Inspection Reports for
St. Mary Villa for Independent & Retirement Living
701 LANSDALE AVENUE,, LANSDALE, PA, 19446
Back to Facility Profile34 Reports
Inspection Report — Jun 15, 2026
Renewal
Date: Jun 15, 2026
Visit Reason
The inspection was conducted as a renewal review of the facility's compliance with licensing requirements.
Findings
The facility had multiple deficiencies related to contract signatures, visitation rights, staff training, medication management, sanitary conditions, lighting, furniture and equipment, egress routes, and documentation. Plans of correction were accepted and implemented for all findings.
Citations (27)
25b Contract Signatures: Resident-home contracts for residents #1 and #2 were not signed by the residents.
42r Visitation: Resident #2 was prevented from receiving visitors due to a sign posted at the nursing station.
65b Rights/Abuse 40 Hours: Staff person A did not complete required training in emergency medical plan and reporting of incidents.
65f Training Topics: Direct care staff person B did not receive training in care for residents with mental illness during 2025.
82b Poisonous Material Storage: A bottle of Clorox Clean-up spray was stored next to food items in the activities area.
85a Sanitary Conditions: Resident #3's glucometer was used on resident #4; unlabeled towel found in shared room; blood or food stains in Secure Dementia Care Unit.
87 Lighting: Shared bathroom between rooms 73 and 75 was dim due to a missing light bulb.
95 Furniture and Equipment: Missing handles on dresser and bedside table; detached door handle; cluttered storage area; alarm sounding for hours.
101j5 Bedside Table/Shelf: No bedside table or shelf by bed closest to door in room 73.
101j7 Lighting/Operable Lamp: Residents #7 and #8 lacked operable bedside lamps.
102i Soap Dispenser: Soap dispensers in bathrooms of rooms 72 and 74 were inoperable.
121a Unobstructed Egress: Egress doors had locks releasing after 15 seconds but lacked signage; courtyard gates would not unlock; trash cans blocked kitchen egress.
181c Self-administration Assessment: Resident #9 self-administers medications but medical evaluation indicates inability to self-administer.
181d Storing Medication: Resident #9 stored medications in unlocked bedroom.
181f Record of Medication: Resident #9's medication record did not include current list of medications.
183b Meds and Syringes Locked: Medications accessible and unlocked in rooms of residents assessed unable to self-administer.
183d Prescription Current: Resident #11 had medications without current or discontinued orders.
183e Storing Medications: Loose pill found in medication cart; damaged medication packaging exposing dose.
184a Resident's Meds Labeled: Pharmacy labels for resident #6's medications lacked dates, instructions, and prescriber information.
185a Implement Storage Procedures: Resident #13's blood glucose reading was inaccurately recorded; narcotic log for resident #14 was incomplete and illegible.
187b Date/Time of Medication Admin.: Resident #11's MAR incorrectly documented administration of Loratadine instead of Cetirizine.
187d Follow Prescriber's Orders: Resident #11 was given Loratadine instead of prescribed Cetirizine due to medication unavailability.
231b Medical Evaluation: Resident #1's medical evaluation lacked diagnosis of dementia and need for secured dementia care unit.
231e No Objection Statement: No documentation that resident #1 and designated person consented to admission to secured dementia care unit.
236 Staff Training: Direct care staff person B had only 1 hour of required 6-hour dementia care training in 2025.
251b Record Entries Legible: Narcotic log for resident #14 was illegible and incomprehensible with obscured information.
251c Standardized Forms: Medical evaluations for all residents were documented on outdated forms instead of current standardized forms.
Report Facts
Residents Served: 66
Residents Served in Secured Dementia Care Unit: 18
Hospice Current Residents: 7
Residents Diagnosed with Mental Illness: 30
Residents with Mobility Need: 27
Residents Age 60 or Older: 65
Notice — Oct 14, 2025
Date: Oct 14, 2025
Visit Reason
The document serves to notify the facility that a waiver request to waive the high school diploma or equivalent requirement for a direct care staff person has been granted.
Findings
The waiver is granted under specific conditions including documentation of education equivalency and annual review during the facility's annual inspection to ensure compliance.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Theresa Hartman | Bureau Director, Human Services Licensing | Signed the waiver approval letter. |
Notice — Oct 8, 2025
Date: Oct 8, 2025
Visit Reason
The document serves to notify St. Mary Villa for Independent & Retirement Living that their request to waive the education qualification requirement for direct care staff has been granted under specified conditions.
Findings
The waiver is granted based on submitted documentation showing equivalent education to a U.S. high school diploma, with conditions for maintaining documentation and annual review during inspections.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Theresa Hartman | Bureau Director, Human Services Licensing | Signed the waiver approval letter. |
Notice — Oct 1, 2025
Date: Oct 1, 2025
Visit Reason
The document serves to notify the facility that a waiver request for direct care staff qualification requirements has been granted under 55 Pa.Code § 2600.19 due to education obtained outside the United States.
Findings
The waiver is granted with conditions including documentation of education equivalency and annual review during inspections to ensure compliance. Failure to comply may result in waiver termination or other licensing actions.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Theresa Hartman | Bureau Director, Human Services Licensing | Signed the waiver approval letter. |
Notice — Sep 5, 2025
Date: Sep 5, 2025
Visit Reason
The document serves to notify the facility that a waiver request to Pennsylvania Code § 2600.54(a)(2) regarding direct care staff qualifications has been granted.
Findings
The waiver allows a specific employee to serve in a direct care position based on credential evaluation of education obtained outside the United States, subject to documentation and annual review during inspections.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Theresa Hartman | Bureau Director, Human Services Licensing | Signed the waiver approval letter. |
Inspection Report — Aug 21, 2025
Monitoring
Date: Aug 21, 2025
Visit Reason
The visit was an unannounced partial inspection conducted as a monitoring review of the facility to verify compliance and implementation of the submitted plan of correction.
Findings
The inspection found multiple deficiencies including failure to timely report an incident, unqualified direct care staff, improper storage and locking of poisonous materials, obstructed emergency egress, medication administration errors, and incomplete preadmission screening forms. The submitted plan of correction was determined to be fully implemented as of the follow-up review.
Citations (7)
Failure to report an incident of alleged abuse to the Department within 24 hours.
Direct care staff person did not have a high school diploma, GED, or active registry status on the Pennsylvania nurse aide registry.
Poisonous materials were stored in unlabeled, non-original containers on a utility cart.
Poisonous materials were not kept locked and inaccessible to residents; lock on utility cart was broken.
Emergency exit door was obstructed by a stop sign that could deter exit in an emergency.
Medication errors including medications without current orders, medications not available in the home, and medication administration not properly documented.
Preadmission screening form did not include a determination that the resident's needs could be met by the services provided.
Report Facts
Residents Served: 61
Secured Dementia Care Unit Residents Served: 20
Current Hospice Residents: 4
Residents with Mobility Need: 27
Total Daily Staff: 88
Waking Staff: 66
Inspection Report — Sep 24, 2024
Monitoring
Date: Sep 24, 2024
Visit Reason
The inspection was a partial, unannounced monitoring visit conducted to review the facility's compliance and implementation of the submitted plan of correction.
Findings
The inspection identified deficiencies related to unsafe storage of poisonous materials, smoking area violations, and improper storage of medications. All deficiencies were addressed with plans of correction accepted and implemented by 10/29/2024.
Citations (3)
Poisonous materials were found unlocked and accessible in a resident's bedside table, with residents not assessed as capable of safely using or avoiding poisons.
Eighteen cigarette butts were found outside on a patio area that is not a designated smoking area, violating smoking area guidelines.
Medication blister packs were observed with punctured foil exposing medication to contamination or improper sanitation.
Report Facts
Residents Served: 54
Secured Dementia Care Unit Residents Served: 14
Resident with Mental Illness: 6
Resident with Mobility Need: 14
Resident Age 60 or Older: 54
Resident with Supplemental Security Income: 0
Resident with Intellectual Disability: 0
Resident with Physical Disability: 0
Inspection Report — Aug 29, 2024
Complaint Investigation
Date: Aug 29, 2024
Visit Reason
The inspection was conducted as a complaint investigation with an unannounced partial inspection on 08/29/2024 to review compliance and follow up on submitted plans of correction.
Complaint Details
The inspection was complaint-driven, triggered by allegations of suspected resident abuse that was not reported timely by staff. The complaint was substantiated with findings of delayed reporting and failure to notify the Department.
Findings
The inspection identified multiple deficiencies including failure to immediately report suspected resident abuse, incomplete staff training in required topics, inaccurate medical evaluation documentation, and missing resident signatures on support plans. Plans of correction were accepted and implemented by 11/19/2024.
Citations (6)
Failure to immediately report suspected abuse of a resident according to the Older Adult Protective Services Act.
Failure to report the incident or condition to the Department’s personal care home regional office within 24 hours as required.
Direct care staff person did not receive required annual training in medication self-administration, dementia care, infection control, and care for residents with mental illness or intellectual disability.
Direct care staff person did not receive required annual training in fire safety and emergency preparedness.
Medical evaluation documentation was inaccurate; 'none' was selected under Special Health or Dietary Needs when it should have indicated secured dementia care and diagnosis.
Resident participated in the development of their support plan but did not sign the support plan.
Report Facts
Residents Served: 58
Secured Dementia Care Unit Residents Served: 18
Current Hospice Residents: 2
Residents Age 60 or Older: 57
Residents with Mobility Need: 51
Residents Diagnosed with Mental Illness: 1
Residents Diagnosed with Intellectual Disability: 1
Inspection Report — Jul 10, 2024
Renewal
Date: Jul 10, 2024
Visit Reason
The inspection was conducted as a renewal visit to review compliance with licensing requirements at St. Mary Villa for Independent & Retirement Living.
Findings
The inspection identified multiple deficiencies including issues with incident reporting, compliance with health and safety laws, contract signatures, staff training, fire safety drills, medication management, and documentation. Plans of correction were accepted and implemented with ongoing audits and education.
Citations (31)
Failure to report an incident involving a resident found on the floor within 24 hours.
Boiler failed inspection and was not fully repaired or certified.
Resident-home contracts not properly signed by residents or home.
Resident records lacked signed statements acknowledging receipt of resident rights and complaint procedures.
Insufficient number of staff certified in CPR/First Aid present during shifts with census above 50.
New staff did not receive complete orientation on fire safety and emergency preparedness topics.
Direct care staff did not complete required training on resident rights, emergency medical plan, and abuse reporting within 40 hours.
Direct care staff provided unsupervised ADL services without completing required training and competency testing.
Direct care staff did not receive required annual training hours or training on specific topics including medication administration and care for residents with dementia.
Staff training plan did not include required training courses for each staff person.
Unsafe bed rail installation creating hazardous conditions for a resident.
Poisonous materials not stored in original labeled containers or kept locked and inaccessible to residents.
Unsanitary conditions including rust stains, debris, and improperly stored personal belongings.
Furniture and equipment not in good repair, including leaking washer and broken towel bar.
Obstructions such as tree branches found in emergency exit walkways.
Failure to provide proof of annual submission of emergency procedures to local emergency management agency.
Fire drills not conducted properly or documented accurately, including missing evacuation times, exit routes, and resident evacuation counts.
Residents not evacuated to designated meeting places during fire drills.
Residents did not receive annual medical evaluations timely.
Medications stored improperly with punctured blister packs exposing medication to contamination.
Medication labels did not match physician orders.
Discrepancies in narcotics counts and documentation of medication administration.
Medications not administered as prescribed, with no explanation provided.
Staff person failed to complete required medication administration training and competency testing.
Residents not educated on their right to refuse medication if they believe there is an error.
Preadmission screening forms and support plans not signed by required personnel.
No documentation that residents or their designated persons objected to admission to secured dementia care unit.
No written approval from authorities for magnetic locks on secured dementia care unit exit doors.
No manufacturer statement verifying magnetic locks will release upon fire alarm activation, power failure, or lock override.
Admission support plan not completed within required 72 hours of admission to secured dementia care unit.
Direct care staff in secured dementia care unit lacked required dementia care training hours.
Report Facts
Residents served: 56
Residents served in secured dementia care unit: 16
Current hospice residents: 2
Residents with mobility need: 16
Residents aged 60 or older: 56
Residents diagnosed with mental illness: 6
Staff total daily: 72
Staff waking: 54
Deficiency count: 40
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff person A | Named in findings related to fire safety orientation and abuse reporting training deficiencies | |
| Staff person B | Named in findings related to fire safety orientation and abuse reporting training deficiencies | |
| Staff person C | Named in findings related to fire safety orientation, direct care training, medication administration competency, and medication errors | |
| Staff person D | Named in findings related to annual training hours, dementia care training, and medication training deficiencies | |
| Resident #2 | Named in multiple findings related to contract signatures, medication labeling, medication administration, right to refuse education, preadmission screening, support plan signatures, and no objection statement | |
| Resident #3 | Named in findings related to contract signatures, medication storage, right to refuse education, no objection statement, and admission support plan | |
| Resident #4 | Named in findings related to contract signatures, medication administration, right to refuse education, preadmission screening, and support plan signatures | |
| Resident #5 | Named in finding related to annual medical evaluation | |
| Resident #6 | Named in finding related to annual medical evaluation | |
| Resident #7 | Named in medication administration and storage findings | |
| Resident #8 | Named in medication storage and narcotics count findings |
Inspection Report — Apr 26, 2023
Monitoring
Date: Apr 26, 2023
Visit Reason
The inspection was a monitoring visit conducted as a partial, unannounced review to verify continued compliance and implementation of the submitted plan of correction.
Findings
The facility was found to have implemented the submitted plan of correction fully. Several deficiencies were identified related to direct care staff qualifications, sanitary conditions, lint removal and duct cleaning, and medication storage and equipment calibration, all of which had corrective plans accepted and implemented.
Citations (5)
Direct care staff person did not have a high school diploma, GED, or active registry status on the Pennsylvania nurse aide registry.
No paper towels were found in the bathroom for the shared bathroom for residents in room 72b.
Approximately 1/4 inch accumulation of lint and debris in the lint trap of the lint tray of the clothes dryer.
Resident #2's prescribed cough medication was not available in the home.
The glucometer for resident #2 was not calibrated to the correct date and time.
Report Facts
Residents Served: 51
Memory Care Residents Served: 14
Current Hospice Residents: 5
Residents Age 60 or Older: 53
Residents with Mobility Need: 14
Residents Diagnosed with Mental Illness: 1
Residents Diagnosed with Intellectual Disability: 1
Inspection Report — Feb 6, 2023
Renewal
Date: Feb 6, 2023
Visit Reason
The inspection was conducted as a renewal visit to review compliance with licensing requirements for ST. MARY VILLA FOR INDEPENDENT & RETIREMENT LIVING.
Findings
The inspection identified multiple deficiencies including contract signature omissions, refund delays, missing posted telephone numbers, staff qualification issues, sanitary and safety concerns, medication management errors, incomplete resident records, and fire safety violations. Plans of correction were accepted and fully implemented by the follow-up date.
Citations (27)
Resident-home contracts for residents #1, #2, and #3 were not signed by the residents.
Resident refunds were not made within 30 days of discharge for residents #4 and #5.
Telephone numbers for regulatory and protective agencies were not posted in a conspicuous place.
Direct care staff person A lacked a high school diploma, GED, or active registry status; diploma was in Arabic without waiver request.
No staff training plan was developed for 2022 or 2023.
Sanitary conditions issues including mold in bathrooms, unlabeled hygiene items, and mildew stains in shower.
Stained ceiling tiles and carpet in resident areas.
Bathroom sink in resident room #71 had no running water due to valve being turned off.
Non-working landline phones in hallways and unsafe bed enabler in resident room #22.
First aid kit in main kitchen lacked a thermometer and no separate first aid kit was present.
Use of common towels without identifying labels in shared bathroom of resident room #72.
Lint trap of dryer in Secured Dementia Care Unit was heavily covered with lint.
No fire safety inspection or fire drill conducted by a fire safety expert in 2021 or 2022.
Fire drill records missing number of residents present and evacuated for multiple drills.
Fire drills routinely held on the last day of each month, not varying days or times.
Residents did not fully evacuate to designated meeting places during fire drills on multiple occasions.
Resident #2's medical evaluation incorrectly marked 'none' instead of 'Secured Dementia Care' for special health or dietary needs.
Medications prescribed for resident #6 were found in med cart but not listed on current medication order.
Opened bottle of eye drops without open date found; should be discarded 28 days after opening.
Resident #6's prescribed medication was not available in the home when needed.
Resident #6's glucometer was not calibrated to the correct date and time.
Resident #6's medication was signed out twice on one date without explanation and not documented on controlled substance log.
Resident #7's medication order changed but resident was given only one tab on one date.
Directions for operating key-locking devices in Secured Dementia Care Unit were not conspicuously posted.
Resident #1's support plan incorrectly indicated minimal supervision and mobility needs while residing in SDCU.
Resident #6's controlled substance record had an entry crossed off and written over.
Resident #3's record did not include the preadmission screening.
Report Facts
Residents served: 49
Residents served in secured dementia care unit: 12
Current hospice residents: 1
Residents aged 60 or older: 48
Residents diagnosed with mental illness: 1
Residents diagnosed with intellectual disability: 1
Residents with mobility need: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Provided education on contract signatures, telephone number postings, staff qualifications, medication management, and other compliance areas | |
| Admissions Director | Monitors admission process and carpet replacement | |
| Admissions Coordinator | Received education on contract signatures | |
| RCC (Resident Care Coordinator) | Conducted audits, provided education, and involved in medication and documentation compliance | |
| Business Office Manager | Completed audit of resident refunds | |
| Director of Environmental Services | Cleaned showers and removed lint | |
| HSK Director | Provided education and audits related to housekeeping and sanitary conditions | |
| Director of Maintenance | Replaced ceiling tiles, removed phones, scheduled fire drills, and conducted audits | |
| Human Resources Director | Completed audit of direct care staff files | |
| Med Technicians | Received education and involved in medication audits | |
| Director of Dietary | Monitors first aid kits and linen/towel monitoring | |
| Director of Laundry | Monitors lint removal and linen labeling |
Inspection Report — Jan 11, 2023
Complaint Investigation
Date: Jan 11, 2023
Visit Reason
The inspection was conducted as a complaint and incident investigation at ST. MARY VILLA FOR INDEPENDENT & RETIREMENT LIVING.
Complaint Details
The complaint involved an incident where Resident #1 was pushed down by nursing staff. The home did not report this incident to the department until after the required 24-hour timeframe. The allegation was investigated, statements were obtained, and no signs of abuse were identified by the resident. The alleged perpetrator was removed from the schedule immediately following the report.
Findings
The facility was found to have delayed reporting an incident where Resident #1 was pushed down by nursing staff. The plan of correction was accepted and fully implemented, including staff education on abuse reporting and prevention.
Citations (1)
Failure to report an incident of abuse involving Resident #1 being pushed down by nursing staff within 24 hours as required.
Report Facts
Residents Served: 51
Secured Dementia Care Unit Residents Served: 13
Current Hospice Residents: 2
Residents Age 60 or Older: 50
Residents Diagnosed with Mental Illness: 1
Residents with Mobility Need: 19
Inspection Report — Jun 16, 2022
Complaint Investigation
Date: Jun 16, 2022
Visit Reason
The inspection was conducted as a complaint investigation to review sanitary and ventilation conditions at the facility.
Complaint Details
The inspection was triggered by a complaint. The plan of correction was submitted and fully implemented as of 12/28/2022.
Findings
The inspection found unsanitary conditions including wet and urine-stained bathroom floors, stained carpets, and strong urine odor in the memory care unit. Additionally, there was inadequate ventilation in a resident's bathroom due to lack of operable windows or vents. Corrective actions were immediately taken and accepted.
Citations (2)
Bathroom floors in resident 1's room were wet with water and urine; toilet had stains and wet seat; carpets in Memory Care unit entrance and hallways had stains; strong urine odor throughout memory care unit.
No operable window, air conditioner, or working vent in resident 1's bathroom to ensure airflow.
Report Facts
Residents Served: 52
Memory Care Unit Residents Served: 17
Inspection Report — Jun 2, 2022
Complaint Investigation
Date: Jun 2, 2022
Visit Reason
The inspection was conducted as a complaint investigation at St. Mary Villa for Independent & Retirement Living.
Complaint Details
The inspection was complaint-related, but no deficiencies or citations were found, and follow-up was not required.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Residents Served: 53
Secured Dementia Care Unit Residents Served: 17
Total Daily Staff: 70
Waking Staff: 53
Residents 60 Years or Older: 52
Residents with Mobility Need: 17
Inspection Report — Apr 11, 2022
Complaint Investigation
Date: Apr 11, 2022
Visit Reason
The inspection was conducted as a complaint investigation following an unannounced partial inspection on 04/11/2022.
Complaint Details
The inspection was complaint-driven as indicated by the reason 'Complaint' and the unannounced partial inspection on 04/11/2022.
Findings
Multiple deficiencies were found including unlocked poisonous materials accessible to residents, unsanitary conditions with urine stains and odors, evidence of rodent infestation, furniture and equipment in disrepair, inadequate bedroom furnishings, and incomplete resident support plans related to toileting and admission procedures.
Citations (12)
Unlocked poisonous materials accessible to residents in multiple medicine cabinets.
Unsanitary conditions including urine stains, strong urine odors, dried urine on floors, lack of hand drying in bathrooms, trash on floors, and overflowing toilets.
Evidence of mouse droppings in multiple resident rooms indicating infestation.
Overflowing, uncovered trash can in women's tub room.
Furniture and equipment issues including loose headboard, leaking and non-flushing toilets, and stained sinks.
Bedrooms lacking adequate chairs for residents.
Residents' beds did not have clean bed linens.
Residents lacked operable lamps or lighting at bedside.
Bedrooms had dirty floors with grime, dust, brown stains, and bowing ceiling tiles.
No thermometer in ice cream freezer in main dining room.
Resident support plans did not document actual toileting plans, causing staff unawareness.
Resident admitted to secured dementia care unit did not have initial support plan completed within required 72 hours.
Report Facts
Residents Served: 50
Residents Served in Dementia Unit: 18
Total Daily Staff: 75
Waking Staff: 56
Residents 60 Years or Older: 48
Residents with Mobility Need: 25
Notice — Jan 31, 2022
Date: Jan 31, 2022
Visit Reason
The document serves to grant a waiver for the requirement to complete a Department-approved competency-based training test prior to initial employment as an administrator at St. Mary Villa for Independent and Retirement Living.
Findings
The waiver is granted under specific conditions including serving as administrator while awaiting the test, obtaining a passing score by February 28, 2022, and maintaining documentation of training and qualifications. Noncompliance may result in termination of the waiver or licensing action.
Report Facts
Scheduled competency test date: Feb 28, 2022
Inspection Report — Nov 19, 2021
Complaint Investigation
Date: Nov 19, 2021
Visit Reason
The inspection was conducted as a complaint investigation with unannounced partial licensing inspections on 11/19/2021, 11/22/2021, and 11/23/2021.
Complaint Details
The inspection was complaint-related as stated, but no substantiation status or further complaint details were provided.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Total Daily Staff: 50
Waking Staff: 38
Residents Served: 27
Secured Dementia Care Unit Residents Served: 14
Residents Age 60 or Older: 76
Residents Diagnosed with Mental Illness: 21
Residents with Mobility Need: 23
Inspection Report — Sep 28, 2021
Renewal
Date: Sep 28, 2021
Visit Reason
The inspection was a full, unannounced renewal inspection conducted on 09/28/2021 to assess compliance with licensing requirements for St. Mary Villa for Independent & Retirement Living.
Findings
The inspection identified multiple deficiencies including missing resident-home contracts, incomplete medication records, failure to post influenza information, unsafe storage of poisonous materials, sanitary issues, hot water temperature violations, and failure to report incidents timely. Plans of correction were accepted or directed for all deficiencies.
Citations (27)
Personal care and assisted living homes must post the required influenza information in a public place year-round; the home did not have an influenza poster on 9/29/21.
Resident 3 did not have a resident-home contract at admission.
Resident-home contracts for residents 4, 5, 6, 7, and 8 did not include a fee schedule of actual amounts charged for available services.
Refunds for deceased residents 9, 10, 11, and 12 were delayed or not issued as required by the Elder Care Payment Restitution Act.
Residents 3, 6, and 8 did not have signed statements acknowledging receipt of resident rights and complaint procedures.
Direct care staff person A provided unsupervised ADL services without completing required training and competency testing.
Laundry room in the memory care unit was unlocked and accessible to residents with poisonous materials stored inside.
Sanitary conditions: rugs had large dark stains; toilet bowl in bedroom 66 had dark black stains.
Hot water temperature in bathrooms of rooms 65 and 66 exceeded 120°F.
Bathroom sink in room 65 had a clogged drainage pipe; hand towel dispenser in public resident bathroom was broken.
Tripping hazards on memory care unit patio due to damp hand towel and wild plants impeding pathway.
Memory care unit had only 1 shower for 18 users, below required ratio.
Toilet paper was missing in public resident bathroom at St. Joseph Wing and bedroom 65.
Food stored on the floor in emergency food stockpile.
Large accumulation of lint in lint traps of all four dryers.
Written emergency procedures were not reviewed, updated, or submitted annually to local emergency management agency.
Resident 14's medication administration record documentation was not available for prescribed medications.
Staff person B administered medications without completing Department-approved medication administration course.
Directions for operating locking mechanism were not conspicuously posted near Secure Dementia Care Unit door.
Incidents involving residents 1 and 2 sustaining injuries from falls were not reported to the department timely.
No emergency telephone numbers posted by telephone in bedroom 65.
Resident 13 did not have access to a source of light that can be turned on/off at bedside.
Freezer temperatures in memory care kitchenette and main kitchen exceeded required limits.
Medical evaluations for residents 3, 5, and 8 did not include the date when completed.
Resident 3’s preadmission screening form was not completed at time of admission.
Resident 6’s most recent additional assessment was not completed timely.
Resident 3's record did not include a home contract.
Report Facts
Residents Served: 58
Memory Care Residents Served: 18
Total Daily Staff: 76
Waking Staff: 57
Deficiencies Cited: 26
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff person A | Named in deficiency for providing unsupervised ADL services without required training | |
| Staff person B | Named in deficiency for administering medications without completing required medication administration course |
Notice — Sep 7, 2021
Date: Sep 7, 2021
Visit Reason
The document serves as a renewal notification and license issuance for the Personal Care Home, St. Mary Villa for Independent & Retirement Living, and informs that an annual inspection will be conducted within the next twelve months.
Findings
No inspection findings are reported in this document; it is a license renewal notice and certificate of compliance.
Report Facts
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary, Office of Long-term Living | Signed the renewal notification letter |
Inspection Report — Jun 24, 2021
Renewal
Date: Jun 24, 2021
Visit Reason
The inspection was conducted as a renewal and complaint investigation of Wesley Enhanced Living at Stapeley on 06/24/2021, 06/25/2021, and 06/28/2021.
Complaint Details
The inspection included a complaint investigation as indicated by the reason for visit: Renewal, Complaint.
Findings
Multiple deficiencies were found including failure to post the resident's rights poster conspicuously, administrator lacking required qualifications documentation, insufficient certified first aid/CPR trained staff during night hours, facility maintenance issues such as torn tiles and water-damaged ceiling tiles, hot water temperature exceeding allowed limits, use of common towels, lack of thermometer in refrigerator, improper use of chairs to block dining room entrance, and incomplete or untimely medical evaluations and support plans for residents in the secured dementia care unit.
Citations (11)
Resident's rights poster was not posted in a conspicuous and public place in the home.
Administrator could not provide required qualifications documentation such as nursing license or degree.
Only one staff person certified in first aid, obstructed airway techniques and CPR was present during night hours for 52 residents.
Stairwell #4 had torn tiles presenting a tripping hazard; ceiling tiles in closet of room 327 were dirty and warped from water damage.
Hot water temperature at bathroom sink in room 320 exceeded 120°F, measuring 129.0°F and 128.4°F.
Unlabeled wash cloths and towels were hanging in the shared bathroom of room 320.
No thermometer was present in the line prep refrigerator in the kitchen.
Chairs were used to block the entrance to the dining room to prevent residents from entering during cleaning.
Resident #1's medical evaluation documenting diagnosis and need for secured dementia care unit was incomplete or untimely.
Resident #1's written cognitive preadmission screening was completed late, after admission to the secured dementia care unit.
Resident #1's initial support plan was completed late and did not meet the 72-hour requirement for secured dementia care unit residents.
Report Facts
Residents served: 54
Residents served in secured dementia care unit: 23
Current hospice residents: 1
Staffing hours: 77
Waking staff: 58
Residents present during CPR deficiency: 52
Hot water temperature: 129
Hot water temperature: 128.4
Inspection Report — Dec 14, 2020
Complaint Investigation
Date: Dec 14, 2020
Visit Reason
The inspection was conducted as a complaint investigation due to reported issues at the facility.
Complaint Details
The inspection was triggered by a complaint regarding no heat in resident rooms and low indoor temperatures. The complaint was substantiated by staff and resident interviews and observations.
Findings
The facility failed to report a heating incident to the Department and had indoor temperatures below 70°F in resident areas over multiple days. The submitted plan of correction was determined to be fully implemented.
Citations (2)
16c - Written Incident Report: The home did not submit an incident report to the Department regarding a heating failure affecting multiple resident rooms from 12/10/20 to 12/14/20. Staff and resident interviews confirmed indoor temperatures fell below 70°F during this period.
83a - Indoor Temperature: The indoor temperature in St. Anne's Hallway and several resident rooms was below 70°F on 12/10/20 through 12/14/20, violating the requirement to maintain at least 70°F when residents are present.
Report Facts
Residents Served: 62
Secured Dementia Care Unit Residents Served: 15
Current Hospice Residents: 1
Residents with Mobility Need: 15
Residents Age 60 or Older: 62
Inspection Report — Nov 9, 2020
Renewal
Date: Nov 9, 2020
Visit Reason
The inspection was a full, unannounced renewal inspection of the personal care home to assess compliance with licensing regulations.
Findings
Multiple deficiencies were identified including failure to post required documents, inadequate staff training, sanitary condition violations such as moldy food and shared glucometers, missing emergency telephone numbers, ventilation issues, outdated or improperly stored food and medications, incomplete medical evaluations and assessments, and medication administration and documentation errors. Plans of correction were accepted for all findings.
Citations (33)
3c - The personal care home did not post a copy of 55 Pa.Code Chapter 2600 in a conspicuous and public place.
65e - Direct care staff person A had no documentation of 12 hours of annual training for 2019.
65f - Direct care staff person A did not receive required annual training on medication self-administration, dementia care, infection control, and other topics in 2019.
65g - Staff persons A and B did not receive required annual training on fire safety, emergency preparedness, resident rights, and falls prevention in 2019.
85a - Sanitary conditions: moldy food items found in kitchen refrigerator and hotdog buns; glucometers shared between residents with blood residue present.
85d - Trash receptacles in kitchen were uncovered and unattended.
86b - Bathrooms in resident rooms 15, 35, and 51 lacked operable ventilation fans and windows.
89a - Insufficient hot and cold water pressure in bathroom sink of resident room 79.
91 - Emergency telephone numbers were not posted by telephones in resident rooms 15 and 51.
101j7 - Resident rooms 51 and 79 lacked operable lamps or lighting at bedside.
103f - Refrigerator temperature in common kitchen was 45°F, exceeding required 40°F maximum.
103g - Food items including frozen omelets and hot dog buns were stored unsealed or opened.
103i - Outdated food including a quesadilla dated 5/29 and unlabeled frozen omelets were found.
121a - A table and chair blocked emergency egress in the St. Camillus Memory Care Unit.
132a - Unannounced fire drills were not held during May, November, December 2019, January and February 2020.
141a - Medical evaluations for residents #1 and #2 were not completed within required timeframes.
141a 1-10 - Resident #3's medical evaluation did not include ability to self-administer medications.
141b1 - Resident #4's most recent annual medical evaluation was missing.
181d - Resident #7 stored self-administered medications unlocked and unattended in bedroom and bathroom.
183e - Loose pills were found in medication carts on multiple wings.
183f - Expired medications including Carbamide Peroxide ear drops and Saline Nasal Spray were found on medication carts.
184a - Medication labels did not reflect changed directions or lacked prescribed dosage and instructions.
184b - OTC medications and CAM were not labeled with resident names.
185a - Medications and glucometer documentation were inconsistent or missing; some medications were unavailable.
187b - Medication administration times and documentation were incomplete or missing for glucose checks.
187d - Prescriber's orders were not followed; medications were missing or not administered as ordered.
225a - Initial assessments were not completed within 15 days for residents #1, #2, and #5.
225c - Previous assessment record for resident #4 was missing.
227a - Initial support plans were not completed for residents #1, #2, and #5 within 30 days of admission.
231e - Resident #5 lacked documentation of no objection statement for admission to secured dementia care unit.
234a - Resident #5's initial support plan for secured dementia care unit was not completed within 72 hours of admission.
236 - Direct care staff person A lacked documentation of 6 hours of annual dementia care training for 2019.
252 - Resident records for #1, #2, #4, and #5 lacked current and previous 2 years' physician examination reports and medical evaluations; resident #4 lacked a recent photograph.
Report Facts
Residents Served: 66
Residents Served: 18
Staff Training Hours: 12
Staff Training Hours: 6
Fire Drills Missed: 5
Loose Pills Found: 23
Expired Medications: 2
Notice — Oct 7, 2020
Date: Oct 7, 2020
Visit Reason
This document serves as a certificate of compliance and notification of license renewal for St. Mary Villa for Independent & Retirement Living, a Personal Care Home. 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 issuance of a regular license following the renewal application and advises that enforcement action may be taken if noncompliance is found during future inspections.
Report Facts
Inspection Report — May 13, 2020
Complaint Investigation
Date: May 13, 2020
Visit Reason
The inspection was a complaint investigation conducted due to a complaint regarding staff behavior and resident care at the facility.
Complaint Details
The complaint involved allegations of verbal abuse, intimidation, privacy violations, and improper restraint by staff person A against resident #1. The complaint was substantiated with evidence including a video posted on Snapchat.
Findings
The investigation found multiple violations involving staff person A, including HIPAA privacy breaches, verbal abuse, intimidation, improper restraint, privacy violations, lack of proper staff qualifications, incomplete resident assessments, and inadequate support plan revisions. Staff member A was suspended and corrective actions including staff reeducation and audits were implemented.
Citations (9)
HIPAA privacy violation occurred when staff person A recorded resident #1 displaying her face and stating her name in a video.
Staff person A verbally taunted and intimidated resident #1 in a video posted on Snapchat, including threatening language and blocking the resident's exit.
Staff person A posted a video showing disrespectful treatment of resident #1, including derogatory language and finger-waving.
Staff person A physically restrained resident #1 by blocking the bathroom door and preventing exit.
Resident #1's privacy was violated when staff person A recorded personal care in the resident's private bathroom and posted it on social media.
Staff person A lacked required qualifications, including a high school diploma, GED, or active registry status on the Pennsylvania nurse aide registry.
The home's record of direct care staff training did not include source, content, length of courses, or copies of certificates received.
Resident #1's assessment dated 5/13/20 did not include that the resident is unsafe with poisons or the need for toileting.
Resident #1's support plan was not revised to address toileting needs and behaviors during care as required within 30 days of assessment.
Report Facts
Residents Served: 65
Secured Dementia Care Unit Residents Served: 19
Hospice Current Residents: 2
Total Daily Staff: 65
Waking Staff: 49
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff member A | Named in multiple findings including HIPAA violation, abuse, restraint, privacy violation, and lack of qualifications |
Inspection Report — Dec 26, 2019
Follow-Up
Date: Dec 26, 2019
Visit Reason
The visit was a follow-up review to verify that the submitted plan of correction for prior deficiencies was fully implemented at St. Mary Villa for Independent & Retirement Living.
Findings
The submitted plan of correction was determined to be fully implemented. The facility demonstrated compliance with medication storage, narcotic accountability, and medication administration procedures.
Citations (3)
2600.183.e: Prescription medications and CAM must be stored under proper conditions. Resident #1's Ativan pill had tape over it, and Resident #2 had missing Oxycodone pills replaced with Loratadine in the blister pack.
2600.185.a: The home must implement procedures for safe storage, access, and use of medications by trained staff. Resident #2's Oxycodone medication was missing and replaced without clear documentation, and Resident #3's medication receipt was not signed off properly.
2600.187.b: Medication administration must be recorded at the time given. Resident #2's Oxycodone was signed off on the narcotic count sheet but not on the medication administration record, and staff initials were missing.
Report Facts
Residents Served: 75
Residents Served: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Thomas Schultz | Administrator | Named as facility administrator and signer of plan of correction |
Inspection Report — Sep 17, 2019
Complaint Investigation
Date: Sep 17, 2019
Visit Reason
The inspection was conducted as a complaint and incident investigation at St. Mary Villa for Independent & Retirement Living on September 17 and 18, 2019.
Complaint Details
The inspection was triggered by a complaint and incident investigation as stated under Inspection Reason on page 2.
Findings
Multiple violations of 55 Pa. Code Ch. 2600 related to resident incident reporting, resident contracts, signed statements, locking poisonous materials, follow prescriber's orders, resident rights to refuse medication, support plan medical/dental, no objection statements, and support plan needs elements were found. Plans of correction were partially implemented with adequate progress noted.
Citations (9)
16c - The home failed to report a resident's fracture incident to the department until 09/05/19, despite the incident occurring on 09/03/19.
25a - Resident #1 did not have a resident-home contract on file upon admission on 08/29/19.
41e - Resident #1's record lacked a signed statement acknowledging receipt of resident rights and complaint procedures.
82c - Poisonous materials including ointments were unlocked and accessible to residents in the secured dementia unit.
187d - The home did not document or measure resident #1's liquid intake as prescribed with a 1000 ml/day liquid restriction starting 09/09/19.
191 - Resident #1 was not educated on the right to refuse medication and no signed receipt was in the record.
227d - Resident #2's support plan did not include a need for a bed enabler, and a bed enabler was observed in the resident's room.
231e - Resident #1's record lacked documentation that the resident and designated person had not objected to admission to the secured dementia care unit.
234b - Resident #1's support plan did not address the use of bed rails, which were in place when the resident was hospitalized.
Report Facts
Residents Served: 64
Residents Served in Dementia Unit: 19
Current Hospice Residents: 3
Total Daily Staff: 83
Waking Staff: 62
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Thomas Schultz | Administrator | Named in relation to findings and plan of correction signatures |
Inspection Report — Jul 30, 2019
Complaint Investigation
Date: Jul 30, 2019
Visit Reason
The inspection was conducted as a complaint investigation at St. Mary Villa for Independent & Retirement Living on July 30, 2019.
Complaint Details
The inspection was triggered by a complaint and was unannounced. The violations found were related to sanitary conditions, furniture and equipment, and program activities.
Findings
Violations of 55 Pa. Code Ch. 2600 related to sanitary conditions, furniture and equipment, and program activities were found. The facility submitted plans of correction addressing these issues with partial implementation noted as of October 7, 2019.
Citations (3)
85a. Sanitary conditions were violated due to a broken commode with feces and a strong odor in the hallway near the dining room for a week. The bathroom was cleaned and the commode repaired.
95. Furniture and equipment were not in good repair, including a non-working commode in the bathroom and two nonoperational terminal air conditioner units in the memory care unit. The commode was repaired and air conditioners were being replaced.
221a. The home failed to provide recreational activities for residents in the memory care unit at the scheduled time of 10:00 am. Part-time recreational aides were filling in and a full-time aide was hired for the memory support unit.
Report Facts
Residents Served: 64
Memory Care Unit Residents Served: 18
Hospice Current Residents: 2
Residents with Mobility Need: 18
Residents Age 60 or Older: 63
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Thomas Schultz | Administrator | Named in relation to the inspection and plan of correction |
| Mia Johnson | Human Services Licensing Supervisor | Signed the inspection report and correspondence |
Notice — Jul 25, 2019
Date: Jul 25, 2019
Visit Reason
The document serves as a renewal notification and license issuance for St. Mary Villa for Independent & Retirement Living as a Personal Care Home. It also informs the facility of 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 approval letter with no deficiencies or compliance issues noted.
Report Facts
Inspection Report — Apr 22, 2019
Annual Inspection
Date: Apr 22, 2019
Visit Reason
The inspection was an annual renewal inspection conducted by the Department’s Bureau of Human Services Licensing to assess compliance with 55 Pa. Code Ch. 2600 for Personal Care Homes.
Findings
Multiple violations of the Pennsylvania Code were found related to contract signatures, sanitary conditions, safety hazards, lighting, egress routes, medication storage and administration, medication records, and key-locking devices. Plans of correction were submitted with partial implementation and adequate progress noted.
Citations (9)
25b. The resident-home contract for Resident #1 was not signed by the Administrator or Designee.
85a. The shower drain in Resident Bedroom #13 had a buildup of soap scum causing slow drainage.
100a. The outside fence near exit 4 was not secured to the ground causing gaps in the fencing.
101j. Resident in Room 71A did not have access to a lamp or light source that can be turned on at bedside.
121a. The left side door gate in the Secure Dementia Care Unit courtyard was secured with a mag lock that could cause a log jam during emergency evacuation.
183.d. Loperamide 2 mg prescribed for Resident #2 was in the medication cart but discontinued on 4/12/19.
185.a. Imodium A-D 2 mg was not available in the home on the day of inspection as prescribed for Resident #2.
187.a. Medication administration record for Resident #3 was not signed to document medication administration on 4/2/19 at 1:00 PM.
233.c. Directions for operating electronic card locking devices were not conspicuously posted near exits 4, 5, and 6 in the Secure Dementia Care Unit.
Report Facts
Residents Served: 54
Residents Served in Dementia Unit: 13
Current Hospice Residents: 1
Resident Support Staff: 0
Total Daily Staff: 67
Waking Staff: 50
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Thomas Schultz | Administrator | Signed multiple plans of correction and identified as Administrator in violation responses |
Inspection Report — Jul 26, 2018
Renewal
Date: Jul 26, 2018
Visit Reason
The document is a renewal of the license to operate St. Mary Villa for Independent & Retirement Living as a Personal Care Home. The Department received a renewal application and will conduct an onsite inspection within the next twelve months as required by regulation.
Findings
This document does not report inspection findings but confirms the issuance of a regular license following the renewal application. It states that an annual inspection will be conducted within twelve months and enforcement action will be taken if noncompliance is found.
Report Facts
Inspection Report — Nov 28, 2017
Annual Inspection
Date: Nov 28, 2017
Visit Reason
The inspection was an annual licensing inspection conducted on November 28, 2017, including renewal and incident investigation.
Findings
Multiple violations of 55 Pa.Code Chapter 2600 related to Personal Care Homes were found, including failures in policy implementation, contract signing, resident rights documentation, criminal background checks, lighting availability, medication labeling and availability, resident education on medication refusal, preadmission screening, and posting of locking mechanism directions.
Citations (10)
55 Pa.Code §2600.16(b): The home failed to develop and implement written policies on prevention, reporting, and management of reportable incidents. Staff member A did not report a resident fall timely.
55 Pa.Code §2600.25(b): Contracts for residents #2 and #3 were not signed by the residents.
55 Pa.Code §2600.41(e): Resident #2 and #3 records lacked signed statements acknowledging receipt of resident rights and complaint procedures.
55 Pa.Code §2600.51: Staff member B did not have a Pennsylvania criminal history background clearance in their file.
55 Pa.Code §2600.101(j)(7): Resident #1's bed did not have a source of light that can be turned on or off at bedside.
55 Pa.Code §2600.184(a): The home used shared stock medications for residents #2, #4, and #5 without individual labeling.
55 Pa.Code §2600.185(a): Resident #4's PRN Acetaminophen 325 mg was not available in the home.
55 Pa.Code §2600.191: Residents #2 and #3 were not educated on their right to refuse medication or documentation of such education was not kept.
55 Pa.Code §2600.224(a): Resident #3's preadmission screening part 3 (determination statement) was not completed.
55 Pa.Code §2600.233(c): Directions for operating the home's locking mechanism were not conspicuously posted near the device or in the SDU courtyard.
Report Facts
Number of Current Hospice Residents: 2
Number of Residents Served in Secured Dementia Care Unit: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Vincent E. Rupert | Legal Entity Representative | Signed multiple violation reports and plans of correction |
Notice — Aug 25, 2017
Date: Aug 25, 2017
Visit Reason
This document serves as a renewal notification and license issuance for St. Mary Villa for Independent & Retirement Living, a Personal Care Home, confirming the renewal application and informing about the requirement for annual onsite inspections.
Findings
No inspection findings are reported in this document. It confirms the issuance of a regular license and outlines the Department's obligation to conduct annual inspections.
Report Facts
Inspection Report — Oct 21, 2016
Renewal
Date: Oct 21, 2016
Visit Reason
The inspection was conducted as part of the Department of Human Services' annual licensing inspections for renewal of the facility license.
Findings
Multiple violations of 55 Pa.Code Chapter 2600 related to personal care home regulations were found, including issues with contract signatures, inoperable bedside lamps, fire alarm system functionality, evacuation times, medication storage and administration, and documentation. Plans of correction were submitted and partially implemented as of the report date.
Citations (19)
55 Pa.Code §2600.25(b) - The contract for resident #1 was not signed by the resident.
55 Pa.Code §2600.101(j)(7) - Resident #2's bedside lamp was inoperable on 10/24/16.
55 Pa.Code §2600.130(g) - The fire alarm sound system was found inoperative during drills on 2/28/16 and 3/31/16.
55 Pa.Code §2600.132(d) - The home's evacuation time exceeded the 12-minute standard during fire drills on 8/23/16 and 9/23/16, with four residents not evacuating.
55 Pa.Code §2600.183(b) - Medication carts were found unlocked without staff present on 10/21/16.
55 Pa.Code §2600.183(d) - Prescription medications and CAM were not properly stored or dated, including resident #5's Lantus vial and pen.
55 Pa.Code §2600.184(a) - Resident #3's medication orders for Dexamethasone and Lasix were discontinued but still located in the medication cart on 10/24/16.
55 Pa.Code §2600.185(a) - Resident #3's PRN medications and glucometer were not available or set correctly.
55 Pa.Code §2600.187(a) - Medication administration records for residents #1, #3, and #4 lacked required diagnosis or indication information.
55 Pa.Code §2600.187(b) - Medication administration records for residents #5 and #6 had documentation errors including missing initials and incorrect dates.
55 Pa.Code §2600.187(d) - Resident #7's blood glucose level was recorded but the glucometer did not have a record of the check.
55 Pa.Code §2600.187(d)(14) - Resident #5's Lorazepam was administered but not initialed on the medication administration record.
55 Pa.Code §2600.190(a) - Staff person A had completed required medication administration training and recertification.
55 Pa.Code §2600.231(b) - Resident #9's medical evaluation did not document diagnosis of dementia within 60 days of admission.
55 Pa.Code §2600.231(c) - Resident #9 did not have cognitive preadmission screening completed within 72 hours prior to admission.
55 Pa.Code §2600.234(a) - Resident #9's initial support plan was not developed within 72 hours of admission.
55 Pa.Code §2600.251(b) - Resident #3's medical evaluation dated 7/12/16 contained white-out.
55 Pa.Code §2600.252 - Residents #3, #6, and #10 had undated photographs in their records.
55 Pa.Code §2600.254(c) - Resident medication record binders and related medical information were accessible in the unlocked medication room on 10/21/16.
Report Facts
Number of Residents Served: 62
Number of Residents Served in Secured Dementia Care Unit: 13
Number of Current Hospice Residents: 2
Number of Hospice Residents in Past Year: 3
Number of Residents Age 60 or Older: 61
Number of Residents with Mobility Need: 13
Total Daily Staff: 75
Waking Staff: 56
Inspection Report — Jul 20, 2016
Renewal
Date: Jul 20, 2016
Visit Reason
The document is a renewal notification and license issuance for St. Mary Villa for Independent & Retirement Living, indicating the Department's intent to conduct an onsite inspection within the next twelve months as part of the renewal process.
Findings
No inspection findings are reported in this document. It serves as a license renewal confirmation and notification of upcoming annual inspection requirements.
Report Facts
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