33 Reports
Inspection Report — Jun 11, 2026
Complaint Investigation
Date: Jun 11, 2026
Visit Reason
The inspection was conducted as a complaint investigation with an unannounced partial inspection to review compliance and the submitted plan of correction.
Complaint Details
The inspection was triggered by a complaint and was conducted as a partial, unannounced visit on 06/11/2026. The submitted plan of correction was reviewed and accepted.
Findings
The inspection identified deficiencies including missing ceiling tiles, incomplete annual medical evaluations lacking medical professional identification, and unsigned resident support plans without documented refusal or inability to sign. The facility implemented corrective actions and education to address these issues.
Citations (3)
88a Surfaces: Numerous ceiling tiles were missing in multiple areas including between bedrooms and near the employee learning center.
141b1 Annual Medical Evaluation: A resident's most recent medical evaluation did not include the name or license number of the medical professional who completed it.
227h Support Plan Refuse Sign: A resident's most recent support plan was not signed and did not document if the resident was unable or refused to sign.
Report Facts
Residents Served: 51
Secured Dementia Care Unit Residents Served: 16
Current Hospice Residents: 6
Inspection Report — Feb 23, 2026
Complaint Investigation
Date: Feb 23, 2026
Visit Reason
The inspection was conducted as a complaint and incident investigation at the facility.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Residents Served: 42
Secured Dementia Care Unit Residents Served: 17
Hospice Current Residents: 11
Residents Age 60 or Older: 59
Residents Diagnosed with Mental Illness: 3
Residents Diagnosed with Intellectual Disability: 1
Residents with Mobility Need: 40
Residents with Physical Disability: 1
Inspection Report — Jan 14, 2026
Complaint Investigation
Date: Jan 14, 2026
Visit Reason
The inspection was conducted as a complaint and incident investigation at the facility.
Complaint Details
Inspection was complaint-related and incident-based. No deficiencies or citations were found.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Residents Served: 61
Secured Dementia Care Unit Residents Served: 17
Hospice Current Residents: 11
Notice — Sep 17, 2025
Date: Sep 17, 2025
Visit Reason
This document serves to notify the facility that a waiver request to 55 Pa.Code § 2600.54(a)(2) regarding direct care staff qualifications has been granted due to education obtained outside the United States.
Findings
The waiver allows a specified employee to serve in a direct care position without a U.S. high school diploma, based on credential evaluation equivalency. The Department will review compliance with waiver conditions annually during inspections.
Inspection Report — Sep 17, 2025
Renewal
Date: Sep 17, 2025
Visit Reason
The inspection was conducted as part of a renewal, complaint, and incident review for the facility.
Findings
No regulatory citations or deficiencies were identified during the inspections conducted on 09/17/2025, 09/18/2025, and 09/25/2025.
Report Facts
Resident Support Staff: 60
Total Daily Staff: 159
Waking Staff: 119
Residents Served: 60
Secured Dementia Care Unit Residents Served: 15
Hospice Current Residents: 9
Residents 60 Years or Older: 60
Residents Diagnosed with Mental Illness: 5
Residents Diagnosed with Intellectual Disability: 2
Residents with Mobility Need: 39
Residents with Physical Disability: 1
Inspection Report — May 21, 2025
Date: May 21, 2025
Visit Reason
The inspection was conducted as a licensing inspection triggered by an incident, with an unannounced partial inspection type.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Residents Served: 58
Residents Served in Dementia Care Unit: 11
Current Hospice Residents: 5
Resident Support Staff: 0
Total Daily Staff: 88
Waking Staff: 66
Residents Age 60 or Older: 57
Residents Diagnosed with Mental Illness: 2
Residents Diagnosed with Intellectual Disability: 2
Residents with Mobility Need: 30
Residents with Physical Disability: 1
Notice — Apr 23, 2025
Date: Apr 23, 2025
Visit Reason
This document serves to notify Schenley Gardens that their request to waive the educational qualification requirement for a direct care staff person has been granted under Pennsylvania regulations.
Findings
The waiver is granted with conditions requiring documentation of the staff member's educational equivalency and annual review during inspections to ensure compliance. Noncompliance may result in waiver termination or licensing action.
Inspection Report — Apr 9, 2025
Complaint Investigation
Date: Apr 9, 2025
Visit Reason
The inspection was conducted as a complaint and incident investigation regarding allegations of verbal and physical abuse of a resident by staff, as well as other regulatory compliance concerns.
Complaint Details
The visit was complaint-related involving allegations of verbal and physical abuse reported by a resident against a direct care staff person. The complaint was substantiated with findings of delayed reporting, failure to suspend the alleged perpetrator, mistreatment of the resident, and unsanitary conditions.
Findings
The investigation found multiple violations including delayed reporting of abuse incidents, failure to immediately suspend the alleged perpetrator, mistreatment of a resident, and unsanitary conditions in a resident's bathroom. Plans of correction were accepted and implemented with staff education and monitoring measures.
Citations (4)
Failure to immediately report alleged verbal and physical abuse of a resident to the Department of Aging and Department of Human Services within required timeframes.
Failure to immediately suspend or place on a plan of supervision the staff person involved in the alleged abuse incident.
Resident was treated without dignity and respect, including aggressive physical handling and hostile verbal behavior by staff.
Unsanitary conditions found in a resident's private bathroom including soiled hand towel and dried urine stain on the floor.
Report Facts
Residents Served: 56
Secured Dementia Care Unit Residents Served: 9
Current Hospice Residents: 7
Residents Age 60 or Older: 55
Residents Diagnosed with Mental Illness: 3
Residents Diagnosed with Intellectual Disability: 2
Residents with Mobility Need: 31
Residents with Physical Disability: 1
Inspection Report — Feb 11, 2025
Complaint Investigation
Date: Feb 11, 2025
Visit Reason
The inspection was conducted as a complaint investigation at the facility Schenley Gardens on 02/11/2025.
Complaint Details
The inspection was complaint-related, but no deficiencies or citations were found, indicating no substantiated issues.
Findings
No regulatory citations or deficiencies were identified as a result of this complaint investigation inspection.
Report Facts
Residents Served: 59
Secured Dementia Care Unit Residents Served: 12
Hospice Current Residents: 5
Residents Age 60 or Older: 58
Residents Diagnosed with Mental Illness: 1
Residents Diagnosed with Intellectual Disability: 3
Residents with Mobility Need: 40
Residents with Physical Disability: 1
Inspection Report — Sep 24, 2024
Renewal
Date: Sep 24, 2024
Visit Reason
The inspection was conducted as a renewal, complaint, and incident review of the facility on 09/24/2024, 09/25/2024, and 09/26/2024 to assess compliance with licensing requirements.
Findings
The inspection identified several deficiencies including failure to conduct annual fire safety inspection and drill timely, improper calibration of a resident's glucometer, incomplete medication administration documentation, medication administration errors, discrepancies in resident assessments, and incomplete support plans. Plans of correction were accepted and implemented with proposed completion dates ranging from October 2024 to April 2025.
Citations (6)
The most recent fire safety inspection and fire drill conducted by a fire safety expert was completed on 4/2/24; however, the previous fire safety inspection and fire drill was completed on 3/1/23, indicating a gap in annual inspection.
Resident #1's glucometer was not set to the current date and time.
Resident #2's August 2024 medication administration record (MAR) does not include the initials of staff who administered numerous medications on multiple dates/times.
Resident #2 was prescribed a medication to be taken twice daily but the medication was not administered on the morning of a specified date.
Resident #1's most recent assessment indicates independence with bladder management and toileting, conflicting with physician orders to assist with straight catheterization every 4 hours while awake and as needed for retention.
Resident #1's most recent support plan does not include the description and plan to meet the service need for catheterization, frequency, or responsible person.
Report Facts
Residents Served: 58
Secured Dementia Care Unit Residents Served: 10
Current Hospice Residents: 5
Residents Age 60 or Older: 57
Residents with Mobility Need: 30
Residents Diagnosed with Mental Illness: 4
Residents Diagnosed with Intellectual Disability: 2
Residents with Physical Disability: 1
Total Daily Staff: 88
Waking Staff: 66
Inspection Report — Jan 17, 2024
Follow-Up
Date: Jan 17, 2024
Visit Reason
The inspection was a partial, unannounced follow-up visit triggered by a complaint and incident to review the submitted plan of correction.
Complaint Details
The visit was complaint-related due to an incident involving missing resident property. The home disputes the violation based on inaccurate dates and inconsistent resident reports, but supports audits and education.
Findings
The submitted plan of correction was determined to be fully implemented. The report details a complaint of missing resident property, describes the corrective actions taken including audits for lockboxes, staff abuse in-service training, and ongoing resident interviews to assess abuse concerns.
Citations (1)
A resident reported that 3 decorative gifts were missing from their room, indicating potential neglect or abuse.
Report Facts
Residents Served: 45
Residents in Secured Dementia Care Unit: 6
Hospice Residents: 8
Residents Age 60 or Older: 44
Residents Diagnosed with Mental Illness: 1
Residents with Mobility Need: 17
Inspection Report — Sep 14, 2023
Complaint Investigation
Date: Sep 14, 2023
Visit Reason
The inspection was conducted as a complaint investigation during an unannounced partial licensing inspection on 09/14/2023.
Complaint Details
The inspection was complaint-related, but no deficiencies or regulatory citations were found, indicating no substantiated issues.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Residents Served: 46
Secured Dementia Care Unit Residents Served: 7
Hospice Current Residents: 10
Residents Diagnosed with Mental Illness: 2
Residents with Mobility Need: 16
Residents 60 Years or Older: 46
Residents with Physical Disability: 1
Inspection Report — Mar 22, 2023
Renewal
Date: Mar 22, 2023
Visit Reason
The inspection was conducted as a renewal, complaint, and incident review of the facility on 03/22/2023, 03/23/2023, and 03/24/2023 to determine compliance and implementation of the submitted plan of correction.
Findings
The submitted plan of correction was found to be fully implemented with deficiencies related to dietary needs, support plan revisions, and resident record content, including outdated photographs. All deficiencies had corrective plans accepted and were implemented by late April 2023.
Citations (3)
Resident #1's special dietary needs were not met as dietary staff were unaware of the prescribed mechanical soft texture diet.
Resident #3's support plan had not been revised to include updated care and services as required.
Resident #4 and #5 had photographs in their records that were more than two years old.
Report Facts
Residents Served: 49
Secured Dementia Care Unit Residents Served: 6
Current Hospice Residents: 8
Residents Age 60 or Older: 48
Residents with Mobility Need: 17
Inspection Report — Aug 15, 2022
Routine
Date: Aug 15, 2022
Visit Reason
The inspection was conducted as a routine licensing inspection by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Inspection Report — Apr 21, 2022
Routine
Date: Apr 21, 2022
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 or deficiencies were identified as a result of this inspection.
Inspection Report — Aug 19, 2021
Renewal
Date: Aug 19, 2021
Visit Reason
The inspection was conducted as a renewal and complaint investigation to assess compliance with licensing requirements and address any complaints.
Complaint Details
The inspection included a complaint investigation component as indicated by the reason for the visit being 'Renewal, Complaint'. Specific substantiation status is not stated.
Findings
The inspection identified multiple deficiencies including sanitary conditions, maintenance issues such as ceiling damage and carpet stains, menu change posting failures, medication storage and prescription management issues, and equipment calibration problems. Plans of correction were accepted and implemented with follow-up audits and staff education scheduled.
Citations (7)
Microwave in 4th floor common activity room kitchenette was splattered with a sticky, yellow substance.
Hole in ceiling near stove and missing ceiling tile in 4th floor activity room kitchenette with active rain water dripping causing a puddle on the floor.
Approximately 14 dark brown, sticky and hardened spots on carpet near resident #2's bed in resident #2's bedroom.
Lunch and dinner menu changes were made on numerous occasions but were not posted in a conspicuous and public place in advance of the meals.
A bottle containing one tablet belonging to resident #1 was unlocked, unattended and accessible on top of the medication cart in the 3rd floor hallway.
Medication prescribed for resident #3 was present in the medication cart but was discontinued on 1/6/21.
Resident #4's glucometer was not calibrated to the current date and time.
Report Facts
Residents Served: 49
Residents in Secured Dementia Care Unit: 8
Current Hospice Residents: 3
Total Daily Staff: 65
Waking Staff: 49
Residents 60 Years or Older: 47
Residents Diagnosed with Mental Illness: 3
Residents with Mobility Need: 16
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN Manager of Resident Services | RN Manager | Responsible for providing education on medication regulations, completing audits, and monitoring compliance related to medication storage, prescription currentness, and glucometer calibration. |
| Housekeeping Supervisor | Cleaned microwave and carpet during inspection and responsible for ongoing cleanliness audits. |
Inspection Report — Jun 2, 2021
Follow-Up
Date: Jun 2, 2021
Visit Reason
The inspection visit was conducted as a follow-up to verify the implementation of a previously submitted plan of correction related to medical evaluation and assessment deficiencies.
Findings
The facility was found to have fully implemented the plan of correction addressing deficiencies in resident #1's annual medical evaluation and annual assessment, including completion of missing evaluation areas and updating diagnoses. Ongoing audits and staff training were established to ensure continued compliance.
Citations (2)
Resident #1’s annual medical evaluation dated 4/7/21 was blank in multiple evaluation areas including height, weight, temperature, medical information pertinent to diagnoses, immunizations, allergies, medication administration ability, overall health status, and cognitive functioning.
Resident #1’s annual assessment dated 5/28/21 did not include diagnoses indicated on the annual medical evaluation dated 4/7/21, specifically Bipolar I disorder and hyperlipidemia.
Report Facts
Residents Served: 50
Secured Dementia Care Unit Residents Served: 9
Current Hospice Residents: 3
Residents Age 60 or Older: 48
Residents Diagnosed with Mental Illness: 1
Residents with Mobility Need: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jon Kimberland | Signed letter confirming plan of correction implementation | |
| RN Manager of Resident Services | Responsible for faxing new DME, providing training, and auditing DME and RASP forms | |
| Administrator | Provided training on regulations 141a and 225 to RN Manager of Resident Services |
Inspection Report — Apr 22, 2021
Follow-Up
Date: Apr 22, 2021
Visit Reason
The inspection was conducted as a complaint investigation and included a follow-up review of the submitted plan of correction to verify its implementation.
Complaint Details
The inspection was complaint-related, focusing on the issue of missed meals and the availability of adequate food for residents who miss scheduled meal times. The plan of correction was accepted and verified as implemented.
Findings
The submitted plan of correction related to missed meals was determined to be fully implemented. The facility now stocks a second kitchen with meal substitutes available after the main kitchen closes to ensure residents who miss meals have access to adequate food.
Citations (1)
When a resident misses a meal, food adequate to meet daily nutritional requirements was not available or offered to the resident.
Report Facts
Residents Served: 50
Secured Dementia Care Unit Residents Served: 9
Current Hospice Residents: 2
Residents Age 60 or Older: 48
Residents Diagnosed with Mental Illness: 10
Residents with Mobility Need: 16
Notice — Nov 10, 2020
Date: Nov 10, 2020
Visit Reason
This document serves as a certificate of compliance and notification of license renewal for the Personal Care Home facility Schenley Gardens. It informs the facility that an annual inspection will be conducted within the next twelve months as required by regulation.
Findings
The document does not report inspection findings but confirms issuance of a regular license following the renewal application. It advises that enforcement action will be taken if noncompliance is found during the upcoming inspection.
Report Facts
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Danielle Bryce | Director of Personal Care Services | Recipient of the renewal notification letter. |
| Jamie L. Buchenauer | Deputy Secretary, Office of Long-Term Living | Signer of the renewal notification letter. |
| Robert E. Robinson | Issuing Officer | Signer of the Certificate of Compliance. |
Inspection Report — Oct 19, 2020
Complaint Investigation
Date: Oct 19, 2020
Visit Reason
The inspection was conducted as a complaint investigation at Schenley Gardens on 10/19/2020.
Complaint Details
The inspection was complaint-related, but no deficiencies or citations were found, and follow-up was not required.
Findings
No regulatory citations or deficiencies were identified during the inspection.
Report Facts
Residents Served: 60
Secured Dementia Care Unit Residents Served: 8
Hospice Current Residents: 2
Inspection Report — Sep 22, 2020
Renewal
Date: Sep 22, 2020
Visit Reason
The document summarizes the results of multiple licensing inspections conducted by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing, for the purpose of facility licensing compliance verification.
Findings
No regulatory citations or deficiencies were identified during the inspections conducted on the listed dates.
Inspection Report — Jul 23, 2020
Routine
Date: Jul 23, 2020
Visit Reason
The inspection was conducted as a routine 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 — May 20, 2020
Complaint Investigation
Date: May 20, 2020
Visit Reason
The inspection was conducted as a complaint investigation following an incident involving a resident's privacy and dignity.
Complaint Details
The complaint was substantiated based on the incident where staff A recorded and shared a video of resident #1 in a private bathroom. The staff member was terminated and corrective actions were taken.
Findings
The investigation found that a staff member recorded a video of a resident in a private bathroom without consent, violating the resident's dignity and privacy rights. The staff member was terminated and corrective education and compliance checks were implemented.
Citations (2)
Regulation 2600.42c: A staff member recorded a video of a resident in a private bathroom exposing the lower half of the resident's body. The video was shared with another staff member, violating the resident's dignity and respect.
Regulation 2600.42s: A resident's right to privacy was violated when a staff member recorded and shared a video of the resident in a private bathroom during a vulnerable moment.
Report Facts
Residents Served: 72
Residents Served in Dementia Unit: 9
Residents with Mobility Need: 34
Residents 60 Years or Older: 70
Inspection Report — May 7, 2020
Routine
Date: May 7, 2020
Visit Reason
The Department’s Bureau of Human Services Licensing Representatives conducted an inspection of the facility on May 7 and May 8, 2020 to assess compliance with 55 Pa. Code Ch. 2600 relating to Personal Care Homes.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Janine Wenzig | Human Services Licensing Supervisor | Signed the inspection report letter |
Inspection Report — Apr 7, 2020
Complaint Investigation
Date: Apr 7, 2020
Visit Reason
The inspection was conducted as a complaint investigation following allegations of resident abuse and related incidents at Schenley Gardens.
Complaint Details
The complaint investigation was substantiated based on findings of verbal and physical abuse of resident #1 by staff persons A and B. The incident was not reported timely to the Area Agency on Aging or Department hotline. Staff B was suspended and terminated after investigation.
Findings
The investigation found that a resident was verbally and physically abused by staff, and the incident was not reported timely to the appropriate authorities. Staff involved were counseled or suspended, and mandatory training on elder abuse was assigned to all staff.
Citations (4)
2600.15a: The home failed to immediately report suspected abuse of a resident in the Secured Dementia Care Unit. Staff witnessed verbal and physical abuse but did not report it to the local Area Agency on Aging until days later.
2600.16c: The home failed to report the incident or condition to the Department's personal care home complaint hotline within 24 hours as required by regulation.
2600.42b: A resident was subjected to verbal and physical abuse by staff, including threats of corporal punishment. Staff responsible were suspended and terminated following investigation.
2600.54a: Direct care staff person B did not have a high school diploma, GED diploma, or active Pennsylvania nurse aide registry as required.
Report Facts
Residents Served: 72
Secured Dementia Care Unit Residents Served: 7
Resident Age 60 or Older: 77
Residents with Mobility Need: 36
Resident Supplemental Security Income: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Danielle Bryce | Administrator | Named as Administrator who initiated investigation and signed reports |
| Josh Hoover | Department representative conducting off-site inspection |
Inspection Report — Mar 10, 2020
Follow-Up
Date: Mar 10, 2020
Visit Reason
The visit was a follow-up review conducted on March 10, 2020, to verify that the previously submitted plan of correction was fully implemented following a complaint-related partial inspection.
Complaint Details
The inspection was complaint-related and partial in nature, triggered by a complaint or incident. The plan of correction addressed medication availability and error reporting issues identified during the complaint investigation.
Findings
The plan of correction was determined to be fully implemented. The facility addressed medication availability issues during a resident's leave of absence and improved medication error reporting procedures.
Citations (2)
187d - The home failed to follow the prescriber's directions by not having resident #1's medications available from 1/21/2020 through 1/25/2020, including Xifaxan 550MG, Sertraline 100MG, Trazodone 100MG, and Gabapentin 300MG.
188b - The facility did not immediately report a medication error involving resident #1's missing prescribed medications from 1/21/2020 through 1/25/2020 to the resident, designated person, and prescriber.
Report Facts
Residents Served: 76
Secured Dementia Care Unit Residents Served: 12
Hospice Current Residents: 4
Residents Age 60 or Older: 76
Residents with Mobility Need: 39
Resident Supplemental Security Income: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Danielle Bryce | Administrator | Named in plan of correction approval and medication error reporting |
Inspection Report — Jan 27, 2020
Complaint Investigation
Date: Jan 27, 2020
Visit Reason
The inspection was conducted as a complaint investigation following an incident involving alleged resident abuse and misuse of a resident's debit card.
Complaint Details
The complaint was substantiated. Direct care staff A admitted to using the resident's debit card without permission and was arrested on 3/10/20.
Findings
The investigation found that direct care staff A stole a resident's debit card number and used it for fraudulent purchases. The staff member was terminated and arrested. The facility implemented new lock boxes and mandatory elder abuse training to prevent recurrence.
Citations (1)
42b. A resident was subjected to financial abuse when direct care staff A stole the resident's debit card number and made unauthorized purchases. The staff member was terminated and arrested.
Report Facts
Residents Served: 74
Secured Dementia Care Unit Residents Served: 10
Current Hospice Residents: 3
Unauthorized Purchase Amount: 15.9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Danielle Bryce | Administrator | Administrator who reported the fraudulent debit card charges and signed the plan of correction |
Inspection Report — Dec 11, 2019
Complaint Investigation
Date: Dec 11, 2019
Visit Reason
The inspection was conducted as a complaint investigation following a complaint received by the Pennsylvania Department of Human Services, Bureau of Human Services Licensing.
Complaint Details
The inspection was complaint-driven and the plan of correction was reviewed and approved, with implementation confirmed on 5/15/2020.
Findings
The facility was found to have deficiencies related to medication administration, preadmission screening, and admission support plans. The submitted plan of correction was reviewed and determined to be fully implemented as of May 15, 2020.
Citations (3)
Regulation 187.d: The home did not follow the prescriber's directions for Resident #1's medication, as Diltiazem ER 120MG was not administered on 11/1/2019 and 11/2/2019 due to unavailability.
Regulation 231.c: Resident #2's written cognitive preadmission screening was not completed within 72 hours prior to admission to the secured dementia care unit.
Regulation 234.a: Resident #2's initial admission support plan was not completed within 72 hours of admission to the secured dementia care unit.
Report Facts
Residents Served: 76
Secured Dementia Care Unit Residents Served: 13
Residents Diagnosed with Mental Illness: 1
Residents with Mobility Need: 18
Residents 60 Years or Older: 74
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Danielle Bryce | Administrator | Named in relation to the plan of correction and signature on violation reports. |
Inspection Report — Sep 26, 2019
Complaint Investigation
Date: Sep 26, 2019
Visit Reason
The inspection was conducted as a provisional and incident-related full inspection of Schenley Gardens, a personal care home, on September 26, 27, and 30, 2019, to investigate regulatory compliance and violations.
Complaint Details
The inspection was triggered as a provisional and incident-related investigation. Specific substantiation status is not stated.
Findings
Multiple violations were found including breaches in record confidentiality, compliance with health and safety laws, sanitary conditions, emergency telephone postings, furniture and equipment safety, toilet paper availability, lint removal, evacuation procedures, medication record keeping, and additional resident assessments. Plans of correction were submitted and partially implemented.
Citations (10)
2600.17 - Resident records confidentiality was breached when a privacy coding sheet with a resident's name was left attached to a publicly posted inspection summary.
2600.18 - Carbon monoxide detectors on the 2nd and 3rd floors had batteries labeled over two years old, violating annual replacement requirements.
2600.85a - The private bathroom of resident room #320 was unsanitary with dried fecal matter and blood stains on surfaces and fixtures.
2600.91 - Emergency telephone numbers were not posted on the phone in the secured dementia care unit activity room.
2600.95 - Enabler bars in resident rooms #525 and #222 were unsecured or improperly mounted, creating fall and entrapment risks.
2600.102h - Toilet paper was not provided in the private bathroom of resident room #320.
2600.105g - Lint traps in laundry rooms on the 2nd and 3rd floors had lint buildup covering significant portions, posing fire hazards.
2600.132d - Fire drills conducted in August and September 2019 exceeded the safe evacuation times specified by the home's fire safety expert.
2600.187a - Resident #5's medication record lacked documentation of insulin dosage for multiple dates in September 2019.
2600.225c - Resident #6's most recent additional assessment was outdated, completed on 12/7/17, exceeding the annual requirement.
Report Facts
Residents served: 71
Residents served in secured dementia care unit: 10
Hospice current residents: 4
Residents aged 60 or older: 69
Residents diagnosed with mental illness: 32
Residents with mobility need: 31
Residents with physical disability: 1
Fire drill residents present: 74
Fire drill evacuation time (minutes): 10.42
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Danielle Bryce | Administrator | Named in multiple findings and plans of correction |
| Scott Klein | Department representative present on inspection dates | |
| Deb McConnell | Department representative present on inspection dates | |
| Mike Marini | Department representative present on inspection dates | |
| LPN Manager of Resident Services | LPN Manager of Resident Services | Completed audits and training related to findings |
Inspection Report — Sep 26, 2019
Annual Inspection
Date: Sep 26, 2019
Visit Reason
Annual inspection conducted by the Department’s Bureau of Human Services Licensing on September 26, 27, 30 and October 22, 2019 to assess compliance with 55 Pa. Code Chapter 2600 relating to Personal Care Homes.
Findings
Multiple violations of state regulations were identified including record confidentiality breaches, compliance with health and safety laws, sanitary conditions, emergency telephone postings, furniture and equipment safety, toilet paper availability, lint removal, evacuation procedures, medication record keeping, and resident abuse. Plans of correction were submitted with partial implementation progress noted.
Citations (11)
Record confidentiality was breached when a privacy coding sheet with a resident's name was left attached to a publicly posted inspection summary.
Carbon monoxide detectors on the 2nd and 3rd floor service areas had batteries labeled over two years old and required replacement.
The private bathroom of resident room #320 was unsanitary with dried fecal matter and blood stains on surfaces and fixtures.
Emergency telephone numbers were not posted near the telephone in the secured dementia care unit activity room.
Enabler bars in resident rooms #525 and #222 were unsecured or mounted in a way that posed entrapment and fall risks.
No toilet paper was available in the private bathroom of resident room #320 at the time of inspection.
Lint traps in laundry rooms on the 2nd and 3rd floors had partial layers of lint covering significant portions, posing fire hazards.
Fire drills conducted took longer than the safe evacuation time specified by the home's fire safety expert, with some residents refusing to evacuate.
Resident #5’s medication record did not include the dosage of Humalog insulin administered on specified dates and times.
Resident #6’s most recent assessment was outdated, completed over one year prior to the inspection.
Resident #1 was verbally and physically abused by a staff person who was subsequently terminated after investigation.
Report Facts
Inspection dates: 4
Residents served: 71
Residents served in secured dementia care unit: 10
Current hospice residents: 4
Residents aged 60 or older: 69
Residents diagnosed with mental illness: 32
Residents with mobility need: 31
Residents diagnosed with intellectual disability: 0
Residents with physical disability: 1
Staff on site: 102
Waking staff: 77
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Danielle Bryce | Administrator | Named in multiple findings and plans of correction |
| Scott Klein | Department Representative | Conducted inspection visits |
| Deb McConnell | Department Representative | Conducted inspection visits |
| Mike Marini | Department Representative | Conducted inspection visits |
| Jan Cutter | Department Representative | Conducted inspection visit on October 22, 2019 |
| Staff person B | Resident care aide | Named in resident abuse finding and termination |
Inspection Report — Aug 29, 2019
Routine
Date: Aug 29, 2019
Visit Reason
The Department’s Bureau of Human Services Licensing conducted an inspection of the facility to assess compliance with 55 Pa. Code Ch. 2600 relating to Personal Care Homes.
Findings
No regulatory citations were identified as a result of this inspection.
Inspection Report — Jun 27, 2019
Routine
Date: Jun 27, 2019
Visit Reason
The Department’s Bureau of Human Services Licensing conducted an inspection of the facility to assess compliance with 55 Pa. Code Ch. 2600 relating to Personal Care Homes.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Inspection Report — May 14, 2019
Original Licensing
Date: May 14, 2019
Visit Reason
The inspection was conducted due to a change in the legal entity operating the facility, which is a new legal entity.
Findings
The facility was found to be in substantial compliance with 55 Pa. Code Chapter 2600 regulations, but citations were issued for violations including carbon monoxide detector placement, trash outside the home, stained carpeting, missing emergency phone numbers, disrepair of bathroom sink, lack of operable lamp, combustible materials storage, missing fire extinguisher inspection tag, and incomplete fire drill records.
Citations (9)
2600.18: The facility lacked sufficient carbon monoxide detectors; only one detector was present for two boilers on the G4 level and hallways lacked detectors within required proximity.
2600.85e: Multiple trash items were found on the ground outside the 4th floor high side exit door and six uncovered dumpsters contained trash in the loading dock.
2600.88a: There were large brown and grey stains on carpeting in bedrooms #119 and #216.
2600.91: No emergency phone numbers were posted on or near the phone in bedroom 411.
2600.95: The sink in the bathroom of bedroom #220 was in disrepair and draining slowly due to clogging.
2600.101j7: Resident #1 did not have a source of light that could be turned on or off from the sofa where she sleeps.
2600.125b: A red plastic 5-gallon container of gasoline was unlocked, unattended, and accessible to residents in the loading dock area.
2600.131f: There was no annual inspection tag on the fire extinguisher by the elevator on level G4, making it unclear if the inspection was current.
2600.132f: The home's fire drill record indicated all exits were used for every drill from 7/18/18 through 4/29/19, but the Terrace Level low-side exit was not used for egress during the drill on 5/31/19.
Report Facts
Residents Served: 78
Residents in Dementia Care Unit: 14
Current Hospice Residents: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Danielle Lynn Bryce | Administrator | Signed multiple violation reports and plans of correction. |
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