow-up to review the submitted plan of correction related to an incident and other compliance issues at the facility.
Findings
The facility was found to have fully implemented the submitted plan of correction. Deficiencies related to resident abuse reporting, abuse incidents involving staff misuse of resident credit cards, and incomplete resident support plans were addressed with staff education and updated documentation.
Citations (4)
Failure to immediately report suspected resident abuse in writing to the local area agency on aging as required.
Staff person A used a resident's credit card without permission to order food for themselves, constituting abuse and theft.
Resident #2 had self-inflicted cuts that were not identified in the resident's support plan, and staff were unaware of the resident's risk for self-harm.
Resident support plans did not document medical, dental, vision, hearing, mental health or behavioral care needs or plans to meet those needs.
Report Facts
Residents Served: 78
Memory Care Residents Served: 34
Current Hospice Residents: 6
Staff Total Daily: 126
Waking Staff: 95
Residents Age 60 or Older: 76
Residents with Mobility Need: 48
Residents Diagnosed with Mental Illness: 2
Residents with Physical Disability: 2
Inspection Report — Sep 8, 2021
Complaint Investigation
Date: Sep 8, 2021
Visit Reason
The inspection was conducted as a complaint investigation to address specific concerns at THE BRYN MAWR TERRACE facility.
Complaint Details
The inspection was complaint-driven, with a follow-up plan of correction submission scheduled. Specific complaint details are not explicitly stated beyond the reason for inspection.
Findings
Multiple deficiencies were found including incomplete staff orientation documentation, unsecured poisonous materials accessible to residents, unsanitary conditions in resident rooms, locked resident bedrooms denying access, lack of operable bedside lamps, improper food storage and labeling, unlocked medications, and delayed resident assessments and support plan revisions.
Citations (8)
Staff orientation training documentation was not signed or dated to confirm completion.
Poisonous materials such as fluoride toothpaste, creams, lotions, and antibiotic soap were unlocked and accessible to residents in the Secure Dementia Unit.
Nebulizer unit nozzle found on floor and feces smeared on toilet seat and bedspread after cleaning in resident rooms.
Resident bedrooms were locked denying access to residents who do not have keys in the Secure Dementia Unit.
Resident did not have access to an operable lamp or source of lighting at bedside.
Unlabeled and undated leftover food and unsealed food items found in the Secure Dementia Care Unit kitchen refrigerator.
Prescription medications and treatment lotions were unlocked and accessible in resident rooms.
Resident #2's annual assessment and support plan revisions were completed late.
Report Facts
Residents Served: 23
Residents Served in Secured Dementia Care Unit: 17
Staffing Hours - Total Daily Staff: 40
Staffing Hours - Waking Staff: 30
Follow-Up Date: Sep 28, 2021
Notice — Jul 21, 2021
Date: Jul 21, 2021
Visit Reason
The document serves as a renewal notification for the Personal Care Home license and informs that an onsite inspection will be conducted within the next twelve months as required by state regulations.
Findings
No inspection findings are reported in this document; it is a license renewal letter and certificate of compliance confirming the facility's authorized operation and capacity.
Report Facts
Inspection Report — Jul 13, 2021
Complaint Investigation
Date: Jul 13, 2021
Visit Reason
The inspection was conducted as a complaint investigation with multiple off-site review dates, culminating in a partial on-site inspection on 07/13/2021.
Complaint Details
The inspection was complaint-driven, with the reason explicitly stated as 'Complaint' and multiple off-site reviews leading to a partial on-site inspection.
Findings
The inspection identified multiple deficiencies including failure to report incidents timely, inadequate mattress condition, failure to assist with transportation to medical appointments, refusal of medication documentation issues, and failure to follow prescriber's medication orders. The submitted plan of correction was accepted and fully implemented.
Citations (5)
Failure to report incidents to the Department within 24 hours, including a resident injury and death.
Resident assigned an uncomfortable and inoperable bed; durable medical equipment was not properly managed or labeled.
Failure to assist resident with transportation to medical appointments, resulting in missed appointments.
Lack of documentation and physician response for resident's refusal of prescribed medication on multiple occasions.
Medication prescribed to resident was not administered due to unavailability in the home.
Report Facts
Residents Served: 62
Memory Care Residents Served: 24
Hospice Residents: 9
Resident Age 60 or Older: 62
Residents with Mobility Need: 24
Residents Diagnosed with Mental Illness: 3
Residents with Physical Disability: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sandi Wooters | Signed the letter confirming plan of correction implementation. | |
| Director of Wellness | Named in multiple plans of correction related to incident reporting, equipment management, medication refusal, and medication administration. | |
| Memory Care Director | Involved in equipment management and medication refusal follow-up. | |
| Executive Director | Responsible for oversight of plan of correction implementation. |
Inspection Report — Jun 8, 2021
Renewal
Date: Jun 8, 2021
Visit Reason
The inspection was a full, unannounced renewal inspection with a complaint component conducted on 06/08/2021 to assess compliance with licensing regulations and facility standards.
Complaint Details
The inspection included a complaint investigation component as noted in the inspection reason, but no substantiation status or further complaint details were provided.
Findings
The inspection identified multiple deficiencies related to posting of licenses and emergency procedures, bedroom furnishings such as chairs and lighting, soap dispensers, and menu postings. All violations were corrected on the day of the inspection with plans of correction implemented and documented.
Citations (6)
The home did not have the license inspection summary or the 2600 regulation book posted in a conspicuous and public place.
Bedroom #302 was occupied by two residents but lacked a chair for one resident.
Resident #2 did not have access to a source of light that can be turned on/off at bedside in their bedroom.
The bathroom in room #302 did not have soap.
The home’s emergency procedures were not posted in a conspicuous and public place.
The home did not have a menu posted on the 2nd or 3rd floor Secured Dementia Care Unit (SDCU).
Report Facts
Residents Served: 54
Secured Dementia Care Unit Residents Served: 22
Hospice Residents: 7
Residents Age 60 or Older: 50
Residents with Mobility Need: 35
Residents with Physical Disability: 4
Total Daily Staff: 89
Waking Staff: 67
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shawn Parker | Signed the letter regarding plan of correction implementation | |
| Business Office Director | Named as primary responsible party for ensuring posting of license inspection summary, emergency procedures, and compliance | |
| Executive Director | Named as secondary or tertiary responsible party for multiple deficiencies including posting and compliance | |
| Director of Sales | Named as primary responsible party for ensuring bedside chairs compliance | |
| Maintenance Assistant | Named as secondary responsible party for bedside chairs, lighting, and soap dispenser compliance | |
| Memory Care Director | Named as secondary responsible party for soap dispenser and menu posting compliance | |
| Director of Dining Services | Named as primary responsible party for menu posting compliance |
Inspection Report — Feb 2, 2021
Complaint Investigation
Date: Feb 2, 2021
Visit Reason
The inspection was conducted as a complaint investigation to review compliance with care requirements at THE TERRACE AT CHESTNUT HILL.
Complaint Details
The inspection was complaint-driven, with the complaint reason explicitly stated. The plan of correction was accepted and fully implemented.
Findings
The facility was found to have deficiencies related to personal hygiene and securing preventative dental care for a resident. The plan of correction was accepted and implemented, with follow-up documentation submitted.
Citations (2)
Resident #1 did not receive assistance with hair grooming or oral hygiene as required by the assessment and support plan.
The home did not arrange dental care for resident #1 after a tooth fell out in June 2020, despite the care plan indicating assistance with dental appointments.
Report Facts
Residents Served: 48
Residents Served in Secured Dementia Care Unit: 18
Current Residents in Hospice: 4
Residents 60 Years or Older: 47
Residents with Mental Illness: 1
Residents with Physical Disability: 4
Residents with Mobility Need: 38
Inspection Report — Aug 5, 2020
Complaint Investigation
Date: Aug 5, 2020
Visit Reason
The inspection was conducted as a complaint investigation with an unannounced partial inspection over three days to review compliance and the submitted plan of correction.
Complaint Details
The inspection was complaint-driven and unannounced. The submitted plan of correction was accepted and fully implemented by the facility.
Findings
The submitted plan of correction was found to be fully implemented. Deficiencies involved resident contract signatures, signed statements acknowledging receipt of resident rights and complaint procedures, and resident education on the right to refuse medication.
Citations (3)
25b - Contract Signatures: The resident home contract dated 3/28/2019 for resident 1 was not signed by the resident.
41e - Signed Statement: Resident 1's record did not contain a statement signed by the resident acknowledging receipt of resident rights and complaint procedures.
191 - Resident Right to Refuse: Resident 1 was not educated on the right to refuse medication if a medication error is suspected.
Report Facts
Residents Served: 67
Total Daily Staff: 99
Waking Staff: 74
Inspection Report — Jun 1, 2020
Complaint Investigation
Date: Jun 1, 2020
Visit Reason
The inspection was conducted as a complaint investigation with multiple off-site review dates from 06/01/2020 to 06/09/2020 to assess compliance with regulations.
Complaint Details
The inspection was complaint-driven as indicated by the inspection reason. The complaint involved medication handling and administration issues. Substantiation status is not explicitly stated.
Findings
The facility was found to have deficiencies related to medication handling, including failure to provide discontinued medications to residents or their designated parties upon discharge and medication administration records not documenting timely administration of medications.
Citations (2)
183f - Discontinued Medications: Resident #1's medications were not given to the resident or designated party upon discharge and were only made available several days later.
187a - Medication Record: Resident #1 received medication administration services with several occasions of medications not administered timely as per regulation, and the eMAR system did not log specific administration times.
Report Facts
Residents Served: 57
Residents Served in Dementia Care Unit: 25
Total Daily Staff: 89
Waking Staff: 67
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dan Anderson | Local Ombudsman | Contacted by the community's Executive Director for assistance regarding medication pick-up dispute. |
Inspection Report — May 12, 2020
Date: May 12, 2020
Visit Reason
The inspection was a partial, unannounced licensing inspection conducted due to an incident.
Findings
No regulatory citations or deficiencies were identified during the inspection.
Report Facts
Residents Served: 67
Secured Dementia Care Unit Residents Served: 27
Hospice Current Residents: 1
Inspection Report — Apr 28, 2020
Complaint Investigation
Date: Apr 28, 2020
Visit Reason
The inspection was conducted as a complaint investigation to review compliance at The Terrace at Chestnut Hill.
Complaint Details
The inspection was complaint-driven and resulted in a finding regarding missing signatures on a resident's support plan. The plan of correction was approved and fully implemented.
Findings
The submitted plan of correction related to support plan signatures was found to be fully implemented. Continued compliance must be maintained.
Citations (1)
227g - Support Plan Signatures: Resident #1 participated in the development of his/her support plan on 6/30/18 and 6/30/19; however, neither the resident nor the resident's designated person signed the support plan.
Report Facts
Residents Served: 67
Memory Care Residents Served: 27
Current Hospice Residents: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lamia Johnson | Administrator | Named in relation to the plan of correction approval and signature |
Inspection Report — Feb 3, 2020
Renewal
Date: Feb 3, 2020
Visit Reason
The inspection was a full, unannounced renewal inspection conducted by the Pennsylvania Department of Human Services Bureau of Human Services Licensing on February 3 and 4, 2020.
Findings
The facility was found to have multiple violations including missing criminal background checks, lack of fire safety training, missing emergency telephone numbers, missing thermometers in freezers, incomplete fire drill records, and deficiencies in resident medical evaluations and medication labeling. All cited deficiencies had approved plans of correction that were fully implemented by July 14, 2020.
Citations (15)
2600.51 Criminal History Checks: Staff member A was hired on 08/19/2019 but the criminal background check was not requested until 08/23/19.
2600.65g Annual Training Content: Staff persons B, C, and D did not receive fire safety training by a fire safety expert during calendar year 2019.
2600.91 Emergency Telephone Numbers: No emergency telephone numbers for the nearest hospital and fire department were posted on or by telephones in rooms #354 and #438.
2600.103f Refrigerator/Freezer Temps: There was no thermometer in the freezer in the 2nd floor memory care dining room.
2600.107d Procedure Emergency Management Agency Submission: The home's written emergency procedures had not been submitted to the municipal emergency management agency.
2600.132c Fire Drill Records: Fire drill records from March 2019 to January 2020 lacked exit route used, number of residents present and evacuated, and drill times.
2600.132e Fire Drill Sleeping Hours: Fire drills were not conducted during sleeping hours from May 2019 through December 2019.
2600.132f Alternate Exit Routes: The home did not document exit routes used during fire drills held from March 2019 to January 2020.
2600.141b1 Annual Medical Evaluation: Resident 1 and Resident 2 had medical evaluations completed on 11/04/19 and 11/11/19 respectively, but previous evaluations were outdated.
2600.184a Labeling OTC/CAM: The pharmacy label for Resident 4's Freestyle Lancets did not include the resident's name.
2600.185a Implement Storage Procedures: Resident 4's glucometer was not calibrated to the correct time and a reading of 414 was not recorded on the MAR.
2600.225c Additional Assessment: Resident 1's current assessment was completed on 11/04/19 but the previous assessment was from 03/19/18.
2600.231f Assessed Annually: Resident 2 was assessed for Secure Dementia Care Unit needs on 08/23/18 and not reassessed until 11/11/19.
2600.233d Electronic/Magnetic System: The gate in the memory care courtyard was not locked with an electronic or magnetic locking system and was easily opened, leading to a hazardous area.
2600.252 Record Content: On 02/04/20, the home was missing Resident 5's medical evaluation from the previous year.
Report Facts
Residents Served: 81
Secured Dementia Care Unit Residents Served: 35
Hospice Current Residents: 2
Total Daily Staff: 133
Waking Staff: 100
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LaMia Johnson | Executive Director | Named in multiple findings and plan of correction approvals |
Inspection Report — Jan 13, 2020
Complaint Investigation
Date: Jan 13, 2020
Visit Reason
The inspection was conducted due to a complaint investigation regarding violations of 55 Pa. Code Ch. 2600 related to Personal Care Homes.
Complaint Details
The visit was complaint-related, investigating allegations of abuse, denial of access to resident records, and failure to safeguard resident property. The family of resident #1 reported missing items and restricted access to the room. The facility disputed the violations but implemented plans of correction.
Findings
The inspection found violations related to abuse, resident record access, and safeguarding resident property. The facility failed to provide proper access to resident records and a system to safeguard a deceased resident's belongings, resulting in missing items and restricted access.
Citations (3)
42b - Abuse: Staff asked resident #2 for items from deceased resident #1's room, leading to missing items and restricted access due to added locks. Resident #1's family filed a police report for the stolen items.
42k - Resident Record: Staff person B denied resident #1's family access to her record related to stolen items from resident #1's room on 12/2/19.
42x - Safeguard: The home failed to provide a system to safeguard deceased resident #1's items, resulting in items being taken from the room between 11/25/19 and 12/2/19.
Report Facts
Residents Served: 82
Memory Care Unit Residents Served: 36
Current Hospice Residents: 3
Residents Age 60 or Older: 81
Residents with Mobility Need: 46
Residents with Physical Disability: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LaMia Johnson | Executive Director | Signed plan of correction documents and named as administrator |
Inspection Report — Oct 10, 2019
Complaint Investigation
Date: Oct 10, 2019
Visit Reason
The inspection was conducted as a complaint investigation with unannounced visits on multiple dates in October and November 2019 to review compliance and verify the implementation of a submitted plan of correction.
Complaint Details
The inspection was complaint-related as indicated by the reason 'Complaint, Incident' and multiple unannounced visits to investigate specific allegations.
Findings
The facility had multiple deficiencies related to failure to report incidents timely, incomplete wound care, inadequate staff training, missing medical evaluations, and incomplete documentation of resident care plans. The submitted plan of correction was fully implemented and approved as of February 27, 2020.
Citations (19)
The home failed to report two resident hospital transfers via EMT services to the department in a timely manner.
Resident #1 with a stage 4 wound ulcer missed 16 days of wound care orders, and the home failed to follow the doctor's orders for wound care.
Staff persons A, B, C, D, and E did not receive orientation or training on evacuation procedures, fire safety, smoking policy, and emergency services notification.
Staff persons A, B, C, D, and E did not complete training on resident rights, emergency medical plan, mandatory abuse reporting, and reporting of incidents.
Direct care staff persons D and E provided unsupervised ADL services without documentation of completing Department-approved direct care training.
Resident #2's medical evaluation did not include the most current list of prescribed medications.
The home did not have a new medical evaluation completed to address Resident #1's new medical condition.
The home failed to have an updated RASP that addresses Resident #1's medical condition.
Resident #3's support plan did not address refusal of personal hygiene care or how the home will meet the resident's needs.
Resident #4 is no longer a resident and the assessor is no longer employed; documentation of all support plans must be reviewed and updated.
Resident #1 was admitted to the Secure Dementia Care Unit on 05/15/2019 without a completed medical evaluation.
Resident #1 was admitted to the Secure Dementia Care Unit on 05/15/2019 without a written cognitive preadmission screening completed.
Resident #1 was admitted to the Secure Dementia Care Unit on 05/15/2019 without documentation that the resident or designated person objected to the admission.
Resident #1 was admitted to the Secure Dementia Care Unit on 05/15/2019 without completion of the initial support plan.
Resident #1's support plan addressing vision needs was completed late and did not ensure appropriate care.
Resident #2's support plan addressing vision needs was completed late and did not ensure appropriate care.
The home failed to complete the initial support plan for Resident #1 admitted to the Secure Dementia Care Unit.
Resident #1's medication errors on multiple dates were not reported timely by the home's staff.
The home failed to have an updated Resident Assessment and Service Plan (RASP) for Resident #1's medical condition.
Report Facts
Residents Served: 85
Secured Dementia Care Unit Residents Served: 34
Hospice Current Residents: 1
Notice — Apr 30, 2019
Date: Apr 30, 2019
Visit Reason
The document serves as a renewal notification for the Personal Care Home license and informs the facility 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 license renewal notice with an enclosed certificate of compliance.
Report Facts
Inspection Report — Apr 23, 2019
Routine
Date: Apr 23, 2019
Visit Reason
The Department’s Bureau of Human Services Licensing conducted an inspection of The Terrace at Chestnut Hill facility on April 23, 2019.
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 |
|---|---|---|
| Mia Johnson | Human Services Licensing Supervisor | Signed the inspection report letter. |
Inspection Report — Apr 3, 2019
Complaint Investigation
Date: Apr 3, 2019
Visit Reason
The inspection was conducted as a complaint investigation at The Terrace at Chestnut Hill on April 3, 2019.
Complaint Details
The complaint investigation was triggered by an allegation of abuse reported on 03/09/19 involving Resident #1. The abuse allegation was not reported to the local area agency on aging. The home also failed to submit an incident report for an unwitnessed fall of Resident #2 on November 18, 2018.
Findings
Violations of 55 Pa. Code Ch. 2600 related to resident abuse reporting, incident reporting, and annual medical evaluations were found. Plans of correction were partially implemented with ongoing staff training and documentation improvements.
Citations (3)
§2600.15.a The home failed to immediately report suspected abuse of a resident as required by the Older Adult Protective Services Act and related regulations.
§2600.16.c The home failed to report an unwitnessed fall incident involving Resident #2 to the Department as required within 24 hours.
§2600.141.b.1 A resident did not have a medical evaluation completed at least annually as required.
Report Facts
Residents Served: 66
Secured Dementia Care Unit Residents Served: 37
Hospice Current Residents: 14
Residents Age 60 or Older: 103
Residents with Mobility Need: 71
Residents with Physical Disability: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nicki Beekman | Executive Director | Named in plans of correction and violation report |
| Mia Johnson | Human Services Licensing Supervisor | Regional Licensing Supervisor and signatory on report |
Inspection Report — Mar 6, 2019
Renewal
Date: Mar 6, 2019
Visit Reason
The inspection was a renewal inspection conducted to assess compliance with 55 Pa. Code Chapter 2600 relating to Personal Care Homes.
Findings
The inspection identified multiple violations related to policies, procedures, safety, privacy, sanitation, and documentation. Plans of correction were developed and partially implemented with adequate progress noted.
Citations (10)
§2600.16(b) The home lacked a written policy on prevention, reporting, notification, investigation, and management of reportable incidents. The reportable incident binder was removed by the previous Wellness Director.
§2600.18 The battery in the carbon monoxide alarm was not labeled with the date of installation as required.
§2600.42(s) Residents reported staff disregarded privacy by not knocking before entering rooms during bathing, dressing, and medical procedures.
§2600.82(b) Poisonous materials, including extractor carpet shampoo labeled 'call local poison control,' were stored improperly on the 3rd floor kitchen counter near food items.
§2600.85(a) On 3-6-19, a staff member's coat was found lying across a medication cart, creating unsanitary conditions during medication administration.
§2600.103(b) Kitchen surfaces, including the refrigerator on the 1st floor, were soiled with juice stains and food particles and required cleaning and sanitizing after each meal.
§2600.103(g) Food items on the 3rd floor were opened and not labeled with dates, including applesauce, mustard, and a plate with chicken and salad.
§2600.141(a)(2) Medical evaluations for residents #1 and #2 did not include all required medical information such as diagnosis, immunization history, and body positioning.
§2600.227(g) Resident #2 participated in developing a support plan but did not sign the plan dated 12/18/18.
§2600.252 Resident #3's record lacked her support plan, and the support plan found in resident #4's record was inaccurate.
Report Facts
Number of Residents Served: 100
Number of Staff: 166
Waking Staff: 125
Number of Residents 60 Years or Older: 100
Number of Residents with Mobility Need: 66
Number of Residents with Physical Disability: 2
Number of Residents Served in Secured Dementia Care Unit: 36
Number of Current Hospice Residents: 4
Number of Hospice Residents in Past Year: 18
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nicki Beekman | Administrator | Named as Administrator and Legal Entity Representative signing plans of correction. |
| Jacqueline L. Rowe | Director | Signed the cover letter for the inspection report. |
| Natasha Braswell | Inspection representative conducting the inspection on 03/06/2019. | |
| Mia Johnson | Regional Licensing Supervisor | Named as Regional Licensing Supervisor on multiple pages. |
Inspection Report — Dec 13, 2018
Routine
Date: Dec 13, 2018
Visit Reason
The Department's Bureau of Human Services Licensing representatives conducted an inspection of The Terrace at Chestnut Hill facility on December 13, 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 — Nov 28, 2018
Complaint Investigation
Date: Nov 28, 2018
Visit Reason
The inspection was conducted as a complaint investigation at The Terrace at Chestnut Hill facility on November 28, 2018.
Complaint Details
The inspection was triggered by a complaint. The violation involved medications of former residents not being properly disposed of as required by Department of Environmental Protection and Federal and State regulations.
Findings
The inspection found violations related to the improper storage of prescription, OTC, and CAM medications belonging to former residents that were not disposed of according to regulations. A plan of correction was submitted to address medication disposal and ongoing audits.
Citations (1)
§2600.183(f) - Prescription, OTC, and CAM medications that are discontinued, expired, or for residents no longer served must be destroyed safely. Medications belonging to former residents were found improperly stored in the wellness room.
Report Facts
Number of Residents Served: 107
Number of Residents Served in Secured Dementia Care Unit: 34
Number of Residents Age 60 or Older: 94
Number of Residents with Mobility Needs: 57
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Natasha Braswell | Department Representative | On-site inspector for the complaint investigation |
| Nicole Beekman | Administrator | Named in plan of correction and signature on report |
Inspection Report — Oct 15, 2018
Complaint Investigation
Date: Oct 15, 2018
Visit Reason
The inspection was conducted due to an incident reported at the facility, triggering a complaint investigation.
Complaint Details
The visit was complaint-related due to an incident involving resident dehydration and neglect. The complaint was substantiated as violations were found.
Findings
Two violations were found: one related to resident hydration and neglect, and another concerning the availability of condiments at dining tables. Plans of correction were submitted addressing hydration monitoring and condiment availability.
Citations (2)
Regulation 55 Pa.Code §2600 2600.42(b): A resident may not be neglected, intimidated, physically or verbally abused, mistreated, subjected to corporal punishment or disciplined in any way. Resident #1 was observed dehydrated and admitted to hospital with altered mental status due to dehydration.
Regulation 55 Pa.Code §2600 2600.104(c): Condiments shall be available at the dining table. On 10/16/18 at 12:30PM, condiments were not available at the dining tables and a resident requested ketchup but none was available.
Report Facts
Number of Residents Served: 106
Number of Current Hospice Residents: 7
Number of Hospice Residents in past year: 15
Number of Residents Served in Secured Dementia Care Unit: 40
Number of Residents who are 60 Years of Age or Older: 106
Number of Residents who Have a Mobility Need: 90
Number of Residents who Have a Physical Disability: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nicki Beekman | Administrator / Executive Director | Named in plan of correction and signature on violation report |
| Patricia Adams | Regional Licensing Director / Regional Licensing Supervisor | Signed cover letter and listed as supervisor on inspection |
| Sabrina Freeman | Department representative on-site during inspection |
Inspection Report — Jun 26, 2018
Complaint Investigation
Date: Jun 26, 2018
Visit Reason
The inspection was conducted as a complaint/incident investigation related to violations of 55 Pa. Code Chapter 2600 for Personal Care Homes.
Complaint Details
The visit was complaint-related and substantiated violations were found as detailed in the violation report.
Findings
Multiple violations were found concerning resident rights, staffing to meet resident needs, support plans, preadmission screening, and documentation requirements. Plans of correction were partially implemented with ongoing oversight.
Citations (6)
55 Pa.Code §2600.43(a): A resident was deprived of his rights when staff forced him to go to bed against his wishes.
55 Pa.Code §2600.60(a): Staffing failed to provide a required two-person assist for resident transfers on the Memory Care Unit.
55 Pa.Code §2600.227(c): The resident's support plan was not revised within 30 days to reflect a required two-person assist.
55 Pa.Code §2600.231(c): Resident was admitted to the secured dementia care unit without a completed cognitive preadmission screening within 72 hours.
55 Pa.Code §2600.231(e): Resident records lacked proper documentation that the resident and designated person did not object to admission or transfer to the secured dementia care unit.
55 Pa.Code §2600.252: Resident's record did not include a photograph as required.
Report Facts
Number of Residents Served: 95
Number of Residents 60 Years or Older: 94
Number of Residents with Mobility Need: 57
Number of Current Hospice Residents: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nicki Beekman | Administrator | Named as Administrator responsible for plans of correction and oversight. |
| Sabrina Freeman | Inspector | Department representative conducting the inspection. |
| Shawn Parker | Human Services Licensing Supervisor | Supervisor overseeing the inspection. |
Inspection Report — Apr 24, 2018
Renewal
Date: Apr 24, 2018
Visit Reason
This document is a renewal application and license issuance for The Terrace at Chestnut Hill Personal Care Home. The Department of Human Services notifies that an onsite inspection will be conducted within the next twelve months as part of the annual inspection requirement.
Findings
No inspection findings are reported in this document. It serves as a license renewal notification and confirmation of the facility's authorized capacity.
Report Facts
Inspection Report — Oct 19, 2017
Complaint Investigation
Date: Oct 19, 2017
Visit Reason
The inspection was conducted as a complaint investigation triggered by an incident involving an allegation of abuse against a staff person at the facility.
Complaint Details
The investigation was triggered by an allegation of abuse made against staff person A regarding resident #1. The allegation was substantiated by the violation report.
Findings
The facility was found to have violated 55 Pa. Code Chapter 2600 related to abuse allegations. Specifically, the home failed to obtain necessary approval for a plan of supervision for a staff person involved in the alleged incident before allowing them to return to work.
Citations (1)
55 Pa.Code §2600.15(b) requires immediate development and implementation of a supervision plan or suspension of staff involved in abuse allegations. The home did not receive necessary approval for the plan of supervision for staff person A before returning to work on 10/18/17.
Report Facts
Number of Residents Served: 99
Total Daily Staff: 162
Walking Staff: 122
Number of Residents Served in Secured Dementia Care Unit: 32
Number of Current Hospice Residents: 7
Number of Hospice Residents in past year: 15
Number of Residents 80 Years or Older: 88
Number of Residents with Mental Illness: 1
Number of Residents with Mobility Need: 63
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nicki Beekman | Administrator | Named in relation to the violation and plan of correction |
| Kenneth L. Wilson | Human Services Licensing Supervisor | Signed the report and approved plan of correction |
| Dean Gray | Department Representative conducting inspection |
Inspection Report — Aug 24, 2017
Complaint Investigation
Date: Aug 24, 2017
Visit Reason
The inspection was conducted as a complaint investigation triggered by an incident at The Terrace at Chestnut Hill.
Complaint Details
The visit was complaint-related due to an incident involving medication errors and failure to complete required medical evaluations. The complaint was substantiated by findings of noncompliance with medical evaluation and medication administration regulations.
Findings
The inspection found multiple violations related to medical evaluations, medication administration, and documentation procedures. The facility failed to complete a 2017 medical evaluation for a resident and did not follow medication refusal policies or report refusals to physicians as required.
Citations (4)
Regulation 55 Pa.Code §2600.141(b)(1): The home does not have a completed 2017 medical evaluation for Resident #1; the last evaluation was dated 03/23/2016.
Regulation 55 Pa.Code §2600.185(a): The home's medication administration policy was not followed; nursing staff refused medication documentation and failed to notify the resident's physician as required.
Regulation 55 Pa.Code §2600.187(c): Resident #1 refused prescribed Saline Mist 0.65% Nasal Spray three times daily on specified dates; the home did not report refusals to the resident's doctor as required.
Regulation 55 Pa.Code §2600.187(d): The home failed to administer the 9:00 am dose of Quetiapine 25 mg to Resident #1 from 07/26/17 through 08/09/17 as ordered by the prescriber.
Report Facts
Number of Residents Served: 98
Number of Current Hospice Residents: 8
Number of Residents Served in Secured Dementia Care Unit: 31
Number of Residents Age 60 or Older: 97
Number of Residents with Mental Illness: 1
Number of Residents with Mobility Need: 59
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Carrie Hehn | Administrator | Named in relation to inspection and plan of correction |
| Tahesia Thomas | Inspector | Conducted the inspection and communicated findings |
| Patricia Adams | Human Services Licensing Supervisor | Regional Licensing Supervisor overseeing the inspection |
Inspection Report — Jun 6, 2017
Renewal
Date: Jun 6, 2017
Visit Reason
The inspection was a renewal licensing inspection conducted by the Pennsylvania Department of Human Services on June 6, 2017, at The Terrace at Chestnut Hill personal care home.
Findings
Multiple violations of 55 Pa.Code Chapter 2600 were found related to staff training, safety, medication administration, documentation, and facility conditions. Plans of correction were submitted and partially implemented with ongoing monitoring.
Citations (20)
§2600.65e - Direct care staff persons A & B did not receive at least 12 hours of annual training for 2016, receiving only 3.5 and 5 hours respectively.
§2600.65f - Direct care staff persons A & B did not receive required annual training on medication self-administration, resident needs, dementia care, infection control, personal care, safe management, and mental health care.
§2600.65g - Direct care staff persons A & B did not receive annual training on fire safety, emergency preparedness, resident rights, Older Adult Protective Services Act, falls and accident prevention.
§2600.85d - Trash can in private bathroom #537 did not have a lid.
§2600.89b - Hot water temperatures in apartments 333, 337, 356, and 428 exceeded 120°F, measuring between 122.7°F and 132°F.
§2600.91 - Apartment 358 did not have emergency service numbers posted on or by the telephone.
§2600.103c - A bowl of uncovered ice cream was observed in the freezer of the 3rd floor secured unit.
§2600.103e - Six plastic bags containing food for residents were observed in the 3rd floor secured unit refrigerator without labels or dates.
§2600.132a - Monthly unannounced fire drills were not documented for July, August, September, October, and November 2016.
§2600.132e - A fire drill during sleeping hours was conducted on 4/27/17 but documentation of the previous overnight drill was not provided.
§2600.141a(1) - Resident #5 was admitted without a completed medical evaluation within 60 days prior to admission.
§2600.141b1 - Resident #3's last medical evaluation was completed on 3/21/17; previous evaluation was on 2/23/16, not annually.
§2600.187d - Resident #3 did not have prescribed medications; resident #7's medication was still in the packet at time of inspection.
§2600.188b - Medication error: Resident #7's medication was still in the packet at time of inspection and not administered.
§2600.224a - Resident #2's pre-admission screening form was incomplete and missing required sections.
§2600.225c - Resident #3's most recent assessment was completed on 3/21/17; previous assessment was on 2/23/16, not annually.
§2600.227g - Resident #2 did not participate in the development of the support plan or sign and date it.
§2600.231b - Resident #5 was admitted without a completed medical evaluation and diagnosis of dementia for secured dementia care unit placement.
§2600.231e - Resident #5's medical evaluation and admission documentation for secured dementia care unit was incomplete.
§2600.162(g) - Resident #2 did not participate in the development of their support plan and did not sign or date it.
Report Facts
Number of Residents Served: 95
Number of Residents Served in Secured Dementia Care Unit: 33
Number of Current Hospice Residents: 5
Number of Hospice Residents in Past Year: 11
Number of Residents 60 Years or Older: 94
Number of Residents with Mental Illness: 2
Number of Residents with Mobility Need: 57
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Carrie Heath | Administrator, Interim ED | Named as legal entity representative signing plans of correction. |
| Bill Kofron | Administrator | Administrator at time of inspection. |
| Sabrina Freeman | Department representative conducting inspection. | |
| Shawn Parker | Department representative conducting inspection. | |
| Roslyn Brewer | Regional Licensing Supervisor | Supervisor overseeing inspection. |
Notice — May 1, 2017
Date: May 1, 2017
Visit Reason
The document serves as a renewal notification for the license to operate The Terrace at Chestnut Hill Personal Care Home and informs about the requirement for an annual onsite inspection within the next twelve months.
Findings
No inspection findings are reported in this document. It is a license renewal notice with an enclosed certificate.
Report Facts
Inspection Report — Mar 8, 2017
Complaint Investigation
Date: Mar 8, 2017
Visit Reason
The inspection was conducted as a complaint investigation triggered by an incident at The Terrace at Chestnut Hill.
Complaint Details
The visit was complaint-related due to an incident. The violations were substantiated as the resident's medical evaluation and assessments were overdue.
Findings
Two violations were found related to failure to complete required annual medical evaluations and additional resident assessments within the mandated timeframes. Plans of correction were initiated but only partially implemented at the time of the report.
Citations (2)
Regulation 65 Pa.Code §2600.141(b)(1): A resident did not have a medical evaluation completed annually as required; the last evaluation was in 2015 with no evaluation in 2016.
Regulation 65 Pa.Code §2600.225(c): The resident did not have additional assessments completed in 2016 as required by the annual assessment schedule.
Report Facts
Inspection date: Mar 8, 2017
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Bill Kofron | Administrator | Named as facility administrator and signed plan of correction |
| Shawn Parker | Regional Licensing Supervisor | Conducted the inspection |
Inspection Report — Nov 16, 2016
Complaint Investigation
Date: Nov 16, 2016
Visit Reason
The inspection was conducted as a complaint and incident investigation related to violations of 55 Pa.Code Chapter 2600 for Personal Care Homes.
Complaint Details
The visit was complaint-related and incident triggered. Specific substantiation status is not stated.
Findings
The inspection found violations including failure to regulate room temperatures causing a hazardous condition, and neglect of a resident resulting in hospitalization due to heat stroke. Plans of correction were submitted addressing temperature regulation and resident care assignment sheets.
Citations (2)
Regulation 55 Pa.Code §2600.42(b): A resident was neglected and suffered heat stroke due to inadequate clothing and hydration, and failure to follow the resident's Assessment and Support Plan.
Regulation 55 Pa.Code §2600.95: Furniture and equipment were not maintained in good repair and free of hazards due to failure to regulate temperatures in resident rooms, creating a hazardous condition.
Report Facts
Number of Residents Served: 95
Number of Current Hospice Residents: 4
Number of Residents Age 60 or Older: 85
Number of Residents with Intellectual Disability: 60
Number of Residents with Mobility Need: 4
Number of Residents with Physical Disability: 4
Number of Residents with Mental Illness: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Roslyn Brewer | Regional Licensing Supervisor | Conducted the inspection and signed the violation report |
| Bill Kofron | Administrator | Named in plan of correction and signature on report |
Inspection Report — Jun 21, 2016
Renewal
Date: Jun 21, 2016
Visit Reason
The inspection was a licensing inspection conducted as a renewal of the facility's license under 55 Pa.Code Chapter 2600 for Personal Care Homes.
Findings
Multiple violations of 55 Pa.Code Chapter 2600 were found, including issues with refunds, sanitary conditions, emergency telephone postings, safety hazards, medication administration, and resident care documentation. Plans of correction were submitted and partially implemented as of the report date.
Citations (11)
55 Pa.Code 2600.28(f)(2) - Refunds shall be made within 30 days of the resident's discharge. The home did not provide the required refund until 6/16/16 after a resident was discharged.
55 Pa.Code 2600.85(a) - Sanitary conditions shall be maintained. Resident #2's glucometer was used to check resident #3's glucose level on 6/10/16.
55 Pa.Code 2600.88(a) - Floors, walls, ceilings, windows, doors and other surfaces must be clean, in good repair and free of hazards. The administrator slipped and fell inside the elevator; no sign indicated the floor was treated.
55 Pa.Code 2600.91 - Emergency telephone numbers must be posted by each telephone. The telephone in room #200 did not have emergency service numbers posted nearby.
55 Pa.Code 2600.94(a) - Interior and exterior doors and fire exits must have a landing. The stairway door at the rear of the mansion stair tower did not have a landing.
55 Pa.Code 2600.100(a) - The exterior of the building and grounds must be in good repair and free of hazards. A large metal drain cover outside the first floor fire exit door posed a hazard.
55 Pa.Code 2600.101(j)(7) - Each resident shall have an operable lamp or source of light at bedside. Residents in rooms 325 and 428 did not have a source of light that could be turned on/off from bedside.
55 Pa.Code 2600.103(f) - Food refrigeration shall be stored at or below 40°F. No thermometer was in the ice cream freezer in the main kitchen on 6/21/16.
55 Pa.Code 2600.182(c) - Medication administration must follow specific activities including identifying the correct resident and documenting administration. Resident #3's glucometer readings did not match medication administration records on multiple dates.
55 Pa.Code 2600.187(a) - Medication records must include specific information for each resident. Resident #4 had an accu-check reading not written on the medication administration record on 6/20/16.
55 Pa.Code 2600.187(d) - The home shall follow the directions of the prescriber. Resident #2 and #4 had prescribed orders for accu-checks but documentation and frequency were inconsistent with orders.
Report Facts
Number of Residents Served: 95
Number of Residents Served in Secured Dementia Care Unit: 41
Number of Current Hospice Residents: 4
Number of Hospice Residents in Past Year: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Michelle Morton | Executive Director | Signed multiple violation reports and plans of correction |
| Lissette Colon | Department Representative on-site during inspection | |
| Dean Gray | Department Representative on-site during inspection |
Notice — June 10, 2020
Date: June 10, 2020
Visit Reason
This document serves as a renewal notification and license issuance for The Terrace at Chestnut Hill Personal Care Home. It informs the facility that an onsite annual 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 following the renewal application.
Report Facts
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