21 Reports
Inspection Report — Jun 18, 2026
Follow-Up
Date: Jun 18, 2026
Visit Reason
The inspection visit was a partial, unannounced follow-up to verify the implementation of a previously submitted plan of correction related to a complaint or incident.
Complaint Details
The visit was triggered by a complaint or incident. The plan of correction addressed issues related to resident paranoia, aggression, and safety risks. The plan was accepted and fully implemented.
Findings
The submitted plan of correction was determined to be fully implemented. The facility demonstrated compliance with requirements related to support plan revisions and resident care needs.
Citations (1)
Support plan revision requirements under 227c were not initially met. Multiple resident assessments indicated increased fear, aggression, and safety concerns requiring updated support plans and interventions.
Report Facts
Residents Served: 58
Current Residents: 1
Resident Support Staff: 0
Total Daily Staff: 75
Waking Staff: 56
Residents Age 60 or Older: 52
Residents Diagnosed with Mental Illness: 1
Residents with Mobility Need: 17
Inspection Report — May 8, 2026
Follow-Up
Date: May 8, 2026
Visit Reason
The inspection was a partial, unannounced follow-up visit triggered by a complaint and incident to verify the implementation of a previously submitted plan of correction.
Complaint Details
The inspection was complaint-related and incident-based, as indicated by the reason 'Complaint, Incident' and the unannounced partial inspection type.
Findings
The facility was found to have fully implemented the plan of correction related to treatment of residents and following prescriber's orders. Two deficiencies were cited involving staff disrespect toward a resident and failure to administer prescribed medication as ordered.
Citations (2)
42c Treatment of Residents: Staff person A treated a resident without dignity and respect by sitting on the resident's bed, pointing a finger, refusing to assist with getting ready for bed, and leaving the resident upset and crying. Staff person A was suspended and staff received sensitivity training with ongoing monitoring planned.
187d Follow Prescriber's Orders: A resident was prescribed medication to be applied three times daily but missed 59 applications due to the family not supplying the over-the-counter medication. Staff were educated to report unavailable medications and monitoring audits were implemented.
Report Facts
Residents Served: 66
Missed medication applications: 59
Current Hospice Residents: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Erica Drumm | DON LPN and PCHA | Provided staff approach and sensitivity training |
Inspection Report — Apr 9, 2026
Complaint Investigation
Date: Apr 9, 2026
Visit Reason
The inspection was a partial, unannounced complaint and incident investigation conducted to review compliance with regulatory requirements.
Complaint Details
The visit was complaint-related and incident-driven, focusing on unreported incidents and medication administration issues. The plan of correction was accepted and implemented with follow-up dates noted.
Findings
The facility failed to report a serious incident involving a resident, did not notify the prescriber of a medication refusal, failed to administer prescribed medication due to unavailability, and delayed revising a resident's support plan despite behavioral changes.
Citations (4)
16c - The home failed to report an incident where a resident wrapped a garbage bag around their head, convulsed, and overturned chairs to the Department as required within 24 hours.
187c - The facility did not notify the prescribing physician when a resident refused to take a prescribed medication as required.
187d - The home failed to administer prescribed medication to a resident because the medication was not available in the facility.
227c - The resident's support plan was not revised timely despite multiple instances of verbal aggression and unsafe behaviors documented after the initial assessment.
Report Facts
Residents Served: 67
Total Daily Staff: 67
Waking Staff: 50
Incident Reporting Training Completion Date: 2026
Plan of Correction Completion Date: 2026
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN PCHA | Named as responsible for re-educating nursing staff on incident reporting and reviewing incidents daily. | |
| LPN DON | Involved in auditing medication administration records and monitoring compliance. | |
| LPN Charge Nurse | Responsible for medication audits, staff retraining, and monitoring medication availability. | |
| Administrator | Responsible for monitoring incident reports and compliance. |
Inspection Report — Sep 11, 2025
Date: Sep 11, 2025
Visit Reason
The inspection was conducted as a partial, unannounced visit due to an incident at the facility.
Findings
No regulatory citations or deficiencies were identified during the inspection.
Report Facts
Total Daily Staff: 76
Waking Staff: 57
Residents Served: 59
Residents Age 60 or Older: 59
Residents with Intellectual Disability: 1
Residents with Mobility Need: 17
Inspection Report — May 7, 2024
Follow-Up
Date: May 7, 2024
Visit Reason
The inspection was a partial, unannounced follow-up visit conducted on 05/07/2024 to review the implementation of a previously submitted plan of correction related to medication management and administration.
Findings
The facility was found to have fully implemented the submitted plan of correction addressing multiple medication-related deficiencies, including expired medications, mislabeled medications, incomplete medication records, and failure to follow prescriber's orders. Continued compliance is required.
Citations (4)
Expired inhaler was found in medication cart removed from its foil pouch with an open date.
Medications were not labeled correctly according to pharmacy labels, with discrepancies in dosage instructions.
Medication administration records indicated medications were administered on certain dates, but medications were not actually administered or present in the home.
Failure to follow prescriber's orders with multiple medications not administered as prescribed on multiple dates.
Report Facts
Residents Served: 48
Total Daily Staff: 72
Waking Staff: 54
Current Hospice Residents: 3
Inspection Report — Mar 12, 2024
Monitoring
Date: Mar 12, 2024
Visit Reason
The visit was a monitoring inspection conducted by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing on 03/12/2024 and 03/13/2024 to review compliance and verify the implementation of a previously submitted plan of correction.
Findings
The inspection found multiple deficiencies including inadequate staffing during night shifts, improper use of glucometers across residents, incomplete and undated medical evaluations, presence of discontinued medications, medication labeling errors, medication administration record inaccuracies, failure to follow prescriber's orders, incomplete fire drill records, and missing resident medical evaluations in the home. Plans of correction were accepted and implemented with ongoing audits and staff training to ensure compliance.
Citations (10)
Inadequate staffing on night shift with only 2 direct care staff for 54 residents including 14 with mobility needs.
Use of resident #1's glucometer to measure blood glucose levels of other residents, risking cross-contamination.
Fire drill record for 12/12/23 did not include the time of the drill.
Resident #5's medical evaluation was incomplete in the areas of Health Status and Cognitive Functioning.
Resident #6's most recent medical evaluation was undated.
Discontinued medications for resident #7 were still present in the home.
Medication label for resident #7 did not accurately reflect directions.
Medication administration record showed resident #7 was given medication that was not available in the home.
Failure to follow prescriber's orders for residents #1, #4, and #7 including missed medications and blood glucose checks.
Resident #6's 2023 medical evaluation was not available in the home; it was kept electronically in a former system no longer used.
Report Facts
Residents served: 53
Staffing count: 2
Residents with mobility needs: 14
Total daily staff: 65
Waking staff: 49
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff Member A | Named in relation to improper use of glucometer and medication administration training |
Inspection Report — Oct 12, 2023
Follow-Up
Date: Oct 12, 2023
Visit Reason
The inspection visit was conducted as a follow-up to verify the implementation of a previously submitted plan of correction related to renewal, complaint, and incident concerns at the facility.
Findings
The report documents multiple deficiencies related to abuse, staffing, sanitary conditions, fire safety drills, medical evaluations, medication management, assessments, and support plan signatures. The facility has taken corrective actions and implemented plans of correction, with ongoing monitoring and audits scheduled to maintain compliance.
Citations (15)
Staff person made unauthorized charges to a resident's credit card and other abuse-related violations.
Insufficient staffing levels to meet residents' needs and assist with emergency evacuation.
Use of a deceased resident's glucometer for blood glucose measurements, violating sanitary conditions.
Failure to conduct fire drills during sleeping hours every six months.
Only stairwells were used as exit routes during fire drills, not alternate exit routes.
Fire drills were routinely held when additional staff were present and at times of low resident attendance.
Medical evaluation for a resident was not completed within required timeframes.
Medical evaluations for residents lacked required information such as vital signs and professional details.
Annual medical evaluations were not completed timely for a resident.
Current prescriptions were not properly maintained; discontinued medications were still present.
Medication records did not accurately reflect prescribed medications and dosages for a resident.
Failure to follow prescriber's orders due to unavailable medication supplies and inaccurate medication records.
Initial resident assessments were incomplete or missing required diagnoses.
Additional resident assessments were not updated to reflect current diagnoses.
Support plans were not signed by residents or assessors, nor documented reasons for lack of signatures.
Report Facts
Residents served: 54
Staffing hours: 71
Waking staff: 53
Residents with mobility needs: 17
Residents diagnosed with mental illness: 30
Residents aged 60 or older: 54
Inspection Report — May 18, 2023
Date: May 18, 2023
Visit Reason
The inspection was conducted as a licensing inspection triggered by an incident, with an unannounced partial inspection type.
Findings
No regulatory citations or deficiencies were identified during this inspection.
Report Facts
Total Daily Staff: 80
Waking Staff: 60
Residents Served: 58
Residents Age 60 or Older: 57
Residents with Mobility Need: 22
Residents Diagnosed with Intellectual Disability: 1
Inspection Report — Oct 4, 2022
Renewal
Date: Oct 4, 2022
Visit Reason
The inspection was conducted as a renewal visit to review compliance with licensing requirements and verify the implementation of the submitted plan of correction.
Findings
The inspection identified multiple deficiencies including improper placement of carbon monoxide detectors, missing contract signature dates, lack of an annual training plan, unlabeled poisonous materials, missing window screens, outdated food items, overdue fire extinguisher inspections, missed fire drills, incomplete evacuation during fire drills, incomplete first aid kits in transport vehicles, medication labeling and administration documentation errors, incomplete preadmission screening forms, incomplete resident assessments, and incomplete support plans. All deficiencies had plans of correction accepted and were implemented by February 18, 2023.
Citations (15)
Carbon monoxide detectors were installed within 5 feet of fossil fuel burning air handlers, violating placement standards.
Resident-home contract for resident #1 lacked the date the resident signed the contract.
The home did not have an annual training plan for the year 2022.
An unlabeled 2-gallon spray bottle containing a hazardous floor cleaner was found in the housekeeping supply room.
Missing window screens in the northwest and northeast stairwell windows on multiple floors.
Outdated food items including a bag of flour and bottle of vinegar were found in the kitchenette cabinet.
Fire extinguishers in laundry rooms had not been inspected since June 2021.
An unannounced fire drill was not held during January 2022.
Fire drill records showed incomplete evacuation of residents during multiple drills in 2022.
First aid kits in two transport vehicles did not include antiseptic.
Medication label for resident #2 did not match prescribed dosage instructions.
Medication administration record for resident #4 lacked staff initials for certain medication administrations.
Resident #4's preadmission screening form did not include a determination that the resident's needs could be met by the home.
Resident #3's assessment did not indicate the need for an assistive enabler bar on the bed.
Resident #2's support plan did not indicate the outside services being provided.
Report Facts
Residents Served: 63
Total Daily Staff: 75
Waking Staff: 56
Current Hospice Residents: 2
Residents Age 60 or Older: 62
Residents with Mobility Need: 12
Residents with Physical Disability: 3
Fire Drill Resident Counts: 90
Fire Drill Resident Counts: 92
Fire Drill Resident Counts: 95
Fire Drill Resident Counts: 96
Fire Drill Resident Counts: 96
Fire Drill Resident Counts: 101
Fire Drill Resident Counts: 103
Fire Drill Resident Counts: 101
Fire Drill Resident Counts: 106
Fire Drill Evacuated Residents: 55
Fire Drill Evacuated Residents: 57
Fire Drill Evacuated Residents: 59
Fire Drill Evacuated Residents: 59
Fire Drill Evacuated Residents: 59
Fire Drill Evacuated Residents: 61
Fire Drill Evacuated Residents: 62
Fire Drill Evacuated Residents: 60
Fire Drill Evacuated Residents: 61
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Chris Hall | Maintenance Director | Made corrections to carbon monoxide detectors, inspected devices, installed window screens, and completed fire extinguisher audits. |
| Nursing Supervisor | Corrected medication label for resident #2 and educated medication technicians. | |
| Administrator | Completed audits of contracts, training plans, food audits, fire extinguisher checklists, fire drills, and preadmission screens. | |
| Housekeeping Supervisor | Corrected unlabeled poisonous material and trained housekeeping staff on handling. | |
| Medication Techs | Conducted medication cart audits. | |
| LPN | Conducted medication cart audits and educated on medication administration. |
Inspection Report — Jan 12, 2022
Renewal
Date: Jan 12, 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.
Notice — Sep 28, 2021
Date: Sep 28, 2021
Visit Reason
The document serves as a renewal notification and license issuance for the Personal Care Home Regency Suites/Regency at South Shore, confirming receipt of the renewal application and advising of the requirement for an annual onsite inspection within the next twelve months.
Findings
No inspection findings are reported in this document; it is an administrative license renewal notice confirming the facility's compliance and outlining future inspection requirements.
Report Facts
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary, Office of Long-term Living | Signed the renewal notification letter. |
Inspection Report — Jul 19, 2021
Renewal
Date: Jul 19, 2021
Visit Reason
The inspection was a full, unannounced renewal inspection conducted on 07/19/2021 and 07/20/2021 to assess compliance with licensing requirements at Regency Suites/Regency at South Shore.
Findings
The inspection identified multiple deficiencies including unsigned resident contracts, missing emergency telephone numbers by resident phones, improper food storage, incomplete medication records, missing diagnoses in resident assessments, and unsigned support plans. All deficiencies had plans of correction accepted and were reported as implemented.
Citations (7)
Resident-home contract for resident #2 was not signed by the resident.
No emergency telephone numbers including nearest hospital and fire department on or by the telephone in room #125 and #216.
Walk-in freezer in the kitchen contained an opened and unsealed bag of approximately 20 chicken patties.
Resident #3's medication administration record did not indicate dosage for additional insulin units according to sliding scale.
Resident #1's assessment did not include diagnoses of neuropathy of feet, hypertension, and urinary retention as indicated on medical evaluation.
Resident #2's assessment did not include diagnoses of low back pain, toxic encephalopathy, and repeated falls as indicated on medical evaluation.
Resident #4’s support plan was not signed by the resident nor indicated inability or refusal to sign.
Report Facts
Residents Served: 59
Current Residents in Hospice: 2
Residents Diagnosed with Mental Illness: 27
Residents Aged 60 or Older: 58
Residents with Mobility Need: 8
Total Daily Staff: 67
Waking Staff: 50
Personal Care Leases Audited: 59
Leases Needing Resident Signatures: 5
Nurses Auditing Medication Records: 3
Nursing Staff Auditing Support Plans: 3
Notice — Oct 23, 2020
Date: Oct 23, 2020
Visit Reason
The document serves as a renewal notification and license issuance for the Personal Care Home Regency Suites/Regency at South Shore. It also informs 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 — Oct 2, 2019
Renewal
Date: Oct 2, 2019
Visit Reason
The inspection was a full, unannounced renewal inspection conducted to assess compliance with licensing requirements at Regency Suites/Regency at South Shore.
Findings
The inspection identified several violations including an exterior hazard, incomplete fire drill evacuation, medication labeling errors, and incomplete resident assessments. All cited deficiencies had approved plans of correction that were fully implemented by the time of the follow-up review.
Citations (4)
2600.100a: A metal rod approximately 3 feet tall was sticking up from the ground next to a bench in the small exterior courtyard, creating a hazard.
2600.132c: The fire drill on 8/22/19 showed 48 residents present and evacuated, but resident #1 was not evacuated during the drill.
2600.184a.4: Prescription medication labels for residents #2 and #5 did not include the sliding scale for Novolog insulin as prescribed.
2600.225c.2: Resident #4's assessment was not updated to reflect sensory needs after a fire drill revealed she could not hear the alarm.
Report Facts
Residents served: 48
Current Hospice Residents: 2
Resident Mobility Need: 3
Residents Age 60 or Older: 48
Residents with Physical Disability: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Patty Kirk | Community Director | Named as legal entity representative and signer of plans of correction |
Notice — Jul 16, 2019
Date: Jul 16, 2019
Visit Reason
The document is a renewal license certificate and letter confirming receipt of a renewal application to operate a Personal Care Home. It notifies the facility that an annual onsite inspection will be conducted within the next twelve months as required by state regulations.
Findings
No inspection findings are reported in this document. It serves as a license renewal notification and outlines the requirement for a future annual inspection.
Report Facts
Inspection Report — Sep 13, 2018
Annual Inspection
Date: Sep 13, 2018
Visit Reason
The inspection was conducted as a full, unannounced visit for renewal and complaint reasons at Regency Suites Regency at South Shore.
Findings
Multiple violations of 55 Pa. Code Chapter 2600 were found, including missing flu posters, privacy concerns with cameras recording, lack of handrails, lint accumulation in dryers, incomplete medical evaluations, and incorrect medication labeling. Plans of correction were submitted with varying implementation statuses.
Citations (6)
55 Pa.Code 2600.18 - No flu poster was displayed in a public place as required by the Influenza Act, enacted July 2016.
55 Pa.Code 2600.42(s) - Cameras were recording in common areas and resident bedroom hallways, violating residents' privacy rights.
55 Pa.Code 2600.93(a) - No handrail was present at the steps of the outside gazebo located in the garden area.
55 Pa.Code 2600.105(g)(1) - Lint accumulation was found in the lint trap of the dryer in the laundry room across from bedroom #111.
55 Pa.Code 2600.141(a)(1) - Resident #1's medical evaluation lacked assessment of ability to self-administer medications and had incomplete medication addendum.
55 Pa.Code 2600.184(a) - Resident #2's prescription medication label did not match the pharmacy label directions.
Report Facts
Number of Residents Served: 48
Staff Total Daily: 48
Walking Staff: 36
Number of Residents Age 60 or Older: 48
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Patty Kirik | Administrator | Named in multiple plans of correction and signature on violation reports. |
Notice — Jul 26, 2018
Date: Jul 26, 2018
Visit Reason
This document serves as a renewal notification and license issuance for the Personal Care Home facility Regency Suites/Regency at South Shore following the receipt of a renewal application dated July 16, 2018.
Findings
No inspection findings are reported in this document. It confirms the issuance of a regular license and states that the Department will conduct an onsite inspection within the next twelve months as required by regulation.
Inspection Report — Sep 27, 2017
Annual Inspection
Date: Sep 27, 2017
Visit Reason
The inspection was an annual licensing inspection conducted by the Pennsylvania Department of Human Services on September 27, 2017, for Regency Suites Regency at South Shore.
Findings
The inspection identified multiple violations related to resident confidentiality, staff training on fire safety and emergency procedures, building safety hazards, emergency evacuation diagrams, fire drills, fire door maintenance, and medication storage and documentation. Plans of correction were submitted and partially implemented with adequate progress noted.
Citations (8)
Regulation 55 Pa.Code §2600.17: Resident records were not kept confidential as a privacy coding document listing resident names was posted in a hallway.
Regulation 55 Pa.Code 2600.65(a): Staff member hired 1/26/17 did not receive training on evacuation procedures, smoking safety, and emergency telephone use until 2/27/17.
Regulation 55 Pa.Code 2600.65(b): Staff member completed 40 scheduled hours but did not receive training on emergency medical plan and reporting of incidents until 2/27/17.
Regulation 55 Pa.Code 2600.100(a): The exit door from the main dining hall opened onto loose river rocks creating a tipping hazard.
Regulation 55 Pa.Code 2600.123(c): Emergency evacuation diagrams did not accurately display travel routes to exit doors on the 2nd and 3rd floors.
Regulation 55 Pa.Code 2600.132(e): A fire drill was conducted more than 6 months after the previous drill, exceeding the required frequency.
Regulation 55 Pa.Code 2600.132(h): Fire rated double doors outside bedrooms 206, 306, and 323 were catching and not closing completely.
Regulation 55 Pa.Code 2600.185(a): Resident glucometers were not calibrated to the current date and time, and blood glucose readings were not properly documented on medication administration records.
Report Facts
Number of Residents Served: 42
Number of Current Hospice Residents: 1
Number of Hospice Residents in Past Year: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kelly N Gebler | Assistant Community Director | Named as legal entity representative signing plans of correction |
Notice — Jul 17, 2017
Date: Jul 17, 2017
Visit Reason
The document serves as a renewal notification for the license to operate the Personal Care Home Regency Suites/Regency at South Shore, confirming receipt of the renewal application and outlining the requirement for an annual onsite inspection within the next twelve months.
Findings
No inspection findings are reported in this document. It only confirms the issuance of a regular license following the renewal application.
Inspection Report — Sep 27, 2016
Renewal
Date: Sep 27, 2016
Visit Reason
The inspection was conducted as an annual licensing renewal inspection of the Regency Suites/Regency at South Shore facility on September 27, 2016.
Findings
Multiple violations of 55 Pa.Code Chapter 2600 were found, including issues with staff training, sanitary conditions, lighting, food storage, fire extinguisher inspections, menu posting, first aid kit contents, and medication labeling and administration. Plans of correction were implemented for all violations.
Citations (9)
55 Pa.Code §2600.65(f) - Two direct care staff did not receive training on medication self-administration and meeting resident needs during the 2015 training year.
55 Pa.Code §2600.85(a) - Glucometers were shared among multiple residents in August and September 2016, violating sanitary conditions.
55 Pa.Code §2600.101(v)(7) - Resident #1's bedroom did not have a source of light that could be turned on/off from bedside.
55 Pa.Code §2600.103(f) - The ice cream freezer in the gift shop lacked a thermometer to monitor temperature.
55 Pa.Code §2600.131(f) - The fire extinguisher in the dining room kitchen had not been inspected by a fire safety expert since April 2014.
55 Pa.Code §2600.162(c) - Menus posted for 9/12-9/25 did not meet the requirement to be prepared one week in advance and posted conspicuously.
55 Pa.Code §2600.171(b)(5) - The home's vehicle first aid kit did not include a thermometer, scissors, breathing shield, or eye coverings.
55 Pa.Code §2600.184(a) - Prescription medication containers for residents #2 and #3 lacked complete pharmacy labels with required information.
55 Pa.Code §2600.187(a) - Resident #3's medication administration records showed nystatin powder was applied twice per day, contrary to directions for three times per day.
Report Facts
Number of Residents Served: 41
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Patty Kirik | Administrator | Named as legal entity representative signing plans of correction. |
Notice — Jul 18, 2016
Date: Jul 18, 2016
Visit Reason
The document serves as a renewal notification for the facility's license to operate a Personal Care Home and informs that the Department will conduct an onsite inspection within the next twelve months as required by law.
Findings
No inspection findings are reported in this document. It confirms receipt of the renewal application and states that a regular license is being issued.
Report Facts
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