42 Reports
Inspection Report — Dec 17, 2025
Follow-Up
Date: Dec 17, 2025
Visit Reason
The inspection was a partial, unannounced follow-up visit triggered by a complaint and incident review to verify correction of previous deficiencies.
Complaint Details
The inspection was complaint-related and included incidents. The complaint was substantiated as deficiencies were found and addressed.
Findings
The facility was found to have fully implemented the submitted plan of correction. Deficiencies included failure to report incidents timely, unsigned resident contracts, missing signed resident rights statements, unlocked poisonous materials accessible to residents, obstructed egress due to snow, and missing no objection statements for dementia care admissions.
Citations (6)
16c - The home failed to report a resident incident to the Department within 24 hours as required.
25b - A resident-home contract was not signed by the resident as required.
41e - Resident's record lacked a signed statement acknowledging receipt of resident rights and complaint procedures.
82c - Poisonous materials, including Crest Toothpaste, were unlocked and accessible to residents not assessed as safe to use them.
121a - Snow blocked egress from the dining room to the patio and exit gate, obstructing safe exit routes.
231e - The facility lacked documentation that a resident and their designated person did not object to admission to the secured dementia care unit.
Report Facts
Residents Served: 26
Secured Dementia Care Unit Residents Served: 13
Hospice Current Residents: 4
Resident Support Staff Hours: 39
Waking Staff Hours: 29
Inspection Report — Nov 6, 2025
Follow-Up
Date: Nov 6, 2025
Visit Reason
The inspection was a partial, unannounced follow-up visit triggered by a complaint and incident to verify the submitted plan of correction.
Complaint Details
The inspection was complaint-related and incident-related, but substantiation status is not stated.
Findings
The submitted plan of correction was determined to be fully implemented. One deficiency was identified regarding incomplete orientation of a new staff person on fire safety and emergency preparedness topics.
Citations (1)
Staff Person A did not receive orientation on evacuation procedures, staff duties during fire drills and emergencies, designated meeting place, smoking safety, fire extinguisher use, smoke detectors, fire alarms, and emergency telephone use on their first work day.
Report Facts
Residents Served: 27
Secured Dementia Care Unit Residents Served: 12
Hospice Current Residents: 5
Inspection Report — Oct 23, 2025
Monitoring
Date: Oct 23, 2025
Visit Reason
The visit was a monitoring inspection conducted by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing, to review the facility's compliance and plan of correction implementation.
Findings
The inspection found multiple deficiencies including incomplete training records, unsafe resident personal equipment, unsanitary conditions, missing bedside furniture and lighting, outdated food, incomplete medical evaluations, failure to follow prescriber's orders, missing additional assessments, and unsigned support plans. Plans of correction were accepted and implemented by mid-December 2025.
Citations (10)
65i Training Record: The home's record of direct care staff training does not include content of course, training source, and length of the courses.
81b Resident Personal Equipment: A resident's enabler was not attached to the bedframe, causing a 10 inch gap between the enabler and mattress.
85a Sanitary Conditions: The refrigerator in the Memory care unit had multiple red sticky stains in the interior.
101j5 Bedside Table/Shelf: There was no bedside table or shelf beside a resident's bed in their bedroom.
101j7 Lighting/Operable Lamp: A resident did not have access to a source of light that can be turned on or off at bedside.
103i Outdated Food: There was an unlabeled, undated container of peaches in the memory care refrigerator.
141a Medical Evaluation Information: A resident's medical evaluation did not include medical diagnosis, emergency treatment information, immunization history, or special health or dietary needs.
187d Follow Prescriber's Orders: Multiple residents were not administered prescribed medications as ordered, including tablets, sprays, and insulin doses.
225c Additional Assessment: Several residents' most recent assessments were incomplete or missing.
227g Support Plan Signatures: A resident participated in the development of their support plan but did not sign it.
Report Facts
Residents Served: 28
Secured Dementia Care Unit Residents Served: 13
Resident Age 60 or Older: 28
Residents with Mobility Need: 16
Staff Total Daily: 44
Staff Waking: 33
Inspection Report — Aug 11, 2025
Renewal
Date: Aug 11, 2025
Visit Reason
The inspection was conducted as a renewal visit combined with complaint, provisional, and monitoring reasons to review compliance and the submitted plan of correction.
Findings
Multiple deficiencies were found related to compliance with health and safety laws, staff training, medication management, medical evaluations, resident assessments, and record keeping. All deficiencies had directed plans of correction with completion dates and were implemented by December 16, 2025.
Citations (33)
The posted license to operate a retail food facility had an expired date and a carbon monoxide detector was missing near the boiler room.
No staff certified in obstructed airway techniques and CPR were present during resident care hours.
The administrator completed zero hours of required annual Department-approved training in 2024.
A new staff person did not receive required orientation on fire safety and emergency preparedness topics on their first day.
A staff person did not complete required orientation on resident rights, emergency medical plan, and mandatory abuse reporting within 40 scheduled working hours.
Poisonous materials were unlocked and accessible to residents not assessed as safe to use or avoid poisons.
Sanitary conditions were not maintained, including brown spills in the refrigerator, mold in the ice machine, and feces in a resident shower.
Trash dumpsters outside the home were uncovered, allowing insect and rodent penetration.
Floors, walls, ceilings, and other surfaces were not clean or in good repair, including a missing ceiling tile and peeling paint.
Bathroom cabinet hardware was missing in a resident's room.
Residents lacked bedside tables or shelves in their bedrooms.
Residents did not have operable lamps or lighting sources at bedside that could be turned on or off.
Outdated or unlabeled food was found in the kitchen freezer.
An exit sign was missing on the gate to exit the ground floor rear courtyard.
Medical evaluations for several residents were not completed within 60 days prior to admission or 30 days after admission.
Some medical evaluations lacked required components such as medical diagnosis, allergy information, or general physical examination.
Residents did not have annual medical evaluations completed within the required timeframe.
Menus were not posted in the Memory Care unit as required.
Discontinued medications were found in the medication cart.
Pharmacy labels on medication bubble packs did not match the prescribed dosages on the Medication Administration Records (MAR).
Over-the-counter medications and complementary alternative medicines (CAM) were not labeled with the resident's name.
Prescribed medications were not available in the home for administration as needed.
A glucometer was not labeled with the resident's name and blood sugar readings were inaccurately recorded on the MAR.
The home's medication procedures did not include documentation of receipt of controlled substances and prescription medications.
Medications observed in the medication cart were not listed on the resident's Medication Administration Record (MAR).
Medication administration records did not include the initials of staff who administered medications at the time of administration.
Medication errors occurred due to incorrect documentation of blood sugar readings, resulting in improper insulin dosing.
Staff administered insulin without completing a Department-approved diabetes patient education program within the past 12 months.
Preadmission screening forms did not include a determination that the resident's needs could be met by the home.
Resident assessments were not current or did not reflect significant changes, such as the need for a bedside mobility device.
Support plans were missing required signatures from assessors and residents.
Resident records lacked documentation that the resident and designated person had not objected to admission or transfer to the secured dementia care unit.
Staff refused to provide the original Physician's Orders for Life-Sustaining Treatment (POLST) to accompany a resident during transport.
Report Facts
Residents served: 33
Document — Jul 16, 2025
Date: Jul 16, 2025
Visit Reason
This document is an invoice issued by the Pennsylvania Department of Human Services for fines and additional assessments related to violations of the 55 PA Code § 2600 at Highgate at Paoli Pointe.
Findings
The invoice lists multiple Class II and Class III violations with associated fines totaling $57,805.00, with a total balance due of $77,660.00 including prior balances.
Report Facts
Fine amount: 16775
Fine amount: 8085
Fine amount: 8085
Fine amount: 8085
Fine amount: 16775
Total current charges: 57805
Total balance due: 77660
Balance from last invoice: 19855
Inspection Report — Jun 18, 2025
Complaint Investigation
Date: Jun 18, 2025
Visit Reason
The inspection was a complaint investigation and fine related to regulatory compliance issues at the facility, conducted on June 18, 2025, with a follow-up document submission on August 5, 2025.
Complaint Details
The inspection was complaint-related with a fine. The report notes a complaint and fine as the reason for the inspection on 06/18/2025.
Findings
The inspection identified multiple deficiencies including failure to post the current license, delayed incident reporting, lack of dignity and respect in resident care, incomplete criminal background checks, unqualified direct care staff, inadequate fire safety orientation, incomplete rights and abuse training, failure to maintain clean and safe surfaces, hazardous exterior deck conditions, inadequate bedding, and multiple medication administration record deficiencies including missing diagnosis, missing staff initials, and failure to follow prescriber's orders.
Citations (14)
The home's current license was not posted in a conspicuous and public place.
Incident of water damage and unlocked exit doors in the Memory Care Unit was not reported to the department timely.
Resident was not treated with dignity and respect; toilet paper was kept out of reach.
Several staff members did not have criminal background checks in accordance with regulations.
Direct care staff persons C, D, E, F, and G lacked required educational qualifications.
Staff persons B and G did not receive required fire safety orientation on their first day.
Staff persons B, G, and H did not complete required 40-hour training within the required timeframe.
Staff person I did not receive required annual training in multiple areas including fire safety and resident rights.
Floors, walls, ceilings, windows, doors and other surfaces were not clean, in good repair, and free of hazards; multiple ceiling openings and leaks observed.
The exterior deck was in poor repair with a large dip and broken column, posing a hazard.
Resident 2's bed lacked bedsheets and blankets.
Medication administration records for multiple residents lacked required diagnosis or purpose for prescribed medications.
Medication administration records lacked initials of staff administering medications on multiple dates for several residents.
Resident 2's prescribed treatment with TED stockings was not completed on multiple dates.
Report Facts
Residents Served: 44
Memory Care Unit Residents Served: 18
Hospice Residents: 4
Staff Total Daily: 64
Staff Waking: 48
Inspection Report — May 22, 2025
Complaint Investigation
Date: May 22, 2025
Visit Reason
The inspection was conducted as a complaint investigation and fine, with an unannounced partial inspection on 05/22/2025 and 05/23/2025 to review compliance and plan of correction implementation.
Complaint Details
The inspection was complaint-related and included a fine. The complaint triggered an unannounced partial inspection on 05/22/2025 and 05/23/2025. The submitted plan of correction was reviewed and determined to be fully implemented.
Findings
Multiple deficiencies were found including unlocked medication and records storage accessible to residents, missing lighting, water leaks, missing handrails, missing soap and towels, obstructed egress routes, incomplete medical evaluations, missing menu postings, and medication administration record errors. Plans of correction were accepted and implemented by December 2025.
Citations (17)
Resident records were unlocked and accessible to all residents on the Memory Care Unit medication station.
Poisonous materials including Germ-X hand sanitizer were unlocked and accessible to residents in the Memory Care Unit medication station.
The 1st floor laundry room was missing two fluorescent tube lights.
Multiple leaks were found throughout the building including open ceiling tiles and holes with water leaking into trash cans.
A ceiling tile with a large black stain, a broken hanging lamp in the 2nd floor laundry, and a missing half soap dispenser in the Memory Care Unit TV room were observed.
The exit door ramp leading to dumpsters in the Personal Care Unit was missing a well-secured handrail.
A fire alarm box near the Memory Care Unit's rear exit door was missing its transparent plastic cover, exposing wiring.
A white plastic drainpipe rose approximately 3 to 4 inches from the ground in the center of the rear exterior walkway, creating a hazard.
A resident did not have access to an operable lamp or other source of lighting at bedside.
A soap dispenser on a resident bathroom sink was empty with no soap present.
A resident did not have towels and washcloths in their living space and lacked access to the home's linen supply.
Two sets of dinner tables and a grill obstructed exit doors and egress routes in the main dining room and activity room on the Terrace Level.
A resident's most recent medical evaluation was overdue, with the previous evaluation also incomplete.
Menus for certain weeks were not posted in a public and conspicuous place throughout the home.
A medication syringe safety box half filled with used syringes was unlocked and unattended on the Memory Care Unit medication cart.
Medication administration records for multiple residents lacked initials of staff who administered medications at specified dates and times.
A resident was not assessed annually for the continuing need for the secured dementia care unit as required.
Report Facts
Residents Served: 44
Memory Care Unit Residents Served: 18
Hospice Current Residents: 4
Total Daily Staff: 64
Waking Staff: 48
Inspection Report — May 2, 2025
Monitoring
Date: May 2, 2025
Visit Reason
The visit was a partial, unannounced monitoring inspection conducted by the Pennsylvania Department of Human Services to review compliance with licensing requirements.
Findings
The inspection found multiple deficiencies including an inoperable air-conditioning system, residents being denied access to bedrooms, combustible materials stored near boilers, and lack of recent furnace inspection documentation. All deficiencies had plans of correction submitted and were implemented by December 8, 2025.
Citations (4)
95 - Furniture and Equipment: The air-conditioning system was inoperable with temperatures reaching 84 degrees Fahrenheit. Portable A/C units were rented until repairs were completed.
101i - Access to Bedroom: Residents of the secured dementia care unit were denied access to their bedrooms due to locked doors by staff. Staff training and audits were implemented to prevent recurrence.
125a - Combustible Storage: Multiple cardboard boxes were stored near boilers, posing a fire hazard. Immediate removal and staff education were conducted with ongoing audits.
126a - Furnace Inspection: The last furnace inspection date was missing. Education was provided and the furnace was cleaned on October 16, 2025, with documentation maintained.
Report Facts
Residents served: 30
Residents served in secured dementia care unit: 17
Residents served in general unit: 30
Inspection Report — Apr 30, 2025
Follow-Up
Date: Apr 30, 2025
Visit Reason
The visit was a follow-up review conducted on June 10 and 20, 2025, to assess the implementation of the plan of correction submitted for the April 30, 2025 inspection.
Findings
The facility was found to have multiple deficiencies including incomplete criminal background checks for staff, inadequate staff orientation and training in fire safety, resident rights, and medication administration, failure to provide fans when indoor temperatures exceeded 80°F due to malfunctioning air conditioning, open ceiling tiles with water leaks, insufficient water pressure in some areas, torn window screens, expired medication storage, and incomplete medication administration records. None of the plans of correction submitted by the facility were implemented as of the follow-up date.
Citations (14)
Staff persons lacked completed criminal background checks as required.
Direct care staff did not receive required orientation on fire safety and emergency preparedness on their first day.
Direct care staff did not complete required training within 40 scheduled working hours on resident rights, emergency medical plan, mandatory reporting of abuse and neglect, and reporting of reportable incidents.
Direct care staff provided unsupervised ADL services without documented completion and passing of Department-approved direct care training and competency test.
Direct care staff did not receive the required 12 hours of annual training related to their job duties during training year 2024.
Direct care staff did not receive required annual training topics including medication self-administration, care for residents with dementia, infection control, and safe management techniques during training year 2024.
Direct care staff did not receive training in fire safety completed by a fire safety expert or equivalent during training year 2024.
Fans were not made available to residents when indoor temperature exceeded 80°F due to malfunctioning air conditioning.
Multiple open ceiling tiles and holes with water leaks were observed in various areas of the facility.
Insufficient hot and cold water pressure was noted in the bathroom shower and kitchen sink in room 318.
A torn window screen was observed in the Terrace Level Dining Room.
Expired medication (Latanoprost Ophthalmic eye drops) was found in the medication cart beyond the discard date.
Medication administration records for multiple residents lacked initials of staff who administered medications on various dates.
Direct care staff working in the Secure Dementia Care Unit had zero hours of required dementia care training during the 2024 training year.
Report Facts
Residents Served: 48
Residents Served in Dementia Unit: 15
Current Hospice Residents: 5
Staff Total Daily: 65
Waking Staff: 49
Indoor Temperature: 82
Indoor Temperature: 80.2
Expired Medication Date: Feb 26, 2025
Training Hours: 4.65
Training Hours: 2.9
Inspection Report — Apr 11, 2025
Enforcement
Date: Apr 11, 2025
Visit Reason
The Department of Human Services issued a notice of intent to assess a fine for regulatory violations at the Personal Care Home Highgate at Paoli Pointe due to uncorrected violations of 55 Pa. Code Chapter 2600.
Findings
The facility was found to have multiple uncorrected violations classified as Class II and Class III, resulting in a total fine assessment of $19,855 for the period from 4/12/2025 to 4/30/2025. Fines will continue to accumulate until all violations are fully corrected and verified.
Citations (5)
55 Pa. Code § 2600 65b Class III violation with uncorrected deficiencies resulting in a fine assessment.
55 Pa. Code § 2600 65f Class III violation with uncorrected deficiencies resulting in a fine assessment.
55 Pa. Code § 2600 65g Class III violation with uncorrected deficiencies resulting in a fine assessment.
55 Pa. Code § 2600 88a Class II violation with uncorrected deficiencies resulting in a fine assessment.
55 Pa. Code § 2600 187b Class II violation with uncorrected deficiencies resulting in a fine assessment.
Report Facts
Fine amount: 19855
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Amy Duncan | Enforcement Manager, Human Services Licensing | Contact for questions regarding the invoice |
| Theresa Hartman | Director | Signed the enforcement letter |
Inspection Report — Mar 20, 2025
Follow-Up
Date: Mar 20, 2025
Visit Reason
The inspection was a complaint investigation conducted on March 20, 2025, with a follow-up review on May 8 and June 9, 2025, to verify the implementation of the plan of correction from the March 20, 2025 inspection.
Complaint Details
The inspection was complaint-related, triggered by a complaint with an exit conference on 03/20/2025. The follow-up review found that the plan of correction from the March 20, 2025 inspection was not implemented as required.
Findings
The facility was found to have multiple deficiencies including incomplete criminal background checks, inadequate fire safety orientation, insufficient annual staff training, unsecured poisonous materials accessible to residents, inoperable bathroom ventilation, missing emergency telephone numbers, furniture and equipment hazards, lack of operable bedside lamps, missing soap dispensers, improper medication storage, unavailable prescribed medications, and insufficient dementia care training for staff. The submitted plan of correction was not fully implemented as of the follow-up dates.
Citations (14)
Staff person A did not have a background check requested until after hire.
Staff person A did not receive required fire safety orientation on first day of work.
Direct care staff persons B and C received 0 hours of annual training in 2024.
Direct care staff persons B, C, and D did not receive required annual training topics including medication self-administration and infection control.
Staff persons B, C, and D did not receive required annual training in fire safety, emergency preparedness, resident rights, and other topics.
Poisonous materials were unlocked and accessible to residents in multiple rooms; not all residents assessed capable of safe use.
Bathrooms in rooms 305, 308, and 314 lacked operable windows or ventilation fans.
Emergency telephone numbers were missing on or by telephones in rooms 314 and 325.
Ceiling light in shower of bathroom in room 314 continuously flickers.
Residents 3 and 4 did not have access to operable bedside lamps.
No soap dispenser within reach of bathroom sinks in rooms 305, 306, 308, and 318.
Five loose pills were observed in the medication cart.
PRN medications prescribed to resident 5 were not available in the home.
Direct care staff persons B and C working in the Secure Dementia Care Unit had 0 hours of dementia care training during 2024.
Report Facts
Residents Served: 49
Secured Dementia Care Unit Residents Served: 18
Hospice Residents: 6
Staffing Hours: 68
Waking Staff: 51
Mobility Need Residents: 19
Loose Pills: 5
Inspection Report — Sep 17, 2024
Complaint Investigation
Date: Sep 17, 2024
Visit Reason
The inspection was conducted as a complaint investigation to assess compliance with regulations following allegations and concerns raised about the facility.
Complaint Details
The complaint investigation was triggered by concerns including inadequate staff training, medication management errors, environmental hazards, and failure to maintain proper resident documentation and care standards. The investigation identified multiple repeat violations and ongoing deficiencies.
Findings
Multiple deficiencies were identified including lack of staff certifications, incomplete resident contracts, inadequate staff training, medication management issues, environmental hazards, and failure to maintain proper documentation and resident care standards.
Citations (68)
No staff present in the kitchen were ServSafe certified during specified hours.
Resident-home contracts for residents #2 and #3 were not signed by the residents.
Resident #2 and #3's records did not contain signed statements acknowledging receipt of resident rights and complaint procedures.
Insufficient staff certified in first aid, obstructed airway techniques, and CPR during specified times.
Staff person A did not receive required fire safety orientation on first day of work.
Staff person A did not complete mandatory orientation training within 40 scheduled work hours including resident rights and abuse reporting.
Direct care staff person D did not receive required annual training in medication administration, dementia care, infection control, and other topics during 2023.
Leak and water damage in 'Paoli Local' room and main dining room requiring repair.
Urinal in public men's room covered with plastic and dishwasher inoperable since 09/01/24.
First aid kit in memory care nurse's station missing thermometer, breathing shield, and eye coverings.
Resident in room #213 lacks operable bedside lamp or lighting.
No thermometer in ice cream freezer in main kitchen.
Dishwasher broken since 09/01/24; disposable plates and utensils used regularly.
Written emergency procedures not submitted to local emergency management agency since 06/07/23.
Fire extinguisher in facility bus not inspected since 08/2022.
Fire drill records missing exit route used and number of residents evacuated for multiple drills.
Fire drill during sleeping hours not conducted within required 6 month interval.
Resident #3's initial medical evaluation not completed within required timeframe.
Resident #4's initial medical evaluation missing body positioning and movement stimulation assessment.
Resident #2 and #5's most recent medical evaluations not completed timely or missing.
Expired or discontinued medications not removed timely from medication storage.
Medication storage not compliant with sanitation, temperature, moisture, and light requirements; loose pills found.
Prescription medications not properly labeled with pharmacy labels including resident name and instructions.
Medication administration records missing required documentation including diagnosis, administration times, and staff initials.
Medications not administered according to prescriber's orders including insulin dosing errors.
Residents #2 and #3 not educated on right to refuse medication if medication error suspected.
Resident #2's preadmission screening form completed after admission date.
Resident #2 and #5's assessments not completed annually or as required.
Resident #4's initial support plan for Secure Dementia Care Unit not completed within required timeframe.
Resident #6 not assessed annually for continuing need for Secure Dementia Care Unit.
Resident #6's support plan missing documentation of bed rails use including need, risks, and safety.
Resident #4's cognitive preadmission screening for Secure Dementia Care Unit not completed within 72 hours prior to admission.
Resident #1 and #2's records missing required personal information including religion and eye color.
Resident #2's support plan not signed by resident.
Resident #8's medication cart contained medications for deceased resident.
Resident #8's prescribed Albuterol Sulfate as needed was not available in the home.
Resident #8's Cephalexin medication count discrepancy; one tablet missing.
Resident #10 and #11's glucometers not calibrated to correct date and time; glucometer readings inaccurately documented.
Portable space heater found in use in resident room 15.
Resident #1's record missing photograph no more than 2 years old.
Resident #8's medication administration record missing diagnosis or purpose for medications.
Resident #10's medication administration record missing diagnosis or purpose for medications.
Resident #8's medication administration record missing staff initials for administration of multiple medications.
Resident #12's medication administration record missing staff initials for administration of Acetaminophen on multiple dates.
Resident #10 administered insulin doses inconsistent with sliding scale orders.
Resident #12 administered Acetaminophen twice daily instead of prescribed three times daily.
Resident #6 does not have operable bedside lamp or lighting.
Resident #4's bed linens stained with dried urine; resident #5's bed lacks bed sheets.
Resident #2's bedside mobility device not securely attached to bed.
Poisonous materials accessible to residents in bathroom cabinet in room 310.
Strong odor of urine in room 202.
Trash cans in bathrooms of rooms 202 and 213 uncovered and filled with used incontinence products.
Bathrooms in multiple rooms lack operable windows or ventilation fans; vents covered with lint and inoperable.
Ceiling tiles in stairwell A/3 water stained.
Garbage disposal in main kitchen inoperable over a month; bathroom cabinet door broken in room 310.
First aid kit in Terrace Level medication room missing breathing shield.
Resident rooms 217, 308, and 309 lack bathroom doors to provide privacy.
Designated acting administrator unfamiliar with emergency preparedness plan; emergency procedures not activated.
Written emergency procedures submitted to county emergency management agency for 2024 were illegible and not approved.
No smoke detector within 15 feet of resident room 213.
Medication cart contained medications for deceased resident #7.
Medication carts contained loose pills and damaged bubble packs.
Pill organizer in medication cart lacked resident name and pharmacy label.
Resident 10's glucometer not calibrated; glucometer readings inaccurately documented in MAR.
Resident 11's medication administration record missing initials of administering staff for multiple medications.
Resident 6's preadmission screening form missing determination that home can meet resident's needs.
Resident 2 participated in support plan development but did not sign the support plan.
Resident 1's record missing photograph no more than 2 years old.
Report Facts
Residents Served: 55
Residents Served in Secured Dementia Care Unit: 21
Total Daily Staff: 79
Waking Staff: 59
Staff Certified in First Aid/CPR: 1
Number of Residents with Mobility Need: 24
Number of Residents 60 Years or Older: 55
Number of Residents Diagnosed with Mental Illness: 1
Number of Residents Diagnosed with Intellectual Disability: 1
Inspection Report — Jul 2, 2024
Complaint Investigation
Date: Jul 2, 2024
Visit Reason
The inspection was conducted as a complaint investigation with unannounced partial inspections on 07/02/2024, 07/10/2024, and 07/11/2024 to review compliance and the submitted plan of correction.
Complaint Details
The inspection was complaint-driven as indicated by the reason 'Complaint' and the unannounced partial inspection dates. The report documents multiple violations related to resident abuse reporting, staff qualifications, training deficiencies, safety hazards, and care plan documentation.
Findings
The facility was found to have multiple deficiencies including failure to report suspected resident abuse, unqualified direct care staff, incomplete staff orientation and training, unlocked poisonous materials accessible to residents, unsanitary conditions, maintenance issues such as water damage and leaks, failure to follow prescriber's orders, and missing documentation for support plans and key-locking device instructions. The submitted plan of correction was accepted and fully implemented by 09/12/2024.
Citations (19)
Failure to immediately report suspected resident abuse to the local area agency on aging.
Direct care staff person did not have a high school diploma, GED, or active registry status on the Pennsylvania nurse aide registry.
Direct care staff persons did not receive required orientation on fire safety and emergency preparedness topics on their first day.
Direct care staff person did not complete required training within 40 scheduled work hours including resident rights and mandatory reporting of abuse.
Direct care staff person provided unsupervised ADL services without completing required training and competency testing.
Direct care staff person did not receive at least 12 hours of annual training relating to job duties in 2023.
Direct care staff person did not receive training in medication self-administration, care for residents with dementia, infection control, and other required topics during 2023 training year.
Direct care staff person did not receive training in fire safety, emergency preparedness, resident rights, and other required annual topics during 2023 training year.
Poisonous materials were unlocked and accessible to residents in memory care areas despite not all residents being assessed as capable of safe use.
Unsanitary conditions observed including strong smell of feces and urine in resident rooms and hallways, and lack of hand drying methods.
Multiple ceiling tiles missing with water damage and active leaks throughout the building.
Cooling system malfunction causing leaks and damage to building infrastructure.
Resident lacked access to a closet or wardrobe with clothing racks or shelves in bedroom.
Egress routes blocked by patio chairs in private dining room.
Menus not posted one week in advance as required.
Failure to properly document and follow orders for resident compression sock application and removal.
Support plans for residents lacked required signatures from accessors.
Directions for operating key-locking devices not conspicuously posted near stairwell doors in Secure Dementia Care Unit.
Direct care staff working in Secure Dementia Care Unit lacked required dementia care training hours.
Report Facts
Residents Served: 47
Secured Dementia Care Unit Residents Served: 17
Current Hospice Residents: 5
Direct Care Staff Total Daily: 89
Waking Staff: 67
Deficiency Repeat Violation Dates: 3
Audit Frequency: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff person B | Named in multiple findings related to lack of qualifications, incomplete orientation and training, failure to follow prescriber's orders, and documentation issues | |
| Staff person C | Named in finding related to incomplete fire safety orientation; no longer employed | |
| Staff person D | Named in findings related to lack of annual training and dementia care training | |
| Staff person E | Named in finding related to inadequate handwashing practices | |
| Staff member F | Maintenance Director | Named in findings related to building leaks, ceiling tile damage, and cooling system failure |
| Staff member G | Named in findings related to improper medication administration and failure to follow prescriber's orders for compression socks |
Inspection Report — Apr 18, 2024
Complaint Investigation
Date: Apr 18, 2024
Visit Reason
The inspection was conducted as a complaint and incident investigation during an unannounced partial inspection on 04/18/2024.
Complaint Details
The inspection was complaint-related and incident-related; no deficiencies were found and follow-up was not required.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Residents Served: 48
Secured Dementia Care Unit Residents Served: 16
Hospice Residents: 8
Resident Support Staff: 0
Total Daily Staff: 74
Waking Staff: 56
Residents Age 60 or Older: 48
Residents Diagnosed with Mental Illness: 4
Residents with Mobility Need: 26
Residents with Physical Disability: 1
Inspection Report — Feb 26, 2024
Complaint Investigation
Date: Feb 26, 2024
Visit Reason
The inspection was a partial, unannounced complaint and incident investigation conducted on 02/26/2024 to review allegations and compliance with care standards at the facility.
Complaint Details
The inspection was complaint-related, triggered by allegations of abuse, neglect, and inadequate care. The complaint was substantiated based on findings of resident injury due to insufficient staff assistance and other care deficiencies.
Findings
Multiple deficiencies were identified including abuse due to inadequate staff assistance, insufficient waking hours of care, unsanitary bathroom conditions, missing or broken equipment, incomplete medical evaluations, lack of posted menus, failure to implement positive interventions for resident behaviors, improper use of restraints, incomplete resident assessments and support plans, and missing incident reports in resident records.
Citations (15)
Resident fell and hit head due to only one staff member assisting when two-person assist was required.
Only 68 and 63 of the required 72 direct care hours were provided during waking hours on two occasions.
Sticky substance resembling urine and yellow/brown feces stains found on bathroom floors in resident rooms.
Missing floor tiles at bathroom entry for a resident's room.
Broken lamp cover in a resident's bedroom.
Resident did not have access to an operable lamp or source of lighting at bedside.
Resident medical evaluations lacked medication lists and emergency pertinent medical information.
Menus for current and upcoming week were not posted in a conspicuous place in the memory care unit.
Resident exhibited hitting and biting behaviors without implementation of positive interventions.
Resident was restrained manually causing bruising; no resolution taken to stop this practice.
Resident support plan did not document need for two-person assistance despite significant change in condition.
Resident support plan did not specify dietary needs as indicated in medical evaluation.
Resident support plan did not document how various assessed needs will be met, including behaviors and ADLs.
Resident medical evaluation did not specify behaviors exhibited by resident admitted to secured dementia care unit.
Resident records lacked incident reports and face sheets with required demographic and medical information.
Report Facts
Residents Served: 50
Residents Served in Dementia Unit: 16
Hospice Residents: 4
Waking Staff Hours Required: 72
Waking Staff Hours Provided: 68
Waking Staff Hours Provided: 63
Inspection Report — Nov 27, 2023
Complaint Investigation
Date: Nov 27, 2023
Visit Reason
The inspection was conducted as a complaint and incident investigation with an unannounced partial inspection on 11/27/2023.
Complaint Details
The inspection was complaint-driven, investigating incidents including medication errors, financial exploitation by staff, rough handling of residents, and failure to maintain proper staff records and training. The complaint was substantiated with multiple deficiencies identified.
Findings
The facility was found to have multiple deficiencies including failure to report medication errors and financial exploitation incidents, inadequate staff orientation and training, failure to maintain a current staff contact list, unsanitary conditions, and failure to follow prescriber's medication orders. Plans of correction were accepted and implemented by early 2024.
Citations (10)
Failure to report a medication error to the Department within 24 hours.
Failure to complete, document, or keep a record of an internal investigation of financial exploitation and failure to submit it to the Department.
Failure to inform other residents or their designated persons about financial exploitation incidents.
Resident was financially exploited by a staff member; missing checks and forged signature noted.
Rough handling of a resident in the Secure Dementia Care Unit by agency staff.
Failure to maintain a current list of all staff including agency staff.
New staff member did not receive required orientation on fire safety and emergency preparedness topics.
New staff member did not complete required orientation training within 40 scheduled working hours on resident rights, emergency medical plan, and mandatory reporting of abuse and neglect.
Sanitary conditions not maintained; pungent urine odor detected on fabric chairs in the Terrace area.
Failure to administer prescribed medications due to omission and unavailability.
Report Facts
Residents Served: 46
Residents Served in Dementia Unit: 16
Hospice Residents: 7
Resident Mobility Need: 36
Total Daily Staff: 82
Waking Staff: 62
Notice — Apr 12, 2023
Date: Apr 12, 2023
Visit Reason
Response to a request submitted by the facility to use the Safely You Falls Management Program for fall detection and management for individuals with cognitive impairment.
Findings
The Department reviewed the submitted information and determined that the informed consent process includes voluntary participation, the right to discontinue use of cameras, and notification of residents' rights. The facility's practices satisfy regulatory requirements regarding residents' right to privacy.
Inspection Report — Mar 8, 2023
Complaint Investigation
Date: Mar 8, 2023
Visit Reason
The inspection was conducted as a complaint investigation with a partial, unannounced visit on 03/08/2023.
Complaint Details
The inspection was complaint-related, but no deficiencies were found and the follow-up type was noted as not required.
Findings
No regulatory citations or deficiencies were identified during this inspection.
Report Facts
Resident Support Staff: 107
Waking Staff: 80
Residents Served: 79
Secured Dementia Care Unit Residents Served: 22
Residents Age 60 or Older: 79
Residents Diagnosed with Intellectual Disability: 1
Residents with Mobility Need: 28
Inspection Report — Feb 9, 2023
Complaint Investigation
Date: Feb 9, 2023
Visit Reason
The inspection was conducted as a complaint investigation to review compliance and verify the submitted plan of correction.
Complaint Details
The visit was complaint-related, and the submitted plan of correction was accepted and fully implemented as of 02/27/2023.
Findings
The submitted plan of correction was determined to be fully implemented. The main deficiency involved a resident's annual medical evaluation not being completed within the required 12 months, which has since been addressed with audits and staff in-service training.
Citations (1)
Resident 1's most recent medical evaluation was not completed within the required 12 months.
Report Facts
Residents Served: 79
Memory Care Unit Residents Served: 22
Hospice Current Residents: 6
Residents Age 60 or Older: 79
Residents Diagnosed with Intellectual Disability: 1
Residents with Mobility Need: 6
Inspection Report — Nov 16, 2022
Follow-Up
Date: Nov 16, 2022
Visit Reason
The inspection was a partial, unannounced follow-up visit triggered by an incident to review the submitted plan of correction related to previous deficiencies.
Findings
The facility was found to have fully implemented the submitted plan of correction addressing abuse, additional staffing, positive interventions, additional assessments, and support plan needs. Continued compliance must be maintained.
Citations (5)
A resident was forcefully pushed to the floor by another resident resulting in a bleeding head wound; the home failed to ensure safety on the memory support unit.
Inadequate staffing on the memory support unit allowed an assault to occur; staff person B was left alone caring for 27 residents.
Failure to use positive interventions to modify or eliminate behavior that endangers residents, resulting in a resident being pushed and injured.
Resident #1's assessment did not address significant changes in agitation, falls, intrusive behaviors, and mobility concerns.
Resident #1's support plan did not address agitation for behavioral concerns and frequent falls with mobility concerns.
Report Facts
Residents Served: 64
Memory Support Unit Residents Served: 27
Current Hospice Residents: 4
Residents with Mobility Need: 33
Total Daily Staff: 97
Waking Staff: 73
Inspection Report — Mar 15, 2022
Renewal
Date: Mar 15, 2022
Visit Reason
The inspection was conducted as a renewal and incident review of the facility Highgate at Paoli Pointe on 03/15/2022 through 03/17/2022.
Findings
Multiple deficiencies were identified including failure to post current license inspection summary, delayed refunds after resident deaths, unqualified direct care staff, incomplete staff training, unsafe storage of trash and combustible materials, improper food storage temperatures, medication administration errors, incomplete resident records, and obstructed egress routes. Plans of correction were accepted and implemented with ongoing audits scheduled.
Citations (17)
The home's current license inspection summary and copy of the 2600 regulation book were not posted in a conspicuous and public place.
Refunds for residents who passed away were issued late, beyond the required 30 days after removal of personal belongings.
Direct care staff persons A and B did not have a high school diploma, GED, or active registry status on the Pennsylvania nurse aide registry.
Staff persons A, B, C, D, E, and F did not complete required training within 40 scheduled work hours on resident rights, emergency medical plan, mandatory reporting of abuse and neglect, and reporting of reportable incidents.
Direct care staff persons B and F began providing unsupervised ADL services without completing required training including demonstration of job duties, supervised practice, and passing the competency test.
Broken chair was found outside the trash dumpster, violating trash storage requirements.
No toilet paper was provided for the toilet in a bathroom.
Temperature in the ice cream freezer was 18 degrees Fahrenheit, above the required 0°F for frozen food.
A dented can of Marinara Sauce was found in the main kitchen food storage for daily use.
Two chairs were blocking the egress from the home's exit on the Terrace Unit.
Highly flammable plastic pipe primer and pipe cement were stored inside the boiler room approximately 10 feet from boilers.
Medication carts contained loose pills in drawers and an override error was found on resident 6's MAR record.
Resident 7's medication administration record showed a count discrepancy for Lorazepam 0.5 mg.
Resident 6's glucometer reading did not match the documented medication administration record.
Resident 8 was administered 9 units of Novolog Flex Pen insulin instead of 6 units as per sliding scale order.
Resident 8's preadmission screening form was missing the date when the screening was completed.
Resident 6's record was missing multiple demographic and identifying information; Residents 9 and 10's records lacked incident reports.
Report Facts
Residents Served: 56
Memory Care Residents Served: 25
Hospice Residents: 4
Staff: 89
Waking Staff: 67
Loose Pills: 3
Dented Can Weight: 6.56
Temperature: 18
Medication Count Discrepancy: 1
Insulin Units Administered: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mia Johnson | Executive Director | Named in multiple findings related to education, audits, and plan of correction implementation. |
| Business Office Manager | Named in relation to education on refunds, medication storage, and medication administration. | |
| Human Resources Manager | Named in relation to education on staff qualifications, training, and medication administration. | |
| Maintenance Director | Named in relation to education on trash storage, combustible materials, and unobstructed egress. | |
| Environmental Services Director | Named in relation to education on trash storage and toilet paper provision. | |
| Dining Services Account Manager | Named in relation to education on food storage temperatures and dented cans. | |
| Sales and Marketing Director | Named in relation to education on required demographic information in resident records. |
Inspection Report — Feb 2, 2022
Complaint Investigation
Date: Feb 2, 2022
Visit Reason
The inspection was conducted as a complaint and incident investigation with unannounced partial on-site and off-site reviews between 02/02/2022 and 02/10/2022.
Complaint Details
The visit was complaint-related and incident-driven. The deficiency involved failure to complete required preadmission screening documentation. The plan of correction was accepted and implemented with follow-up dates scheduled.
Findings
The facility was found to have a deficiency related to the failure to complete a required written cognitive preadmission screening for a resident admitted to the Secure Dementia Care Unit within the regulatory timeframe. The submitted plan of correction was fully implemented and compliance was maintained.
Citations (1)
Resident 1 was admitted to the Secure Dementia Care Unit without a completed written cognitive preadmission screening within 72 hours prior to admission as required.
Report Facts
Residents Served: 55
Residents Served in Memory Care Unit: 23
Hospice Residents: 6
Residents Age 60 or Older: 55
Residents with Intellectual Disability: 2
Residents with Mobility Need: 32
Total Daily Staff: 87
Waking Staff: 65
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mia Johnson | Signed letter regarding plan of correction implementation | |
| Memory Support Director | Named in plan of correction for re-education and completion of preadmission screening | |
| Executive Director | Re-educated Memory Support Director on admission criteria and regulatory timeframes |
Inspection Report — Jan 19, 2022
Routine
Date: Jan 19, 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 were identified as a result of this inspection.
Inspection Report — Jan 5, 2022
Date: Jan 5, 2022
Visit Reason
The inspection was a partial, unannounced licensing inspection conducted due to an incident.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Residents Served: 53
Memory Care Residents Served: 25
Total Daily Staff: 86
Waking Staff: 65
Residents Age 60 or Older: 53
Residents with Intellectual Disability: 2
Residents with Mobility Need: 33
Inspection Report — Feb 24, 2021
Renewal
Date: Feb 24, 2021
Visit Reason
The inspection was a renewal visit to assess compliance with licensing requirements and regulations at the facility.
Findings
The inspection identified multiple deficiencies including missing carbon monoxide alarms, unsigned resident contracts, lack of privacy due to missing bathroom doors, incomplete criminal background checks for staff and contractors, sanitation issues, medication administration errors, incomplete resident education on medication refusal rights, and unsecured resident records. Plans of correction were accepted and implemented for all deficiencies.
Citations (12)
Carbon monoxide alarms were not installed as required near fossil-fuel burning devices.
Resident #1's contract was not signed by the resident.
Resident #1's record lacked a signed statement acknowledging receipt of resident rights and complaint procedures.
Resident #1's bathroom lacked a door to provide privacy; a curtain was installed instead.
Staff person A did not have a valid criminal background check; contractors were onsite without background checks.
Sanitary conditions were compromised: clogged sink and improper handling of medication during observation.
Lint accumulation in lint traps of dryers in memory care and commercial laundry rooms.
Medication administration errors for resident #2 including mismatched glucometer readings and missed insulin dose.
Resident #1 was not educated on the right to refuse medication if a medication error is suspected.
Resident #2's preadmission screening form was completed late.
Resident #3's cognitive preadmission screening was completed after admission to the secured dementia care unit.
Records for multiple residents were unlocked, unattended, and accessible in the rehabilitation room.
Report Facts
Residents Served: 48
Residents Served in SCDU: 19
Current Hospice Residents: 6
Residents with Mobility Need: 29
Total Daily Staff: 77
Waking Staff: 58
Notice — Dec 16, 2020
Date: Dec 16, 2020
Visit Reason
The document serves as a renewal notification and license issuance for the Personal Care Home Highgate at Paoli Pointe. It informs the facility that an annual onsite inspection will be conducted within the next twelve months as required by regulation.
Findings
No inspection findings are reported in this document. It confirms the issuance of a regular license following the renewal application.
Report Facts
Inspection Report — Jun 22, 2020
Complaint Investigation
Date: Jun 22, 2020
Visit Reason
The inspection was a complaint investigation conducted through multiple off-site review dates from 06/22/2020 to 07/01/2020 to evaluate compliance with regulations following a complaint.
Complaint Details
The inspection was complaint-related, triggered by a complaint. The plan of correction was accepted and fully implemented as confirmed by follow-up document submissions.
Findings
The facility was found to have deficiencies related to failure to report an incident, failure to follow prescriber's medication orders, and incomplete resident support plans. The submitted plan of correction was accepted and fully implemented by the time of the final document submission.
Citations (3)
16c - Written Incident Report: The home failed to report an incident on 4/22/2020 when Resident #1 was observed outside the home by police.
187d - Follow Prescriber's Orders: Resident #1 was not administered prescribed medications on multiple occasions in April 2020 as ordered.
227a - Support Plan 30 Days: Resident #1's support plan lacked description of service needs, plan to meet needs, frequency, and responsible party.
Report Facts
Residents Served: 39
SDCU Residents Served: 15
Hospice Current Residents: 0
Inspection Report — Feb 7, 2020
Renewal
Date: Feb 7, 2020
Visit Reason
The inspection was conducted as a renewal visit to review compliance with licensing regulations at Highgate at Paoli Pointe.
Findings
The report documents multiple violations related to medication administration, confidentiality breaches, abuse, staffing qualifications, housekeeping, safety, and record keeping. Plans of correction were submitted and fully implemented by August 20, 2020.
Citations (29)
16c - Written Incident Report: Resident #1 missed two days of medication and the home failed to report this to the Department.
17 - Record Confidentiality: The Wellness room was unlocked and accessible to unauthorized persons, and laboratory technicians removed urine without documentation.
18 - Compliance With Laws: The home was unable to locate the annual boiler certificate required by the Department of Labor and Industry.
26a - Quality Management Plan: The home had not conducted a quality management review in over a year.
42b - Abuse: Staff neglected resident #2 by failing to check a soiled colostomy bag and failed to train staff on colostomy care.
51 - Criminal Background Check: Staff person A's criminal background check was not completed until after hire and painters worked without proper checks or supervision.
54a - Direct Care Staff: Direct care staff persons B and C lacked a high school diploma, GED, or active Pennsylvania nurse aide registry status.
60b - Additional Staffing: Medication technician staffing was insufficient for a census of 60 residents, causing late medication administration.
60c - Housekeeping/Maintenance: Housekeeping and maintenance staff were short staffed, resulting in incomplete cleaning and maintenance tasks.
65d - Initial Direct Care Training: Staff person A provided unsupervised ADL services without completing required training and competency testing.
66c - Training Documentation: The home did not maintain documentation of staff training completion including colostomy care.
85a - Sanitary Conditions: Urine odor and stained toilets were observed, and gloves were not readily available during medication audit.
85d - Trash Receptacles: A broken lid was found on a kitchen trash can, violating sanitary requirements.
88a - Surfaces: Floors, carpets, and ceilings in multiple rooms were unclean or stained and not properly maintained.
91 - Telephone Numbers: Emergency telephone numbers for nearest hospital and fire department were not posted in the kitchen.
101i - Access to Bedroom: Rooms 303, 305, and 306 in memory care were locked and inaccessible to residents.
101q - Storage Space: Incontinence products and a walker were improperly stored in resident rooms and showers.
102k - No Common Towel: No paper towels or proper drying means were available in the male bathroom.
103b - Clean/Sanitized Kitchen Surfaces: Refrigerator and freezer surfaces were unclean and sticky.
103c - Food Protected: Ice cream tubs in freezer were uncovered, risking contamination.
103d - Storing Food Off Floor: Emergency water and other items were stored on the floor in the kitchen.
183f - Discontinued Medications: Expired medications were not properly destroyed and medication records were incomplete.
184a - Labeling OTC/CAM: Medication labels lacked resident name, medication name, date, dosage, and prescriber information.
184b - Resident's Meds Labeled: OTC medications were not labeled with the resident's name as required.
185a - Implement Storage Procedures: Insulin and glucometer were improperly stored and not calibrated.
187a - Medication Record: Medication administration records lacked staff initials and names for multiple residents.
187d - Follow Prescriber's Orders: Several medications were not administered as prescribed or were missing documentation.
188b - Medication Error Reporting: Medication errors were not reported to the resident or designated person as required.
252 - Record Content: Resident #10's record did not include a death certificate as required.
Report Facts
Residents Served: 59
Memory Care Residents Served: 23
Hospice Current Residents: 7
Total Daily Staff: 93
Waking Staff: 70
Residents Served Age 60+: 59
Residents with Mental Illness: 2
Residents with Mobility Need: 34
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Miller | Executive Director | Named in multiple plans of correction and findings |
| Mia Johnson | Human Services Licensing Supervisor | Signed report letter |
| Natasha Braswell | On-site Department representative during inspection | |
| Tahesia Thomas | On-site Department representative during inspection |
Inspection Report — Dec 16, 2019
Complaint Investigation
Date: Dec 16, 2019
Visit Reason
The inspection was conducted as a complaint investigation to review compliance at Highgate at Paoli Pointe.
Complaint Details
The inspection was complaint-driven and the plan of correction was fully implemented as of 5/18/20.
Findings
The submitted plan of correction related to medication administration and glucometer use was found to be fully implemented. The facility must maintain continued compliance.
Citations (1)
Regulation 185a requires safe storage and use of medications by trained staff. The glucometer for resident #1 showed an incorrect time and for resident #2 showed an incorrect date and time. Blood sugar checks for resident #1 were completed but not documented properly.
Report Facts
Residents Served: 58
Secured Dementia Care Unit Residents Served: 25
Current Hospice Residents: 8
Total Daily Staff: 100
Waking Staff: 75
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Page | Administrator | Named as facility administrator |
| Dean Gray | Department representative on-site during inspection | |
| Jennifer Miller | Executive Director | Signed plan of correction |
Inspection Report — Oct 21, 2019
Routine
Date: Oct 21, 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.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mia Johnson | Human Services Licensing Supervisor | Signed the inspection report. |
Notice — Aug 21, 2019
Date: Aug 21, 2019
Visit Reason
The document serves as a renewal approval for the Personal Care Home license at Highgate at Paoli Pointe 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 confirms the issuance of a regular license following the renewal application.
Report Facts
Inspection Report — Mar 25, 2019
Routine
Date: Mar 25, 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 — Mar 6, 2019
Annual Inspection
Date: Mar 6, 2019
Visit Reason
The inspection was conducted as an annual licensing inspection of the Personal Care Home facility Highgate at Paoli Pointe to assess compliance with 55 Pa. Code Chapter 2600.
Findings
Multiple violations of the Personal Care Homes regulations were found, including staff qualification issues, uncovered dumpster, unsecured gutter, outdated food items, blocked egress, and missing exit codes on doors. Plans of correction were submitted and partially implemented with adequate progress as of May 3, 2019.
Citations (6)
Regulation 2600.54(a): Direct care staff person A does not have a high school diploma, GED diploma, or active registration status on the Pennsylvania nurse aide registry.
Regulation 2600.85(e): The dumpster outside Stairwell A was not covered to prevent penetration of insects and rodents.
Regulation 2600.100(a): The gutter was not secured to the roof outside of Stairwell A and was hanging down the side of the building.
Regulation 2600.103(j): There were opened packages of pepperoni and hamburgers in the home that were not dated as to when they were opened.
Regulation 2600.121(a): Exercise equipment blocked the egress from the home's therapy gym at 10:00 A.M. on 3/6/19.
Regulation 2600.233(c): Stairwell D and Stairwell E do not have codes posted to exit the outside doors.
Report Facts
Number of Residents Served: 69
Number of Residents Served in Secured Dementia Care Unit: 22
Number of Current Hospice Residents: 8
Number of Hospice Residents in Past Year: 25
Number of Residents Age 60 or Older: 69
Number of Residents with Mental Illness: 2
Number of Residents with Mobility Needs: 48
Inspection Report — Nov 13, 2018
Routine
Date: Nov 13, 2018
Visit Reason
The Department's Bureau of Human Services Licensing conducted an inspection of the facility on November 13, 2018.
Findings
No regulatory violations 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 — Jul 30, 2018
Complaint Investigation
Date: Jul 30, 2018
Visit Reason
The inspection was conducted as an incident investigation related to violations found at the Personal Care Home facility.
Complaint Details
The inspection was triggered by an incident. No substantiation status is explicitly stated.
Findings
The inspection found violations related to sanitary conditions, including a strong smell of urine in the memory care unit and sticky floors creating tripping hazards. Plans of correction involved increased cleaning schedules and housekeeping assignments.
Citations (2)
55 Pa.Code §2600.85(a) - Sanitary conditions shall be maintained. The memory care unit had a strong smell of urine throughout the unit on inspection.
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 kitchen floor in the memory care unit was sticky and soiled, creating a tripping hazard, and the kitchen sink had a thick mineral build up.
Report Facts
Number of Residents Served: 67
Number of Residents Served in Secured Dementia Care Unit: 21
Number of Current Hospice Residents: 6
Number of Hospice Residents in past year: 11
Number of Residents Age 60 or Older: 67
Number of Residents with Mental Illness: 2
Number of Residents with Intellectual Disability: 1
Number of Residents with Mobility Need: 14
Number of Residents with Physical Disability: 0
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Margot Sottesanti | Executive Director | Named as Administrator and legal entity representative in the violation report and plan of correction |
| Natasha Braswell | Department representative conducting the inspection | |
| Jennie Vasquez | Department representative conducting the inspection |
Inspection Report — Jun 22, 2018
Renewal
Date: Jun 22, 2018
Visit Reason
The document is a renewal application and license issuance for the Personal Care Home 'Highgate at Paoli Pointe'. The Department of Human Services will conduct an onsite inspection within the next twelve months as required by regulation.
Findings
This document does not contain inspection findings but confirms the issuance of a regular license for the facility to operate with a maximum capacity of 124 residents and a secure dementia care unit capacity of 30.
Report Facts
Inspection Report — Dec 13, 2017
Renewal
Date: Dec 13, 2017
Visit Reason
The inspection was a renewal visit conducted by the Pennsylvania Department of Human Services Bureau of Human Services Licensing to assess compliance with 55 Pa. Code Chapter 2600 for Personal Care Homes.
Findings
Multiple violations were found including lack of carbon monoxide detector, excessive hot water temperatures, missing emergency numbers by telephones, outdated fire safety inspections, unsecured medications, expired prescriptions, missing activity calendars, and improper posting of locking mechanism instructions. Plans of correction were submitted and partially or fully implemented as of September 10, 2018.
Citations (9)
55 Pa.Code §2600: The boiler room was not equipped with a carbon monoxide detector.
55 Pa.Code §2600: Hot water temperature exceeded 120°F in apartments 103, 102, and 018.
55 Pa.Code §2600: Telephones in rooms 103 and 218 did not have emergency service numbers posted near the phone.
55 Pa.Code §2600: The last fire safety inspection by a fire safety expert was conducted in June 2014, not annually as required.
55 Pa.Code §2600: Prescription and over-the-counter medications were kept unlocked and accessible in residents' bedrooms without proper assessment for self-administration.
55 Pa.Code §2600: A prescribed medication (Betamethasone Valerate 0.1) for resident #1 was expired as of 8-10-17.
55 Pa.Code §2600: Resident #2's Arnica gel medication lacked a pharmacy label.
55 Pa.Code §2600: The home did not have a current weekly activity calendar posted in the memory care unit.
65 Pa.Code §2600: Instructions for operating the home's locking mechanism were not conspicuously posted near the elevator on the third floor of the SDCU.
Report Facts
Number of Residents Served: 47
Number of Residents Served in Secured Dementia Care Unit: 17
Number of Current Hospice Residents: 5
Number of Hospice Residents in Past Year: 24
Resident Age 60 or Older: 47
Residents with Mobility Needs: 23
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Margot Sottesanti | Executive Director | Named as administrator and legal entity representative signing plans of correction |
| Nalasha Braswell | Department Representative | On-site inspector for the inspection visit |
| Sabrina Freeman | Department Representative | On-site inspector for the inspection visit |
Notice — Jul 7, 2017
Date: Jul 7, 2017
Visit Reason
The document serves as a renewal notification and license issuance for the Personal Care Home 'Highgate at Paoli Pointe' following receipt of a renewal application.
Findings
No inspection findings are reported in this document. It confirms the license issuance and states that an onsite annual inspection will be conducted within the next twelve months.
Report Facts
Notice — Nov 29, 2016
Date: Nov 29, 2016
Visit Reason
Response to a waiver request for qualifications of direct care staff persons under 55 Pa.Code § 2600.54(a).
Findings
The waiver request was determined not to be needed as the staff member's education exceeds the criteria for a high school diploma.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tara Pride | Director of Regulatory Implementation | Signed the letter responding to the waiver request. |
Inspection Report — Oct 13, 2016
Renewal
Date: Oct 13, 2016
Visit Reason
The inspection was conducted as part of the annual licensing renewal for the Highgate at Paoli Pointe personal care home.
Findings
Violations related to compliance with 55 Pa.Code Chapter 2600 were found, including failure to provide a prescribed mechanical soft diet to a resident and failure to develop a support plan within 72 hours for a resident admitted to the secured dementia care unit.
Citations (2)
Regulation 55 Pa.Code §2600 2600.161(d) - A resident was prescribed a mechanical soft diet by a physician, but the home did not provide this diet to the resident.
Regulation 55 Pa.Code §2600 2600.234(a) - Resident support plan was not developed within 72 hours of admission to the secured dementia care unit as required.
Report Facts
Number of Residents Served: 56
Number of Residents Served in Secured Dementia Care Unit: 16
Number of Current Hospice Residents: 13
Number of Hospice Residents in Past Year: 20
Total Daily Staff: 84
Walking Staff: 63
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Margot Sottosanti | Executive Director | Signed plan of correction and named as Administrator on page 2 and 3 |
| Debra Liney | Executive Director | Addressee of the cover letter on page 1 |
Notice — Jun 14, 2016
Date: Jun 14, 2016
Visit Reason
The document serves as a renewal notification and license issuance for the Personal Care Home 'Highgate at Paoli Pointe' following receipt of the renewal application dated June 13, 2016.
Findings
No inspection findings are reported in this document. It advises that an onsite inspection will be conducted within the next twelve months as required by regulation.
Report Facts
Document — September 19, 2025
Date: September 19, 2025
Visit Reason
This document is an invoice issued by the Pennsylvania Department of Human Services for a Class II assessment related to regulatory noncompliance at Highgate at Paoli Pointe.
Findings
The invoice indicates a Class II violation under 55 PA Code § 2600 with an additional assessment totaling $3,025.00 for the period from 8/1/2025 to 8/11/2025.
Report Facts
Fine amount: 3025
Total balance due: 93885
Viewing
Loading inspection reports...
