18 Reports
Inspection Report — Mar 30, 2026
Renewal
Date: Mar 30, 2026
Visit Reason
The inspection was conducted as a renewal and complaint investigation to review compliance and verify the submitted plan of correction.
Complaint Details
The inspection included a complaint investigation component, but the report does not explicitly state substantiation status.
Findings
The facility was found to have multiple deficiencies related to carbon monoxide alarms, resident personal equipment safety, medication storage and administration, and adherence to prescriber's orders. The submitted plan of correction was fully implemented and accepted.
Citations (6)
Applicable Health and Safety Laws require carbon monoxide alarms near fossil fuel devices with dated batteries. The facility lacked alarms in the laundry and mechanical rooms and one alarm battery was undated.
Wheelchairs, walkers, prosthetic devices and other resident apparatus must be clean, in good repair and free of hazards. A bedside mobility device was not rigidly attached and posed an entrapment risk.
Prescription and OTC medications and syringes must be kept locked, including those in resident rooms. Multiple medications were found unlocked and accessible to residents not assessed to self-administer.
Medications must be stored in an organized manner under proper conditions. Loose pills were found in medication carts and a blister card was damaged exposing medication.
Medication administration times must be recorded at the time of administration. Resident #2's medications were incorrectly marked as self-administered.
The home shall follow the directions of the prescriber. Resident #8 received incorrect insulin doses or missed doses on multiple occasions, and Resident #6's medication was incorrectly held.
Report Facts
Residents Served: 85
Secured Dementia Care Unit Residents Served: 26
Current Hospice Residents: 7
Inspection Report — Oct 30, 2024
Renewal
Date: Oct 30, 2024
Visit Reason
The inspection was conducted as a renewal and complaint investigation for Keystone Villa at Ephrata.
Complaint Details
The inspection included a complaint investigation related to medication administration errors and other care concerns. The submitted plan of correction was fully implemented and accepted.
Findings
The inspection identified multiple deficiencies including failure to report a medication error, improper use of elevators during a fire drill, failure to implement physical therapy orders, discrepancies in blood sugar documentation, and failure to follow prescriber's medication orders. Corrective actions and trainings were implemented and accepted.
Citations (5)
Failure to report a medication error where a family member administered medication to Resident #1 without reporting to the Department.
Use of elevators during a fire drill, which is prohibited.
Failure to implement physical therapy orders for Resident #1 while away from the home.
Discrepancies between blood sugar readings on residents' glucometers and documented readings on medication administration records.
Medications for Resident #6 were held outside of prescribed parameters according to the MAR.
Report Facts
Residents Served: 88
Secured Dementia Care Unit Residents Served: 25
Current Residents in Hospice: 8
Residents Age 60 or Older: 88
Residents with Mobility Need: 25
Residents with Physical Disability: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Hope O'Pake | Director of Quality Services | Conducted training on incident reporting, fire drill procedures, and medication administration. |
Inspection Report — May 28, 2024
Follow-Up
Date: May 28, 2024
Visit Reason
The inspection was a partial, unannounced follow-up visit to verify the implementation of a previously submitted plan of correction.
Findings
The submitted plan of correction was determined to be fully implemented. Deficiencies related to annual medical evaluations, medication storage, and documentation were addressed with corrective actions and ongoing quality assurance measures.
Citations (4)
A resident did not have a medical evaluation completed at least annually.
Prescription medications, OTC medications, CAM and syringes were not kept locked in the resident's room.
Prescription medications, OTC medications and CAM were not stored in an organized manner under proper conditions as per manufacturer’s instructions.
The home failed to develop and implement procedures for safe storage, access, security, distribution and use of medications and medical equipment by trained staff.
Report Facts
Residents Served: 80
Residents Served in Dementia Unit: 22
Hospice Residents: 11
Total Daily Staff: 104
Waking Staff: 78
Residents with Mobility Need: 24
Residents with Physical Disability: 2
Inspection Report — Jun 27, 2023
Renewal
Date: Jun 27, 2023
Visit Reason
The inspection was conducted as a renewal review of the Keystone Villa at Ephrata facility to assess compliance with licensing requirements.
Findings
The inspection found multiple deficiencies including insufficient first aid/CPR trained staff during a night shift, uncovered trash receptacles in the kitchen, lint accumulation in the dryer lint trap, discrepancies in medication storage and documentation, and failure to follow prescriber's orders regarding blood sugar monitoring and medication administration. The submitted plan of correction was accepted and fully implemented.
Citations (5)
Only one staff person certified in first aid, obstructed airway techniques and CPR was present during a night shift when 74 residents were in the home.
Two uncovered, unattended trash cans were found in the home's main kitchen.
Approximately 2-inch accumulation of lint was found in the lint trap of the home's dryer on the second floor.
Discrepancies were observed with Resident 1 and Resident 2 glucometers and electronic medication administration record (EMAR) blood sugar readings; multiple boxes of insulin Kwik pens were found in Resident 3's bedroom without proper assessment for self-administration.
Resident 2's blood sugar reading was not entered in the EMAR and medication was not administered as prescribed, constituting a repeated violation.
Report Facts
Residents present during night shift: 74
Uncovered trash cans: 2
Lint accumulation: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Genevieve Rich-Turenne | Lead Inspector | Lead inspector for the follow-up inspection on 06/27/2023 |
| Resident Care Director | Named in multiple findings related to staffing, medication documentation, and training | |
| Resident Care Coordinator | Named in multiple findings related to medication documentation and training | |
| Executive Director | Responsible for oversight and ensuring ongoing compliance with corrective actions | |
| Maintenance Director | Involved in correcting uncovered trash can lids and lint removal | |
| Food Service Director | Responsible for ensuring trash cans are covered and staff re-education | |
| Assistant Food Service Director | Assists Food Service Director with trash can compliance |
Inspection Report — Mar 23, 2023
Complaint Investigation
Date: Mar 23, 2023
Visit Reason
The inspection was conducted as a complaint investigation during an unannounced partial licensing inspection of the facility.
Complaint Details
The inspection was complaint-related; however, no deficiencies were found and no follow-up was required.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Residents Served: 81
Secured Dementia Care Unit Residents Served: 25
Hospice Residents: 10
Residents 60 Years or Older: 81
Residents with Mobility Need: 29
Residents with Physical Disability: 2
Total Daily Staff: 110
Waking Staff: 83
Inspection Report — Jan 24, 2023
Complaint Investigation
Date: Jan 24, 2023
Visit Reason
The inspection was conducted as a complaint investigation to review compliance with regulations and assess the facility's response to reported issues.
Complaint Details
The inspection was complaint-driven as indicated by the reason 'Complaint' and was conducted unannounced on 01/24/2023.
Findings
The inspection identified multiple deficiencies including failure to report a resident fall incident, potential entrapment risk due to uncovered enabler bar, sanitary condition issues with urine odors, lack of operable bedside lighting for a resident, stained carpets and damaged walls, lint accumulation in dryer lint trap, incomplete medication records missing diagnoses, and unsecured medication cart with resident information visible.
Citations (8)
Failure to report a resident fall incident to the Department within 24 hours.
Resident had an uncovered enabler bar on bed causing potential entrapment risk.
Strong urine smell in bathroom, hallway, and resident rooms indicating poor sanitary conditions.
Resident did not have access to a source of light that can be turned on/off at bedside.
Carpet stains in multiple Memory Care apartments and plaster damage on wall.
Accumulation of lint in dryer lint trap posing fire hazard risk.
Medication administration records for residents missing diagnoses or purposes for medications.
Medication cart unattended with computer screen unlocked exposing resident medication information.
Report Facts
Residents Served: 81
Memory Care Residents Served: 25
Hospice Current Residents: 10
Waking Staff: 82
Total Daily Staff: 109
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director | Named in multiple findings including incident reporting, sanitary conditions, lint removal, medication record and medication cart security. | |
| Resident Care Director | Named in findings related to incident reporting, medication record updates, and staff education. | |
| Resident Care Coordinator | Named in incident reporting and medication record findings. | |
| Memory Care Director | Named in incident reporting and carpet stain reporting. | |
| Maintenance Director | Named in findings related to covering enabler bar, installing bedside lamp, carpet extraction, and lint removal. | |
| Assistant Maintenance Director | Named in ongoing carpet stain monitoring. |
Inspection Report — Jul 19, 2022
Renewal
Date: Jul 19, 2022
Visit Reason
The inspection was a renewal inspection conducted on 07/19/2022 and 07/20/2022 to review compliance with licensing requirements for Keystone Villa at Ephrata.
Findings
The inspection identified multiple deficiencies including lack of operable lamps at bedside for some residents, combustible materials stored near heat sources, unlocked medications, improper labeling of insulin pens, incomplete medication documentation, missing preadmission screening form dates, and unsigned support plans. All deficiencies had plans of correction implemented by 08/12/2022.
Citations (9)
Residents #1, #2 and #3 did not have a source of light within reach that could be turned on/off at bedside.
A cart containing combustible and flammable materials was stored directly in front of hot water heaters.
Various over the counter (OTC) medications were unlocked, unattended and accessible in Resident #6's bedroom.
Discontinued medications were found in the home's medication cart for Resident #4.
Resident #7's insulin pen labels did not include the initials of the staff member that opened the pen or the date the pen was opened.
Resident #7's medication administration record did not document parameters for holding medication based on systolic blood pressure.
Resident #7's blood pressure was not documented at the time medication was administered as required.
Resident #4's preadmission screening form did not include a date of completion.
Support plans for Resident #1 and Resident #5 and their Power of Attorney lacked dated signatures.
Report Facts
Residents Served: 84
Secured Dementia Care Unit Residents Served: 25
Hospice Residents: 8
Total Daily Staff: 112
Waking Staff: 84
Residents with Mobility Need: 28
Residents with Physical Disability: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Resident Care Coordinator | Named in multiple findings related to medication administration, safety checks, and plan of correction implementation. | |
| Maintenance Director | Named in findings related to installation of lamps and removal of combustible materials. | |
| Assistant Maintenance Director | Named in findings related to removal of combustible materials and ongoing safety checks. | |
| Executive Director | Named in findings related to staff re-education, quality assurance reviews, and oversight of plan of correction. | |
| Resident Care Director | Named in findings related to medication audits, staff training, and documentation compliance. | |
| Memory Care Director | Named in staff re-education and compliance monitoring. | |
| Memory Care 1st shift med tech | Named in removal of improperly labeled insulin pens. |
Inspection Report — Feb 1, 2022
Renewal
Date: Feb 1, 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 — Apr 27, 2021
Renewal
Date: Apr 27, 2021
Visit Reason
The inspection was conducted as a licensing inspection by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing.
Findings
No regulatory citations were identified as a result of this inspection.
Inspection Report — Apr 8, 2021
Renewal
Date: Apr 8, 2021
Visit Reason
The document is related to the renewal of the facility's license to operate as a Personal Care Home, with notification that an onsite inspection will be conducted within the next twelve months as required by state regulations.
Findings
A regular license is being issued in response to the renewal application. The Department will conduct an inspection within the next twelve months and will take enforcement action if noncompliance is found.
Report Facts
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary, Office of Long-term Living | Signed the renewal notification letter |
Inspection Report — Mar 26, 2021
Follow-Up
Date: Mar 26, 2021
Visit Reason
The inspection was conducted as a complaint investigation with an unannounced partial inspection to review the submitted plan of correction and verify compliance.
Complaint Details
The visit was complaint-related, focusing on issues such as bed rails, medical evaluations, medication administration records, and support plan revisions. The complaint was substantiated as deficiencies were identified and subsequently corrected.
Findings
The submitted plan of correction was found to be fully implemented with all steps completed. Deficiencies related to resident safety equipment, medical evaluations, medication records, and support plan revisions were addressed and corrected.
Citations (4)
A bed rail with an opening of approximately 16 inches was attached to the bed of Resident 1, creating a potential risk of serious injury.
The medical evaluation for Resident 2 and Resident 3 did not document the need for bed rails.
Resident 1 and Resident 4's medication administration records did not indicate the diagnosis or purpose for prescribed medications.
Resident 1's, Resident 2's, and Resident 3's support plans were not updated to include diagnoses or needs related to pressure ulcers and bed rails.
Report Facts
Residents Served: 71
Secured Dementia Care Unit Residents Served: 21
Hospice Current Residents: 2
Residents with Mobility Need: 24
Residents 60 Years or Older: 71
Residents with Physical Disability: 2
Inspection Report — Oct 30, 2020
Renewal
Date: Oct 30, 2020
Visit Reason
The inspection was conducted as part of the Pennsylvania Department of Human Services, Bureau of Human Service Licensing's licensing inspections for the facility Keystone Villa at Ephrata.
Findings
No regulatory citations were identified as a result of the inspections conducted on multiple dates in late 2020.
Inspection Report — Sep 2, 2020
Renewal
Date: Sep 2, 2020
Visit Reason
The inspection was conducted as a licensing inspection by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing for Keystone Villa at Ephrata.
Findings
No regulatory citations were identified as a result of the inspection conducted on 09/02/2020, 09/03/2020, and 09/04/2020.
Inspection Report — Jan 22, 2020
Annual Inspection
Date: Jan 22, 2020
Visit Reason
The inspection was conducted as part of the Pennsylvania Department of Human Services Bureau of Human Services Licensing annual licensing inspections.
Findings
The facility was found to be in compliance with 55 Pa. Code Ch. 2600 relating to Personal Care Homes.
Inspection Report — Dec 18, 2019
Renewal
Date: Dec 18, 2019
Visit Reason
The document is a renewal notice and license issuance for Keystone Villa at Ephrata Personal Care Home. It informs the facility of the renewal of their license and the requirement for an annual onsite inspection within the next twelve months.
Findings
No inspection findings are reported in this document. It is a license renewal notification with no deficiencies or compliance issues noted.
Report Facts
Inspection Report — Nov 15, 2019
Complaint Investigation
Date: Nov 15, 2019
Visit Reason
The inspection was conducted as a complaint investigation during an unannounced partial inspection of Keystone Villa at Ephrata on November 15, 2019.
Complaint Details
The inspection was triggered by a complaint. The violation for abuse was a repeat violation from 8/29/19. The plan of correction was approved and implemented as of 1/15/2020.
Findings
The inspection found violations related to abuse and support plan documentation. The facility submitted plans of correction which were reviewed and determined to be fully implemented.
Citations (2)
42b - Abuse: On 9/27/19, Resident 1 struck Resident 2 causing a reddened area and scratch mark. Resident 1 was removed from the shared apartment and appropriate assessments and notifications were completed.
227h - Support Plan Refuse Sign: The support plan for Resident 3 dated 2/8/19 was not signed by the resident nor documented for refusal or inability to sign.
Report Facts
Residents Served: 77
Secured Dementia Care Unit Residents Served: 22
Hospice Current Residents: 1
Resident Age 60 or Older: 76
Residents with Mobility Need: 23
Residents with Physical Disability: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Michele Glover | Administrator | Named in relation to the violation report and plan of correction |
Inspection Report — Aug 29, 2019
Complaint Investigation
Date: Aug 29, 2019
Visit Reason
The inspection was conducted as a complaint investigation related to violations of 55 Pa.Code Ch. 2600 concerning Personal Care Homes at Keystone Villa at Ephrata.
Complaint Details
The inspection was triggered by a complaint. The violations related to abuse and medication administration were substantiated as described in the violation report.
Findings
Violations were found including abuse where a resident had two gold rings stolen by a staff member, and failure to follow prescriber's orders where medication was not administered as prescribed. Plans of correction were submitted and partially implemented as of October 15, 2019.
Citations (2)
42b - Abuse: Resident 1 had two gold rings stolen by Staff Person A. The staff member was arrested and removed from the facility.
187d - Follow Prescriber's Orders: Resident 1 was prescribed Ropinirole 0.25 mg tablets three times daily, but medication was not administered from 7/28/19 to 8/8/19.
Report Facts
Residents Served: 83
Secured Dementia Care Unit Residents Served: 24
Hospice Current Residents: 1
Residents Age 60 or Older: 83
Residents with Mobility Need: 25
Residents with Physical Disability: 3
Inspection Report — Mar 26, 2019
Original Licensing
Date: Mar 26, 2019
Visit Reason
The inspection was conducted due to a change in legal entity and as part of the initial licensing inspection for Keystone Villa at Ephrata.
Findings
The facility was found to be in substantial but not complete compliance with 55 Pa. Code Chapter 2600. Two violations were cited related to hot water temperature exceeding 120°F and incomplete fire drill records documentation.
Citations (2)
Regulation 55 Pa.Code 2600.89(b): Hot water temperature in resident rooms #435 and #336 exceeded 120°F, measuring 124°F and 126°F respectively.
Regulation 55 Pa.Code 2600.132(c): Fire drill records did not document the number of personal care residents in the home or the total number evacuated for drills on 1/11/19, 2/26/19, and 3/21/19.
Report Facts
Number of Residents Served: 80
Number of Residents Served in Secured Dementia Care Unit: 25
Number of Current Hospice Residents: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Michele Glover | Executive Director | Named as Legal Entity Representative and signer of Plan of Correction |
| Laura Heemer | Department Representative conducting inspection |
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