31 Reports
Notice — Aug 4, 2026
Date: Aug 4, 2026
Visit Reason
The document serves as a response to a waiver request to allow unlicensed direct care staff to administer subcutaneous injections of GLP-1 agonist medications in a personal care home.
Findings
The waiver is granted with specific conditions including required training, monitoring, documentation, and availability of a licensed clinical contact to oversee administration of GLP-1 agonist medications.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Theresa Hartman | Bureau Director, Human Services Licensing | Signed the waiver approval letter. |
Inspection Report — Feb 18, 2026
Follow-Up
Date: Feb 18, 2026
Visit Reason
The inspection was a partial, unannounced follow-up visit triggered by a complaint to verify the implementation of a previously submitted plan of correction.
Complaint Details
The inspection was complaint-related as indicated by the reason 'Complaint' and was conducted to verify correction of deficiencies.
Findings
The inspection found multiple violations related to food safety and sanitation, including evidence of mouse infestation, uncovered trash receptacles, uncovered food items, food stored on the floor, and unlabeled leftover food. The facility has implemented corrective actions and education, with ongoing monitoring and scheduled audits.
Citations (5)
85.b. Mouse feces were observed on the floor and on various food items in the main kitchen pantry, including a bag of powdered sugar with a hole chewed through it.
85.d. There was a full, uncovered, and unattended trash can in the main kitchen.
103.c. Three uncovered small plates of applesauce were stored in the main kitchen refrigerator.
103.d. A frozen bag of hamburger buns was stored on the floor in the walk-in freezer.
103.e. There was an unlabeled and undated pan of lasagna in the main kitchen refrigerator.
Report Facts
Residents Served: 69
Secured Dementia Care Unit Residents Served: 15
Hospice Current Residents: 9
Residents Age 60 or Older: 69
Residents Diagnosed with Mental Illness: 1
Residents Diagnosed with Intellectual Disability: 0
Residents with Mobility Need: 27
Residents with Physical Disability: 1
Inspection Report — Jun 3, 2025
Renewal
Date: Jun 3, 2025
Visit Reason
The inspection was conducted as a renewal, complaint, and incident investigation at THE WOODS AT CEDAR RUN facility on 06/03/2025 and 06/04/2025.
Complaint Details
The inspection included complaint investigation related to resident abuse involving inappropriate communication and conduct between staff and resident, which resulted in staff termination.
Findings
The inspection found multiple deficiencies including failure to conspicuously post a waiver, resident abuse involving inappropriate staff conduct, unsafe resident personal equipment, unsecured medications, failure to follow prescriber's orders, and incomplete preadmission screening documentation. Plans of correction were accepted and fully implemented by 07/17/2025.
Citations (7)
Failure to publicly and conspicuously post a waiver for staff member's non-US education.
Resident abuse involving inappropriate text messages and sending naked pictures from staff to resident.
Uncovered bedside mobility device posing potential limb or head entrapment risk.
Unlocked and accessible medications in resident's bathroom cabinet without assessment for self-administration.
Medications not current or without physician orders kept in resident's bathroom cabinet.
Failure to follow prescriber's orders resulting in residents not receiving prescribed medications and supplements.
Preadmission screening form incomplete, missing date of completion.
Report Facts
Residents Served: 58
Residents in Secured Dementia Care Unit: 15
Current Hospice Residents: 8
Total Daily Staff: 79
Waking Staff: 59
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Executive Operations Officer | Named in multiple findings including posting waiver, abuse investigation, medication management, and education. | |
| Maintenance Director | Removed unsafe bedside mobility device from resident's bed. | |
| Resident Wellness Director | Involved in medication management and education, and approval of enabler bars. | |
| Med Tech | Named in medication error finding related to Ensure supplement. |
Inspection Report — Mar 19, 2025
Follow-Up
Date: Mar 19, 2025
Visit Reason
The inspection visit was conducted as a complaint investigation and a follow-up to verify the implementation of a previously submitted plan of correction.
Complaint Details
The visit was complaint-related and included a follow-up to verify correction of cited deficiencies. The plan of correction was accepted and fully implemented.
Findings
The plan of correction related to unobstructed egress in the secured dementia care unit was found to be fully implemented. The inspection noted that a chair, bench, and trashcan had previously blocked egress routes but were promptly removed, and staff were trained to prevent future blockages.
Citations (1)
A chair blocked egress from the sunroom in the secured dementia care unit to the gated courtyard. A bench and a metal trashcan blocked egress from the gated courtyard to the back of the home.
Report Facts
Residents Served: 64
Secured Dementia Care Unit Residents Served: 17
Hospice Current Residents: 11
Residents Age 60 or Older: 63
Residents with Mobility Need: 22
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Med Tech | Med Tech on duty moved the chair blocking the exit door during the inspection | |
| Director of Maintenance | Director of Maintenance moved the bench and trashcan blocking egress routes |
Inspection Report — Nov 20, 2024
Complaint Investigation
Date: Nov 20, 2024
Visit Reason
The inspection was conducted as a complaint investigation with unannounced partial inspections on 11/20/2024 and 12/05/2024.
Complaint Details
The visit was complaint-related with substantiated findings of abuse, neglect, medication errors, and regulatory noncompliance.
Findings
The facility was found to have multiple violations including failure to report suspected resident abuse, medication errors, confidentiality breaches, improper medication storage and labeling, failure to follow prescriber's orders, and inadequate resident assessments. Several staff members were terminated due to noncompliance. Plans of correction were accepted and implemented with ongoing monitoring and training.
Citations (16)
Failure to immediately report suspected resident abuse and comply with reporting requirements.
Failure to report incidents to the Department within required timeframes.
Resident records were unlocked, unattended, and accessible to unauthorized persons.
Resident abuse including verbal abuse, neglect, and intimidation by staff members.
Detection of marijuana odor in the wellness office indicating possible staff drug use.
Direct care staff providing unsupervised ADL services without completing required training.
Resident initial medical evaluation did not include medical information pertinent to diagnosis and treatment in case of emergency.
Prescription medications and syringes were found unlocked and unattended in resident rooms.
Expired and discontinued medications were found in medication carts and storage areas.
Medications were not properly labeled with resident name, prescription date, dosage, instructions, or prescriber information.
Over-the-counter medications and CAM were not labeled with resident names.
Failure to implement safe storage, access, security, and distribution procedures for medications and medical equipment.
Medication records lacked diagnosis or purpose for administration of medications.
Failure to follow prescriber's orders including missed medication administrations and incorrect medication availability.
Resident assessments and support plans were not updated to reflect significant changes in condition.
Directions for operating key-locking devices on Secure Dementia Care Unit doors were indecipherable.
Report Facts
Residents Served: 70
Residents in Secured Dementia Care Unit: 17
Current Hospice Residents: 4
Residents Age 60 or Older: 69
Residents with Mobility Need: 23
Total Daily Staff: 93
Waking Staff: 70
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff Member A | Named in multiple abuse and neglect findings, terminated for violations. | |
| Staff Member B | Failed to report abuse allegations and incidents, terminated for noncompliance. | |
| Staff Member C | Responsible for reporting incidents, involved in abuse reporting failures. | |
| Staff Member D | Witnessed verbal abuse, terminated unrelated to violation. | |
| Staff Member G | Witnessed staff laughing at resident during abuse incident. | |
| Staff Member H | Involved in abuse incident, terminated after investigation. | |
| Executive Operations Officer | Provided training, monitored compliance, and implemented corrective actions. | |
| Resident Wellness Director | Terminated due to failure to comply with state regulations and facility expectations. | |
| Director of Memory Care | Involved in review and monitoring of resident care and assessments. |
Inspection Report — Jun 11, 2024
Renewal
Date: Jun 11, 2024
Visit Reason
The inspection was an unannounced full renewal inspection conducted on 06/11/2024 and 06/12/2024 to review compliance with licensing regulations.
Findings
The inspection found multiple deficiencies including failure to post current licensing summaries, staff qualification issues, inadequate CPR/First Aid coverage, unsanitary conditions, equipment safety concerns, medication storage and labeling violations, incomplete resident records, and issues with emergency phone numbers and fire drill documentation. Plans of correction were accepted and fully implemented by 07/24/2024.
Citations (21)
Current licensing inspection summaries were not posted in a conspicuous and public place in the home.
Direct Care Staff Member A attended a non-U.S. educational institution without a Department-issued waiver.
Only one staff member with CPR and first aid certification was present during a night shift when 55 residents were in the home.
An uncovered enabler device on a resident's bed posed a potential risk of entrapment.
Three drawers in a medication cart contained dirt, dust, hair, and trash creating unsanitary conditions.
Bathroom ventilation fan in resident room #112 was inoperable.
Emergency phone numbers posted were incorrect or missing near phones.
Heavy accumulation of lint in the dryer lint trap in resident room #322.
Fire drill records did not include actual evacuation times or number of residents present at the time of drills.
Resident #1's medical evaluation was overdue prior to being completed on 2/1/24.
Menus were not posted one week in advance as required.
Staff Member B transported residents without completing required direct care staff training.
Medication containers with loose tablets/capsules were found in medication carts.
Loose white pills were found in medication carts.
A bottle of pills in a medication cart was unlabeled and unidentifiable.
Resident #7's glucometer was not calibrated to the correct date and time.
Resident medications were missing diagnosis or purpose on Medication Administration Records.
Resident support plans did not include specific information about bedside mobility devices.
Directions for egress from the secured dementia care unit locking mechanism were posted in a disguised manner not permitting immediate egress.
Resident records did not include photographs no more than 2 years old.
Medication office containing resident medical files was unlocked, unattended, and accessible.
Report Facts
Residents served: 43
Residents in secured dementia care unit: 12
Hospice residents: 4
Staff total daily: 66
Waking staff: 50
Residents with mobility need: 23
Residents aged 60 or older: 67
Residents present during CPR deficiency: 55
Medication containers found: 6
Loose white pills found: 2
Unlabeled pills found: 30
Inspection Report — Feb 1, 2024
Complaint Investigation
Date: Feb 1, 2024
Visit Reason
The inspection was conducted as a complaint investigation with an unannounced partial inspection on 02/01/2024.
Complaint Details
The visit was complaint-related as stated under Inspection Information with a reason of Complaint.
Findings
The inspection found deficiencies related to medication management, specifically medications and syringes not being locked and medications not stored properly under required conditions. A plan of correction was submitted and fully implemented by 02/20/2024.
Citations (2)
Medications and syringes were found unlocked, unattended, and accessible on medication carts.
Medications were not stored in an organized manner under proper conditions of sanitation, temperature, moisture, and light as required.
Report Facts
Residents Served: 61
Memory Care Residents Served: 14
Hospice Residents: 6
Resident Support Staff: 81
Waking Staff: 61
Residents Age 60 or Older: 59
Residents with Mobility Need: 20
Inspection Report — Apr 4, 2023
Renewal
Date: Apr 4, 2023
Visit Reason
The inspection was conducted for renewal and complaint reasons as part of a full unannounced inspection on 04/04/2023 and 04/05/2023.
Findings
The inspection identified multiple deficiencies including breaches in record confidentiality, insufficient first aid/CPR trained staff during night shifts, incomplete direct care staff training, missing annual fire safety training, unsafe resident personal equipment, lack of grab bars in bathrooms, outdated emergency procedures, missing fire department notification, incomplete medical evaluations, improper medication equipment calibration, and unsigned support plans. Plans of correction were accepted and implemented by early June 2023.
Citations (11)
Resident narcotic count binders were unlocked and unattended on medication carts, and resident information was accessible on an unattended computer screen.
Only one staff person certified in first aid, obstructed airway techniques, and CPR was present during night shifts when 58 residents were in the home.
Direct Care Staff Member A provided unsupervised ADL services without completing and passing the Department-approved direct care training course and competency test.
Staff Members B and C did not receive required annual training in fire safety and emergency preparedness during the 2022 training year.
Resident #1 had an enabler bar on the bed with an opening exceeding FDA guidelines, posing a potential entrapment or fall hazard.
No grab bar, hand rail, or assist bar was located near the bathroom toilet in a resident room.
The home's written emergency procedures had not been reviewed since 2022 and were not submitted to the local emergency management agency.
The home lacked documentation of written notification to the local fire department regarding the home's address, bedroom locations, and evacuation assistance needs.
Resident #3's annual medical evaluation did not include the date of evaluation or form completion.
Resident #1's glucometer was not calibrated to the correct date or time.
Residents #3 and #4 participated in support plan development but neither the resident nor the assessor signed the support plan.
Report Facts
Residents present during inspection: 58
Memory Care residents served: 14
Residents served: 58
Residents age 60 or older: 56
Residents with mobility needs: 17
Residents with mental illness: 1
Residents with intellectual disability: 0
Residents with physical disability: 0
Inspection Report — Mar 29, 2022
Renewal
Date: Mar 29, 2022
Visit Reason
The inspection was conducted as a renewal inspection of the facility license for THE WOODS AT CEDAR RUN.
Findings
The inspection found multiple deficiencies including failure to report a medication error, unsigned resident-home contracts, insufficient staff certified in first aid and CPR during night shifts, evacuation drill exceeding maximum allowed time, unsecured medications, incomplete medication administration records, failure to report medication refusal, missing signatures on support plans, incomplete preadmission screenings, and delayed admission support plans. Plans of correction were accepted and implemented for all deficiencies.
Citations (10)
Failure to report a medication error when Resident #1 missed a weekly dose of prescribed medication.
Resident-home contracts for Resident #1 and Resident #2 were not signed by the residents.
Not at least two staff persons trained and certified in first aid and CPR present during the 11PM to 7AM shift based on census.
Fire drill evacuation time of 14 minutes and 9 seconds exceeded the maximum allowed time of 13 minutes.
Medications and syringes were not locked and accessible in Resident #5's room and bathroom.
Medication administration record for Resident #1 lacked glucometer reading for 3/29/22 despite physician order for daily blood sugar check.
Refusal of medication by Resident #4 on 3/19/22 was not reported to the prescriber.
Resident Assessment and Support Plans for Resident #1 and Resident #3 were not signed by the staff person who developed the plans.
Written cognitive preadmission screening was not completed for Resident #2 prior to admission to the Secure Dementia Care Unit.
Resident #4's initial support plan was completed after admission to the Secure Dementia Care Unit, not within 72 hours as required.
Report Facts
Residents Served: 59
Residents Served in Dementia Care Unit: 13
Hospice Residents: 6
Evacuation Time: 849
Maximum Allowed Evacuation Time: 780
Staff Certified in First Aid and CPR Required: 2
Total Daily Staff: 74
Waking Staff: 56
Inspection Report — Aug 31, 2021
Renewal
Date: Aug 31, 2021
Visit Reason
The inspection was conducted as part of the Pennsylvania Department of Human Services, Bureau of Human Service Licensing's licensing inspections of the facility on 08/31/2021 and 09/03/2021.
Findings
No regulatory citations were identified as a result of this inspection.
Inspection Report — Dec 7, 2020
Renewal
Date: Dec 7, 2020
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.
Notice — Nov 5, 2020
Date: Nov 5, 2020
Visit Reason
This document serves as a renewal notification and certificate of compliance for The Woods at Cedar Run Personal Care Home, confirming the facility's licensed capacity and informing about the upcoming annual inspection required by regulation.
Findings
The Department has issued a regular license in response to the renewal application and will conduct an onsite inspection within the next twelve months to ensure compliance with applicable regulations.
Report Facts
Inspection Report — Jul 31, 2020
Renewal
Date: Jul 31, 2020
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 — Jun 25, 2020
Follow-Up
Date: Jun 25, 2020
Visit Reason
The inspection was a partial, unannounced follow-up visit triggered by an incident to review the submitted plan of correction for the facility.
Findings
The facility was found to have implemented the submitted plan of correction related to resident supervision and staffing deficiencies. Continued compliance was required to maintain.
Citations (2)
23a. Activities of Daily Living Assistance: The resident assessment showed Resident #1 required moderate assistance with supervision. Resident #1 used a wheelchair leg to break a glass window and eloped through the window due to inadequate supervision during the incident.
60a. Staff/Support Plan: Staffing was insufficient to meet resident needs in the Secure Dementia Care Unit, with only one direct care staff and one medication technician on duty. Residents requiring assistance were left unsupervised or without adequate help.
Report Facts
Residents Served: 61
Secured Dementia Care Unit Residents Served: 19
Current Hospice Residents: 4
Residents Age 60 or Older: 61
Residents with Mobility Need: 19
Residents with Physical Disability: 2
Total Daily Staff: 80
Waking Staff: 60
Inspection Report — May 18, 2020
Follow-Up
Date: May 18, 2020
Visit Reason
The visit was a follow-up review conducted by the Pennsylvania Department of Human Services, Bureau of Human Services Licensing, to verify that the previously submitted plan of correction was fully implemented following an incident-related partial inspection.
Findings
The submitted plan of correction was determined to be fully implemented. The main deficiency involved a support plan for a resident that was not signed by both the home and the resident, which has since been corrected.
Citations (1)
2600.227.g Individuals who participate in the development of the support plan shall sign and date the support plan. The support plan for Resident #1, dated 4/22/2020, was not signed by the home and the resident.
Report Facts
Residents Served: 58
Secured Dementia Care Unit Residents Served: 14
Hospice Current Residents: 3
Total Daily Staff: 81
Waking Staff: 61
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Heather Pastick | Administrator | Named as facility administrator and involved in plan of correction |
Notice — Apr 21, 2020
Date: Apr 21, 2020
Visit Reason
This document serves as a waiver notification granting a temporary waiver for direct care staff qualifications at The Woods at Cedar Run, effective from April 10, 2020 to June 30, 2020.
Findings
The waiver allows a specified direct care staff member to work without a high school diploma until June 30, 2020, with conditions including no medication administration until diploma is obtained and proper training is completed.
Report Facts
Waiver effective dates: From April 10, 2020 to June 30, 2020
Notice — Apr 10, 2020
Date: Apr 10, 2020
Visit Reason
This document serves to notify the facility of a granted waiver for a direct care staff member who has not yet met the educational qualifications required by regulation, valid from April 10, 2020 to June 30, 2020.
Findings
The waiver allows the specified staff member to serve as direct care staff without administering medications until she obtains her high school diploma by June 30, 2020. The Department will review compliance with this waiver annually during inspections.
Inspection Report — Feb 26, 2020
Complaint Investigation
Date: Feb 26, 2020
Visit Reason
The inspection was conducted as a complaint investigation triggered by an incident.
Complaint Details
The complaint was substantiated as the facility did not report suspected abuse immediately as required by the Older Adult Protective Services Act and related regulations.
Findings
The facility failed to immediately report suspected abuse of a resident as required by regulations. The submitted plan of correction was determined to be fully implemented.
Citations (1)
2600.15.a The home failed to immediately report suspected abuse of a resident served in the home. Resident #1 reported an allegation of abuse on 2/1/20, but it was not reported to the Department until 2/5/20.
Report Facts
Residents Served: 63
Residents Served in Secured Dementia Care Unit: 13
Hospice Current Residents: 4
Residents Age 60 or Older: 63
Residents with Mobility Need: 26
Residents with Physical Disability: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Heather Pastick | Administrator and PCHA LPN | Named in relation to the inspection and plan of correction |
Inspection Report — Oct 10, 2019
Renewal
Date: Oct 10, 2019
Visit Reason
The document is a renewal application and license issuance for The Woods at Cedar Run Personal Care Home. The Department received the renewal application on October 10, 2019, and will conduct an onsite inspection within the next twelve months as required by state regulations.
Findings
This document does not contain inspection findings but confirms the issuance of a regular license following the renewal application. It outlines the requirement for an annual onsite inspection within twelve months to ensure compliance with applicable laws.
Report Facts
Inspection Report — Sep 24, 2019
Renewal
Date: Sep 24, 2019
Visit Reason
The inspection was an annual licensing inspection conducted on September 24 and 25, 2019, as part of the facility's license renewal process.
Findings
The inspection identified violations related to fire safety, resident support plan signatures, and secure storage of resident records. Plans of correction were submitted and partially implemented to address these issues.
Citations (3)
2600.105.g requires removal of lint from dryer lint traps after each use to reduce fire hazards. On 9/25/19, lint accumulation was found in second floor dryer lint traps though dryers were not in use.
2600.227 requires individuals participating in support plan development to sign and date the plan. Several resident support plans lacked signatures from assessors and residents.
2600.254.c requires resident records to be stored in locked or secured areas accessible only to authorized personnel. On 9/25/19, wellness office doors were open with no staff present, exposing resident records.
Report Facts
Residents Served: 67
Secured Dementia Care Unit Residents Served: 15
Hospice Current Residents: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Heather Pastuck | Executive Director | Named as signer of plans of correction and responsible for staff education and compliance |
Inspection Report — Oct 1, 2018
Annual Inspection
Date: Oct 1, 2018
Visit Reason
The inspection was conducted as part of the Bureau of Human Services Licensing annual inspection for The Woods at Cedar Run facility.
Findings
The facility was found to be in compliance with 55 Pa.Code Ch. 2600 relating to Personal Care Homes during the inspection conducted on October 1 and 2, 2018.
Inspection Report — Oct 1, 2018
Renewal
Date: Oct 1, 2018
Visit Reason
The document is a renewal license issued to The Woods at Cedar Run to operate a Personal Care Home. The Department of Human Services will conduct an onsite inspection within the next twelve months as required by law.
Findings
No inspection findings are reported in this document. It is a license renewal notice confirming the issuance of a regular license and advising of future inspection requirements.
Report Facts
Inspection Report — May 2, 2018
Complaint Investigation
Date: May 2, 2018
Visit Reason
The inspection was conducted as a complaint and incident investigation at The Woods at Cedar Run personal care home.
Complaint Details
The inspection was triggered by a complaint and incident involving medication administration errors for Resident 1. The violations were substantiated as the medication administration records and prescriber directions were not properly followed.
Findings
The facility was found to have violations related to medication administration records and failure to follow prescriber directions for Resident 1. The medication administration records incorrectly documented medications and some prescribed medications were not administered as ordered.
Citations (2)
55 Pa.Code §2600.187(a) - The medication administration record for Resident 1 incorrectly documented prescribed medications including drug names, dosages, and administration times. Resident 1 was not in the home on the date medications were documented as administered.
55 Pa.Code §2600.187(d) - The home did not follow the directions of the prescriber when several medications were not administered to Resident 1 during specified periods in November and December 2017.
Report Facts
Number of Residents Served: 65
Total Daily Staff: 67
Walking Staff: 65
Number of Residents Served in Secured Dementia Care Unit: 17
Number of Current Hospice Residents: 8
Number of Hospice Residents in Past Year: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Courtney Bolinsky | Administrator | Named as administrator in violation report |
| Laura Heemer | Department representative conducting inspection |
Notice — Mar 23, 2018
Date: Mar 23, 2018
Visit Reason
The document is a response to a waiver request related to qualifications for direct care staff persons under 55 Pa.Code Ch. 2600 for a personal care home facility.
Findings
The Department of Human Services determined that the waiver is not needed because the staff person meets the educational requirements to serve as a direct care staff person. The facility must keep a record of this letter and related educational documents in the personnel file.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jill Kachmar | Regulatory Licensing Manager | Signed the waiver response letter. |
Inspection Report — Oct 26, 2017
Annual Inspection
Date: Oct 26, 2017
Visit Reason
The Department of Human Services conducted an annual licensing inspection of The Woods at Cedar Run on October 26 and 27, 2017 to assess compliance with 55 Pa.Code Ch. 2600 relating to Personal Care Homes.
Findings
The facility was found to be in compliance with the applicable regulations during the annual licensing inspection.
Inspection Report — Oct 16, 2017
Renewal
Date: Oct 16, 2017
Visit Reason
The document is a renewal application response and license issuance for The Woods at Cedar Run 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 certificate issuance.
Report Facts
Inspection Report — Aug 10, 2017
Complaint Investigation
Date: Aug 10, 2017
Visit Reason
The inspection was conducted as a complaint investigation at The Woods at Cedar Run facility on August 10, 2017.
Complaint Details
The inspection was triggered by a complaint. The violation involved medication errors related to insulin and glucose administration to Resident 1.
Findings
The facility failed to follow the directions of the prescriber regarding medication administration for Resident 1. Staff administered incorrect doses of Novalog and glucose chew tabs on multiple occasions.
Citations (1)
55 Pa.Code 2600.187(d): The home failed to follow the directions of the prescriber on 8-5-2017 when Staff member A administered 85 units of Novalog to Resident 1 instead of the prescribed amount. Staff members B and C also administered glucose chew tabs incorrectly to Resident 1 on 8-5-2017 and 8-7-2017.
Report Facts
Number of Residents Served: 62
Number of Residents Served in Secured Dementia Care Unit: 15
Number of Current Hospice Residents: 0
Number of Hospice Residents in Past Year: 2
Units of Novalog administered incorrectly: 85
Glucose chew tabs administered incorrectly: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Courtney Bolinsky | Executive Director | Named in relation to the medication administration violation and plan of correction. |
Inspection Report — Apr 20, 2017
Complaint Investigation
Date: Apr 20, 2017
Visit Reason
The inspection was conducted as a complaint investigation and licensing inspection of The Woods at Cedar Run facility on April 20, 2017, related to compliance with 55 Pa.Code Chapter 2600 for Personal Care Homes.
Complaint Details
The visit was complaint-related and substantiated by findings of neglect leading to a resident's fatal injury.
Findings
The investigation found a violation of 55 Pa.Code §2600.42(b) involving neglect of Resident #1, who was found unresponsive and alone after a fall resulting in a fatal subdural hematoma. The facility was cited for neglect by leaving the resident unsupported and alone in the bathroom.
Citations (1)
55 Pa.Code §2600.42(b) - Resident #1 was neglected by being left unsupported and alone in the bathroom, resulting in a fall and fatal subdural hematoma.
Report Facts
Number of Residents Served: 62
Number of Residents Served in Secured Dementia Care Unit: 13
Number of Current Hospice Residents: 7
Number of Hospice Residents in past year: 22
Number of Residents Age 60 or Older: 62
Number of Residents with Mobility Need: 25
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Courtney Bolinsky | Executive Director | Signed violation report and plan of correction |
| Gloria Emick | Human Services Licensing Supervisor | Signed cover letter regarding licensing inspection |
Inspection Report — Nov 2, 2016
Annual Inspection
Date: Nov 2, 2016
Visit Reason
The inspection was conducted as part of the Department of Human Services' annual licensing inspections on November 2, 3, and 4, 2016, including renewal, complaint, and incident reasons.
Findings
The inspection identified violations related to facility maintenance, resident safety equipment, and documentation of resident assessments. Plans of correction were submitted and partially implemented to address these issues.
Citations (5)
55 Pa.Code §2600.88(a) Floors, walls, ceilings, windows, doors, and other surfaces must be clean, in good repair and free of hazards. A ceiling tile over the sink area in the first floor activities room had approximately 1 square foot water stain and water stains were found on ceiling tiles near the patio and in the Administrator's office.
55 Pa.Code §2600.102(d)(1) Toilet and bath areas must have grab bars, hand rails or assist bars. There was no grab bar, hand rail or assist bar within reach of the toilet in Resident Room 218's bathroom.
55 Pa.Code §2600.225(c) The resident shall have additional assessments annually, if condition changes, or upon Department request. Resident 4 was evaluated for hospice services but the home did not complete a new assessment reflecting significant changes. Resident 3's updated medical evaluation was not reflected in a new assessment.
55 Pa.Code §2600.225(a) A resident shall have a written initial assessment documented within 15 days of admission. Resident 2's initial assessment did not document the date it was completed.
55 Pa.Code §2600.227(h) If a resident or designated person is unable or refuses to sign the support plan, a notation of inability or refusal must be documented. Support plans for Residents 1 and 2 were not signed and no notation of refusal or inability was made.
Report Facts
Number of Residents Served: 69
Number of Residents Served in Secured Dementia Care Unit: 15
Number of Current Hospice Residents: 15
Number of Hospice Residents in past year: 25
Residents 60 Years of Age or Older: 69
Residents with a Mobility Need: 24
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Courtney Bolinsky | Legal Entity Representative | Signed multiple plans of correction and violation reports |
| Laura Heemer | Department Representative | Conducted on-site inspections |
| Michael Showers | Department Representative | Conducted on-site inspections |
Notice — Oct 6, 2016
Date: Oct 6, 2016
Visit Reason
The document serves as a renewal notification and license issuance for The Woods at Cedar Run Personal Care Home following receipt of the renewal application dated September 30, 2016.
Findings
The Department confirms issuance of a regular license and advises that an annual onsite inspection will be conducted within the next twelve months to ensure compliance with applicable regulations.
Report Facts
Inspection Report — Nov 9, 2015
Annual Inspection
Date: Nov 9, 2015
Visit Reason
The inspection was conducted as part of the Department of Human Services' annual licensing inspections on November 9 and 10, 2015, for The Woods at Cedar Run personal care home.
Findings
Multiple violations of 55 Pa.Code Chapter 2600 were found, including failure to post licensing inspection summary, failure to report suspected abuse, medication errors, resident dignity issues, privacy violations, inadequate fire drills, and improper storage of medications and food. Plans of correction were submitted for all violations.
Citations (17)
2600.3(c) - The License Inspection Summary from the inspection conducted on 7/30/15 was not posted in the home.
2600.15(a) - The home failed to immediately report suspected abuse of Resident #3 involving financial theft to the local Area Agency on Aging.
2600.16(c) - Resident #4 was not administered prescribed medications on 9/3/15 and 9/4/15 and no incident report was submitted to the Department.
2600.42(c) - Staff members failed to treat Resident #5 with dignity and respect during assistance with wheelchair use.
2600.42(s) - Resident #6 violated privacy rights when allowed to sort mail for other residents.
2600.63(a) - Only one staff person certified in First Aid and CPR was present during the inspection period instead of the required ratio.
2600.103(f) - The freezer temperature in the Secure Dementia Unit was 15 degrees Fahrenheit, exceeding the required maximum of 0 degrees.
2600.105(g)(1) - Lint was found in the lint trap of a dryer in Resident #7's room, posing a fire hazard.
2600.132(a) - No fire drill was conducted in January 2015 as required by regulation.
2600.132(b) - The fire drill record for 10/28/15 did not accurately document the number of residents present during the drill.
2600.171(c) - The home failed to maintain current vehicle registration and insurance documentation for vehicles used to transport residents.
2600.183(d) - Expired medications were found in the medication cart for Resident #2 and Resident #4.
2600.187(a) - Medication administration records for Residents #2 and #4 did not include diagnosis or purpose for prescribed medications.
2600.224(a) - Pre-admission screening forms for Residents #2, #4, and #7 did not contain determinations that the home can meet their service needs.
2600.227(h) - Resident #8's support plan lacked a signature or indication of refusal to sign.
2600.233(b) - The home failed to provide a statement from the manufacturer verifying that the electronic or magnetic locking system will release during a fire alarm.
2600.234(e) - Residents #2 and #9 were not involved in the development and revisions of their support plans.
Report Facts
Number of Residents Served: 69
Resident Support: 69
Total Daily Staff: 177
Waking Staff: 133
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Chris S. Fuchs | Executive Director | Named in multiple plans of correction and violation responses |
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