Inspection Reports for
Serenity Gardens at Mount Carmel
135 VERMONT DRIVE,, KULPMONT, PA, 17834
Back to Facility Profile34 Reports
Inspection Report — Apr 9, 2026
Follow-Up
Date: Apr 9, 2026
Visit Reason
The inspection was a partial, unannounced follow-up visit triggered by an incident to verify the implementation of a previously submitted plan of correction.
Findings
The facility was found to have fully implemented the plan of correction related to incomplete cognitive preadmission screenings for residents admitted to the secured dementia care unit. The facility conducted audits and staff training to ensure ongoing compliance.
Citations (1)
231c. A written cognitive preadmission screening was incomplete for a resident admitted to the secured dementia care unit because it did not indicate if the resident required secured care. The facility completed the screening upon identification and implemented staff training and audits for compliance.
Report Facts
Residents Served: 55
Secured Dementia Care Unit Residents Served: 19
Hospice Current Residents: 2
Inspection Report — Mar 4, 2026
Follow-Up
Date: Mar 4, 2026
Visit Reason
The inspection was a partial, unannounced follow-up visit triggered by an incident to verify the implementation of a plan of correction related to medication storage and transportation procedures.
Findings
The facility had previously failed to develop and implement proper procedures for the safe storage and transportation of medications. The plan of correction was found to be fully implemented with new policies and staff training in place.
Citations (1)
185a - The home failed to develop and implement procedures for safe storage, access, security, distribution, and use of medications during transport to another facility. Medications were transported unsecured, and the facility lacked policies on accountability, secured packaging, and delivery records.
Report Facts
Residents Served: 55
Secured Dementia Care Unit Residents Served: 19
Hospice Current Residents: 3
Medication count discrepancy: 12
Inspection Report — Sep 10, 2025
Renewal
Date: Sep 10, 2025
Visit Reason
The inspection was conducted as a full, unannounced renewal inspection with an incident review on 09/10/2025.
Findings
The inspection identified multiple deficiencies including delayed abuse incident reporting, lack of thermometer in freezer, combustible storage issues, incomplete fire drill records, failure to evacuate a resident to a fire-safe area, incomplete annual medical evaluations, smoking area violations, unsecured medication storage, improper medication administration, inaccurate medication records, and incorrect preadmission screening documentation. All deficiencies had plans of correction accepted and were implemented by 11/18/2025.
Citations (11)
16c - The home failed to report an abuse allegation involving 4 residents to the Department within 24 hours as required.
103f - There was no thermometer in the freezer in the memory care kitchenette at the time of inspection.
125a - Two piles of lint were observed behind the dryer in the laundry room near heat sources, posing a combustible storage hazard.
132c - The fire drill record lacked required details and staff interviews indicated a resident was not evacuated during fire drills.
132h - A resident was not evacuated to a designated fire-safe area during fire drills as required.
141b1 - A resident's annual medical evaluation did not include confirmation that their needs can be safely met at the personal care home.
144c1 - Six cigarette butts were found on the ground in the smoking area, violating smoking area guidelines.
181d - A resident self-administered medications stored in an unlocked drawer in their room, failing to secure medications properly.
182c - Medication administration was improper as staff did not move the medication cart near the resident when administering medications.
187a - A resident's medication record listed a discontinued medication as active, indicating inaccurate medication documentation.
224a - A resident's preadmission screening form had an incorrect completion date, failing to document needs assessment within 30 days prior to admission.
Report Facts
Residents Served: 47
Secured Dementia Care Unit Residents Served: 15
Hospice Current Residents: 2
Age 60 or Older: 47
Residents with Mobility Need: 21
Residents with Physical Disability: 1
Inspection Report — Apr 15, 2025
Follow-Up
Date: Apr 15, 2025
Visit Reason
The inspection was a partial, unannounced follow-up visit triggered by an incident to review the submitted plan of correction for compliance.
Findings
The submitted plan of correction was determined to be fully implemented, with continued compliance required. A deficiency was found related to the lack of a required cognitive preadmission screening for a resident admitted to the secured dementia care unit.
Citations (1)
No cognitive preadmission screening completed for a resident prior to moving into the Secure Dementia Care Unit.
Report Facts
Residents Served: 55
Secured Dementia Care Unit Residents Served: 20
Current Hospice Residents: 1
Total Daily Staff: 85
Waking Staff: 64
Inspection Report — Dec 12, 2024
Renewal
Date: Dec 12, 2024
Visit Reason
The inspection was an unannounced renewal inspection conducted on 12/12/2024 to review the facility's compliance with licensing requirements.
Findings
The inspection identified multiple deficiencies including failure to post required regulations and emergency phone numbers, unsecured poisonous materials, obstructed emergency egress, combustible storage hazards, incomplete fire drill records, medication administration documentation errors, and incomplete resident assessments and support plans. All deficiencies had plans of correction accepted and were implemented or scheduled for ongoing compliance monitoring.
Citations (15)
The 55 PA Code Chapter 2600 regulations were not posted in a public conspicuous area of the home.
An unattended cleaning cart with a bucket of blue liquid was found in the Secured Dementia Care Unit, accessible to residents not assessed to safely handle poisonous materials.
Resident #2 did not have the required emergency telephone numbers posted by the resident’s outgoing landline telephone in the resident’s bedroom.
Several small pieces of broken glass were found near the home’s dumpster.
A yellow and black cloth barrier was blocking egress to the emergency exit in the dining room, with confusing signage on the exit door.
Combustible and flammable materials were located near natural gas hot water heaters in the mechanical room.
Fire drill record did not indicate if the drill was conducted in the AM or PM.
Fire drills were routinely held between 5am and 6am, making them predictable.
Resident #3’s Documentation of Medical Evaluation did not include weight or type of evaluation.
Resident #2 had medications in their room but was not assessed to self-administer medications.
Medication administration records for Residents #4 and #5 were not documented at the time medications were administered on multiple occasions.
Resident #6 missed a required blood glucose reading and insulin dose; Resident #7 did not receive insulin as ordered based on blood glucose reading.
Resident #3's support plan did not document behavioral and cognitive care needs or how these needs will be met.
Resident #8 and/or their designated person were not involved in the development of the support plan.
Resident records were found accessible with the office door open and no staff present, risking unauthorized access.
Report Facts
Residents Served: 46
Residents Served in SDCU: 16
Total Daily Staff: 68
Waking Staff: 51
Inspection Report — Sep 4, 2024
Date: Sep 4, 2024
Visit Reason
The inspection was a licensing inspection conducted by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing on 09/04/2024.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Residents Served: 49
Residents Served in Secured Dementia Care Unit: 17
Total Daily Staff: 76
Waking Staff: 57
Residents 60 Years or Older: 49
Residents with Mobility Need: 27
Inspection Report — Feb 8, 2024
Renewal
Date: Feb 8, 2024
Visit Reason
The inspection was conducted as a renewal inspection of the facility's license, including a full unannounced review and follow-up on plan of correction submissions.
Findings
The inspection found multiple deficiencies related to staff training, resident room lighting, hygiene supplies, food storage, egress routes, medication storage and administration, and support plan documentation. All deficiencies had plans of correction accepted and were reported as implemented or in progress with specified completion dates.
Citations (12)
Direct care staff person did not complete and pass the Department-approved direct care training course and competency test before working unsupervised.
Residents in rooms 302 and 307 did not have an operable lamp or other source of lighting at bedside.
Room 302 bathroom had one bar of soap not labeled or in a labeled container.
Two dented cans were found in the kitchen can storage area.
Snow was not removed from behind the courtyard gate, blocking immediate egress.
Prescription medications and syringes were left unlocked and unattended in resident #1's room and on the medication cart.
Resident #1's medication container lacked proper pharmacy labeling and instructions did not match the medication administration record.
Medications for residents #1 and #2 were not available as ordered.
Narcotic medication count for resident #3 was inaccurate and not completed at shift change.
Resident #4 missed a prescribed dose of medication.
Resident #5's support plan did not indicate hospice services despite admission to hospice.
Resident #6 had a fall with injury; no addendum was completed to document safety measures.
Report Facts
Residents Served: 49
Secured Dementia Care Unit Residents Served: 17
Current Hospice Residents: 2
Total Daily Staff: 76
Waking Staff: 57
Inspection Report — Jul 18, 2023
Original Licensing
Date: Jul 18, 2023
Visit Reason
The inspection was conducted due to a change in legal entity and initial licensing of the facility under new ownership.
Findings
The facility was found to be in substantial compliance with applicable regulations but the inspection was not fully completed due to the new legal entity status. Several citations were identified related to safety hazards such as a tripping hazard outside the secured dementia unit, an exit door that required excessive force to open, and incomplete evacuation documentation during a fire drill.
Citations (3)
Tripping hazard due to a 12"x12" cut out in the cement filled with wood that had sunk by approximately 1 inch in the courtyard of the secured dementia unit.
Exit door outside the administrator's office would not open without excessive force, preventing immediate egress in an emergency.
Fire drill on 6/26/23 showed 56 residents present but only 52 evacuated; 3 residents were unaccounted for in evacuation documentation.
Report Facts
Residents Served: 54
Residents Served in Secure Dementia Care Unit: 15
Staffing Hours: 80
Waking Staff: 60
Fire Drill Residents Present: 56
Fire Drill Residents Evacuated: 52
Inspection Report — Oct 12, 2022
Follow-Up
Date: Oct 12, 2022
Visit Reason
The inspection was a follow-up review conducted on 10/12/2022 to verify that the submitted plan of correction was fully implemented at Serenity Gardens at Mount Carmel.
Findings
The facility was found to have fully implemented the plan of correction for previous deficiencies, including proper labeling of poisonous materials, hot water temperature adjustments, correction of emergency telephone numbers, monthly fire drills, fire drill record keeping, designated meeting place evacuation procedures, and smoking area safety.
Citations (7)
Poisonous materials were stored in spray bottles without original manufacturers' labels.
Hot water temperature in resident-accessible areas exceeded 120°F, measuring 129°F and 131°F in two bathrooms.
Wrong number for the personal care home complaint hotline was posted with emergency telephone numbers.
No fire drill was conducted in December 2021.
Fire drill logs from 1/22-9/22 lacked documentation of exit routes used and residents evacuated.
Resident #1 was not evacuated during fire drills contrary to policy and physician/legal guardian instructions.
Four nylon fabric chairs were located in the designated smoking area, posing a fire hazard.
Report Facts
Residents served: 57
Secured Dementia Care Unit residents served: 13
Hospice residents: 3
Residents with mobility need: 20
Residents aged 60 or older: 57
Residents diagnosed with intellectual disability: 1
Hot water temperature: 129
Hot water temperature: 131
Resident Support Staff: 20
Total Daily Staff: 97
Waking Staff: 73
Inspection Report — Dec 22, 2021
Follow-Up
Date: Dec 22, 2021
Visit Reason
The inspection visit on 12/22/2021 was a partial, unannounced follow-up to review the submitted plan of correction related to an incident at the facility.
Findings
The submitted plan of correction was determined to be fully implemented, with staff retraining on resident rights completed and ongoing compliance to be maintained by the administrator.
Citations (1)
Resident #1 was found tied to a wheelchair with a bedsheet to prevent falling, which is a prohibited manual restraint.
Report Facts
Residents Served: 58
Secured Dementia Care Unit Residents Served: 15
Hospice Current Residents: 4
Total Daily Staff: 73
Waking Staff: 55
Inspection Report — Sep 28, 2021
Renewal
Date: Sep 28, 2021
Visit Reason
The inspection was conducted as a renewal and complaint investigation of the facility Serenity Gardens at Mount Carmel on 09/28/2021 and 09/29/2021.
Complaint Details
The inspection included a complaint investigation as part of the renewal process. The report does not explicitly state the substantiation status of the complaint.
Findings
The inspection found multiple deficiencies including failure to post the current license inspection summary, lack of documentation for periodic Quality Management meetings, incomplete criminal background checks, missing emergency telephone numbers, incomplete or outdated resident medical evaluations and assessments, inaccuracies in medication documentation, and issues with support plans and preadmission screenings. Plans of correction were accepted and implemented for all deficiencies.
Citations (15)
The most current LIS dated 8-20-2019, was not posted in a conspicuous location.
There was no documentation of a periodic Quality Management meeting having been held within the last 12 months.
Staff member A had their Criminal Background check completed on 1/30/2017 but results were under review and no documentation of receiving results within 90 days.
The landline phone located in the room of resident 1 did not have emergency numbers posted near the phone.
Resident 2 and Resident 3 had incomplete or missing annual medical evaluations.
Meal menus were only posted up until 10/02/2021 instead of a full week in advance.
Resident 4’s glucometer reading was documented incorrectly in the MAR log.
Pre-admission screening forms for Resident 5 and Resident 6 did not indicate that the resident’s needs can be met by the home.
Resident 6 did not have a completed assessment plan within 15 days of admission.
Resident 7 and Resident 2 had outdated or missing additional assessments and support plans.
Resident 3’s diet change was not reflected in their current support plan.
Resident 7 was transferred to the secured dementia unit without a current DME and missing cognitive preadmission screening and non-objection statement.
Resident 7 was not assessed annually for continuing need in the secured dementia care unit.
Instructions to open the locked gate from the secured dementia unit outside patio were faded and unreadable.
Resident 7 did not have a new support plan completed within 1 year of admission to the secured dementia unit.
Report Facts
Residents Served: 54
Secured Dementia Care Unit Residents Served: 16
Hospice Residents: 3
Residents with Mobility Need: 21
Total Daily Staff: 75
Waking Staff: 56
Notice — Aug 31, 2021
Date: Aug 31, 2021
Visit Reason
The document serves as a renewal notification and license issuance for the Personal Care Home 'Serenity Gardens at Mount Carmel' following receipt of the renewal application dated July 29, 2021.
Findings
The Department issued a regular license in response to the renewal application and advised that an onsite inspection will be conducted within the next twelve months to ensure compliance with applicable regulations.
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 10, 2021
Plan of Correction
Date: Jun 10, 2021
Visit Reason
The inspection was conducted as a follow-up review to verify that the submitted plan of correction was fully implemented at the facility.
Findings
The Pennsylvania Department of Human Services determined that the submitted plan of correction was fully implemented and that continued compliance must be maintained.
Report Facts
Residents Served: 43
Secured Dementia Care Unit Residents Served: 14
Hospice Current Residents: 2
Resident Support Staff Hours: 0
Total Daily Staff: 59
Waking Staff: 44
Residents Age 60 or Older: 43
Residents with Mobility Need: 16
Residents Receiving Supplemental Security Income: 2
Inspection Report — Jan 15, 2021
Routine
Date: Jan 15, 2021
Visit Reason
The inspection was conducted as a licensing inspection by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing on 01/15/2021.
Findings
No regulatory citations were identified as a result of this inspection.
Inspection Report — Oct 14, 2020
Date: Oct 14, 2020
Visit Reason
The inspection visits on 10/14/2020, 10/19/2020, 10/23/2020, and 10/30/2020 were conducted as licensing inspections by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing.
Findings
No regulatory citations were identified as a result of these inspections.
Inspection Report — Sep 1, 2020
Renewal
Date: Sep 1, 2020
Visit Reason
The document is a renewal application and license issuance for Serenity Gardens at Mount Carmel Personal Care Home. The Department will conduct an onsite inspection 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.
Report Facts
Inspection Report — Aug 12, 2020
Routine
Date: Aug 12, 2020
Visit Reason
The inspection was conducted as a licensing inspection by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing on 08/12/2020 and 08/13/2020.
Findings
No regulatory citations were identified as a result of this inspection.
Inspection Report — Jun 5, 2020
Complaint Investigation
Date: Jun 5, 2020
Visit Reason
The inspection was conducted as a complaint investigation and incident review at Serenity Gardens at Mount Carmel.
Complaint Details
The visit was complaint-related and incident-driven. Specific medication errors and privacy concerns were investigated. The plan of correction was accepted and fully implemented as of the follow-up date.
Findings
The inspection identified multiple medication errors including failure to administer prescribed medications and failure to report these errors. Additional findings included improper use of resident medications, privacy concerns in the COVID-19 isolation room, and failure to follow prescriber's orders.
Citations (5)
16c - Written Incident Report: The home failed to report medication errors involving Resident 1 to the Department within 24 hours as required.
20b4 - Use of Funds: Staff borrowed medications from other residents to administer to Resident 1, violating the requirement that resident funds and property be used only for the resident's benefit.
42s - Privacy: The COVID-19 isolation room lacked window coverings, allowing a resident to be seen while changing, violating privacy rights.
187d - Follow Prescriber's Orders: Resident 1 did not receive prescribed medications on 6/2/20 and 6/3/20, and the home failed to ensure pharmacy orders were received and followed.
188b - Medication Error Reporting: Medication errors involving Resident 1 were not reported to the resident, designated person, or prescriber as required.
Report Facts
Residents Served: 60
Secured Dementia Care Unit Residents Served: 22
Hospice Current Residents: 5
Staff Total Daily: 83
Staff Waking: 62
Notice — Jun 1, 2020
Date: Jun 1, 2020
Visit Reason
This document grants a waiver for the administrator training and orientation requirement under 55 Pa.Code § 2600.64(a)(1) due to the unavailability of the orientation session.
Findings
The waiver is granted with conditions including completion of a 100-hour training course, passing a competency test, and attending the orientation session once available. The Department will review compliance annually during inspections.
Inspection Report — May 13, 2020
Complaint Investigation
Date: May 13, 2020
Visit Reason
The inspection was conducted as a complaint investigation to review compliance with regulations and verify the submitted plan of correction.
Complaint Details
The inspection was complaint-driven and included a follow-up to verify the plan of correction. The plan of correction was accepted and fully implemented.
Findings
The facility was found to have multiple deficiencies related to incident reporting, resident assessments, and support plans. The submitted plan of correction was accepted and fully implemented.
Citations (5)
16c - Written Incident Report: The home failed to report the death of Resident #1 to the department within 24 hours, reporting it five days later.
225a - Assessment 15 Days: Resident 2's initial assessment was not completed within 15 days of admission, being completed over a month later.
225c - Additional Assessment: Resident 3's annual assessment was overdue, last completed on 3/29/19 and due on 4/12/20.
227a - Support Plan 30 Days: Resident 2's initial support plan was not completed within 30 days of admission, completed over a month late.
227c - Support Plan Revision: Resident 3's annual support plan revision was overdue, last completed on 3/29/19 and due on 4/12/20.
Report Facts
Residents Served: 61
Secured Dementia Care Unit Residents Served: 20
Hospice Current Residents: 1
Residents 60 Years or Older: 61
Residents with Mobility Need: 24
Inspection Report — Mar 30, 2020
Complaint Investigation
Date: Mar 30, 2020
Visit Reason
The inspection was conducted as a complaint investigation to review compliance at Serenity Gardens at Mount Carmel.
Complaint Details
The visit was complaint-driven. It was determined that the administrator did not meet the required presence hours. The plan of correction was approved and fully implemented.
Findings
The facility was found to have a violation regarding administrator staffing, specifically the administrator was not present for the required average of 20 hours per week during March. The submitted plan of correction was fully implemented as of the follow-up date.
Citations (1)
2600.56 Administrator Staffing - The administrator was not present in the home for an average of 20 hours per week in March. The administrator was assisting in another building and unable to complete required hours.
Report Facts
Residents Served: 66
Secured Dementia Care Unit Residents Served: 21
Current Hospice Residents: 7
Administrator Staffing Hours Required: 20
Administrator Staffing Hours Not Met: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lisa Sikes | Administrator | Named in relation to administrator staffing violation |
Inspection Report — Mar 16, 2020
Routine
Date: Mar 16, 2020
Visit Reason
The Department’s Bureau of Human Services Licensing conducted an inspection of Serenity Gardens at Mount Carmel on March 16, 2020.
Findings
No regulatory citations with 55 Pa. Code Ch. 2600 relating to Personal Care Homes were identified as a result of this inspection.
Inspection Report — Oct 3, 2019
Follow-Up
Date: Oct 3, 2019
Visit Reason
The visit was conducted as a follow-up to verify the implementation of a previously submitted plan of correction following a complaint investigation.
Complaint Details
The inspection was triggered by a complaint. The plan of correction was fully implemented as verified on site.
Findings
The plan of correction was found to be fully implemented on site. The report includes descriptions of prior violations related to incident reporting, fire drill documentation, and evacuation procedures, all of which have been addressed.
Citations (3)
2600.16c: The home failed to report a resident's fall resulting in a right arm hematoma to the Department within 24 hours as required. This was a repeated violation from 2-1-19.
2600.132c: Fire drill records for drills conducted on 7/24/19, 8/15/19, and 9/30/19 did not include the number of residents in the facility, number evacuated, or AM/PM time of drills.
2600.132h: On 9/13/19, a fire alarm sounded and an immobile resident was not evacuated to a designated meeting place away from the building or within the fire-safe area.
Report Facts
Residents Served: 74
Residents Served in Dementia Unit: 21
Current Hospice Residents: 1
Resident Support Staff Total Daily Staff: 99
Waking Staff: 74
Number of Reportable Events Staff Trained: 19
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Anne Graziano | Human Services Licensing Supervisor | Signed letter confirming plan of correction implementation |
Inspection Report — Aug 20, 2019
Renewal
Date: Aug 20, 2019
Visit Reason
The inspection was a renewal inspection conducted by the Department’s Bureau of Human Services Licensing to assess compliance with 55 Pa. Code Ch. 2600 for the facility Serenity Gardens at Mount Carmel.
Findings
Multiple violations of state regulations were identified, including issues with record confidentiality, compliance with laws, training topics, fire safety, medication administration, and storage. Plans of correction were submitted and partially implemented with ongoing monitoring required.
Citations (15)
2600.17 Resident records were left unattended with the door to the medication room open, compromising confidentiality.
2600.18 The home had two gas-fired water heaters with a carbon monoxide monitor installed inside the room, not outside as required by law.
2600.65f Staff person A did not have required medication self-administration training for 2018.
2600.65g Staff persons A and B did not have annual fire safety training by a fire safety expert for 2018.
2600.124 The home’s notice to the fire department did not reflect the correct number of residents requiring evacuation assistance and omitted total home capacity.
2600.125a Combustible materials were found behind the dryer in the home’s laundry room.
2600.132c The home did not document the number of residents present or evacuated on fire drill logs for multiple drills.
2600.132g Fire drills were held at times when additional staff were not routinely present to assist with evacuations.
2600.132h During a fire drill, resident #1 refused to evacuate to the designated meeting place.
2600.133.1 The exit door outside the office/pantry was not labeled with an exit sign.
2600.182b Documentation for staff persons C and D’s medication administration training was incomplete and not signed by the trainer.
2600.183e Loose white pills were found in the memory care unit medication cart drawers.
2600.184c Resident #2’s medication label instructions did not match the medication administration record.
2600.187a Resident #3’s medication record did not document the number of insulin units administered on specified dates.
2600.231c Resident #4’s cognitive preadmission screening was completed less than 72 hours prior to admission to the memory care unit.
Report Facts
Residents Served: 66
Residents Served: 16
Current Residents: 1
Residents with Mobility Need: 23
Residents 60 Years or Older: 66
Residents Served: 66
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lisa Sikes | Administrator | Named as legal entity representative and signer of plans of correction |
Notice — Jul 1, 2019
Date: Jul 1, 2019
Visit Reason
This document serves as a renewal notification and license issuance for the Personal Care Home Serenity Gardens at Mount Carmel, confirming the facility's authorized capacity and informing about 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 and compliance certificate without any noted deficiencies or violations.
Report Facts
Inspection Report — Feb 1, 2019
Complaint Investigation
Date: Feb 1, 2019
Visit Reason
The inspection was conducted due to an incident involving an allegation of sexual abuse reported by a resident.
Complaint Details
Resident #1 alleged sexual abuse by staff on 01-05-19, but the home delayed reporting until 01-07-19. A formal investigation found no evidence of abuse or foul play. The facility was reminded that all abuse allegations must be reported promptly.
Findings
The facility failed to report an allegation of sexual abuse within the required time limits. Additionally, the resident's support plan did not include information regarding formal support services or physical therapy as required. The facility has taken partial corrective actions including staff training and updating documentation.
Citations (2)
55 Pa.Code §2600.16(c): The home failed to report an allegation of sexual abuse to the Department within the required 24-hour timeframe.
55 Pa.Code §2600.227(d): The resident's support plan did not include information about formal support services or physical therapy received twice weekly.
Report Facts
Number of Residents Served: 41
Number of Residents Served in Secured Dementia Care Unit: 19
Number of Current Hospice Residents: 2
Number of Residents Age 60 or Older: 41
Number of Residents with Mobility Need: 22
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jessica Kross | Administrator | Named as legal entity representative and signer of plan of correction |
Inspection Report — Oct 16, 2018
Renewal
Date: Oct 16, 2018
Visit Reason
The document is a renewal license issued to Senior Care of Kulpmont LLC for Serenity Gardens at Mount Carmel to operate a Personal Care Home. The Department advises that an onsite inspection will be conducted within the next twelve months as part of the annual inspection requirement.
Findings
No inspection findings are reported in this document. It is a license renewal notice with information about future inspection requirements and enforcement actions if noncompliance is found.
Report Facts
Inspection Report — Sep 27, 2018
Complaint Investigation
Date: Sep 27, 2018
Visit Reason
The inspection was conducted as a complaint investigation with unannounced visits on September 27, 2018 and October 16, 2018 to assess compliance with 55 Pa.Code Chapter 2600 for Personal Care Homes.
Complaint Details
The inspection was triggered by a complaint. The report documents substantiated violations related to resident neglect, failure to report deaths, inadequate staffing, and failure to update care plans.
Findings
The facility was found to have multiple violations including failure to report resident deaths timely, inadequate supervision and care leading to resident harm, insufficient direct care staffing hours, and failure to update resident support plans. Plans of correction were partially implemented with ongoing monitoring.
Citations (5)
55 Pa.Code §2600.16(c) - The home failed to report a resident death to the Department within 24 hours as required by regulation.
55 Pa.Code §2600.42(b) - A resident was neglected and suffered harm due to choking and inadequate supervision, and the home failed to provide necessary goods or services to maintain resident health.
55 Pa.Code §2600.57(b) - The home did not have sufficient direct care staff hours to meet the needs of 65 residents and 27 residents with mobility needs, providing only 84.75 hours instead of the required 93 hours.
55 Pa.Code §2600.57(d) - The home failed to provide at least 75% of personal care service hours during waking hours, with only 65.25 hours available instead of the required amount.
55 Pa.Code §2600.227(d) - The home did not properly document new diet orders and failed to update resident support plans timely, impacting resident care.
Report Facts
Residents with Mobility Needs: 27
Direct Care Staff Hours Required: 93
Direct Care Staff Hours Provided: 84.75
Personal Care Service Hours During Waking Hours Required: 69.75
Personal Care Service Hours During Waking Hours Provided: 65.25
Residents Receiving Supplemental Security Income: 2
Current Hospice Residents: 2
Hospice Residents in Past Year: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jessica Kross | Administrator | Named as responsible party in multiple findings and plan of correction signatures |
| Ryan Novak | Inspector | Conducted on-site inspections on 09/27/2018 and 10/16/2018 |
| Amy Deluca | Inspector | Participated in on-site inspection on 10/16/2018 |
Inspection Report — Aug 2, 2018
Renewal
Date: Aug 2, 2018
Visit Reason
The inspection was a renewal visit conducted by the Department's Bureau of Human Services Licensing to assess compliance with 55 Pa. Code Chapter 2600 for the Personal Care Home Serenity Gardens at Mount Carmel.
Findings
The inspection identified multiple violations related to fire safety, medical evaluations, documentation, and vehicle registration. Plans of correction were submitted and partially implemented with adequate progress noted.
Citations (5)
Regulation 2600.105(g)(1): Lint was found in the filters of the dryers with no clothing in the units, posing a fire hazard risk.
Regulation 2600.141(a)(1): Resident #1's medical evaluation was completed outside the allowable timeframe, over 60 days after admission.
Regulation 2600.141(a)(2): Resident #2's medical evaluation did not include required medication lists, immunizations, or assessment of ability to manage medications.
Regulation 2600.171(c): The home's vehicle registration on file was expired and no updated owner's card was available in the vehicle.
Regulation 2600.231(c): Resident #3's cognitive prescreening form was incomplete and lacked required dementia diagnosis and cognitive screening documentation.
Report Facts
Number of Residents Served: 70
Total Daily Staff: 91
Walking Staff: 68
Number of Current Hospice Residents: 21
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jessica Kross | Administrator | Named as administrator and legal entity representative signing plans of correction. |
| Anne O'Haire | Inspector | On-site inspector conducting the inspection. |
| Michael Palermo | Inspector | On-site inspector conducting the inspection. |
Notice — Aug 10, 2017
Date: Aug 10, 2017
Visit Reason
The document acknowledges receipt of an appeal request by Senior Care of Kulpmont LLC regarding the Department's decision to deny a waiver for Serenity Gardens at Mount Carmel.
Findings
The Department denied the waiver request related to environmental protection regulations for resident rooms. The letter explains the denial and informs the recipient of the appeal process.
Report Facts
Occupancy: 71
Occupancy: 60
Requested waiver: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lisa Sikes | Regional Director | Author of the appeal letter requesting waiver. |
| Jacqueline L. Rowe | Director | Signed letters denying waiver and acknowledging appeal. |
| Kevin Brumbach | Enforcement Manager | Recipient of appeal request and referenced in waiver denial letter. |
Inspection Report — Aug 2, 2017
Renewal
Date: Aug 2, 2017
Visit Reason
The inspection was a renewal licensing inspection conducted by the Pennsylvania Department of Human Services on August 2, 2017, to assess compliance with 55 Pa.Code Chapter 2600 for Personal Care Homes.
Findings
Multiple violations of 55 Pa.Code Chapter 2600 were found, including issues with resident record confidentiality, lack of carbon monoxide detectors, incomplete quality management reviews, privacy violations due to audio monitoring devices, unsanitary conditions, fire hazards, insufficient emergency water supply, medication storage and administration errors, and missing emergency evacuation codes. Plans of correction were submitted and partially implemented as of September 22, 2017.
Citations (14)
Regulation 2600.17: Resident records were found in a hanging file folder outside the Director of Nursing Office, exposing confidential resident information.
Regulation 2600.18: The facility lacked installed carbon monoxide detectors as required by the Care Facility Carbon Monoxide Alarms Standards Act.
Regulation 2600.26(b): The facility's quarterly quality management review did not include reportable incident and condition reporting procedures, complaint procedures, staff training, licensing violations, or resident/family councils.
Regulation 2600.42(s): An audio monitoring device was located in the main hallway, violating resident privacy as monitoring is prohibited.
Regulation 2600.85(a): Heavy accumulation of dust and dirt was observed on heating and air conditioning vents in the main hallway.
Regulation 2600.105(g)(2): Lint buildup was found behind dryers in the laundry area, creating a fire hazard.
Regulation 2600.107(c): The facility had only 96 gallons of water on hand, below the required minimum of 210 gallons for emergency use based on census.
Regulation 2600.125(a): Flammable materials were stored near heat sources in the laundry area, posing a fire risk.
Regulation 2600.183(d): Advair inhalers were not dated when opened and were disposed of outside the manufacturer’s timeframe.
Regulation 2600.183(c): Two unidentified pills were found in the bottom of a medication cart drawer, indicating improper medication storage.
Regulation 2600.185(a): Resident medications were not available as prescribed, including PRN medications and proper labeling.
Regulation 2600.187(a): The facility failed to follow prescriber orders for medication administration for residents #1 and #2, including missed doses and lack of documentation.
Regulation 2600.188(b): Medication errors were not immediately reported to residents, designated persons, or prescribers as required.
Regulation 2600.233(c): Emergency evacuation codes were not posted at the secured dementia unit courtyard gate, and the posted code was removed due to weather damage.
Report Facts
Number of Residents Served: 70
Number of Residents Served in Secured Dementia Care Unit: 21
Number of Current Hospice Residents: 1
Number of Hospice Residents in Past Year: 1
Total Daily Staff: 91
Waking Staff: 68
Gallons of Water on Hand: 96
Required Minimum Gallons of Water: 210
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jessica Kross | LPN/DON/PCHA | Named in multiple findings and plans of correction related to resident records, carbon monoxide detectors, quality management, privacy, sanitation, fire safety, medication administration, and emergency preparedness |
Notice — Jul 31, 2017
Date: Jul 31, 2017
Visit Reason
The document is a letter denying a waiver request for certain Pennsylvania Code regulations related to environmental protection and resident bedrooms at a licensed personal care home.
Findings
The Department determined that a waiver for 55 Pa.Code § 2600.101(b) is not needed and denied the waiver for 55 Pa.Code § 2600.232(b) as it does not believe residents would benefit from it. The purpose of the regulation is to reduce agitation and injury risk in residents with dementia.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Brumbach | Enforcement Manager | Signed the denial letter from the Bureau of Human Services Licensing. |
| Jacqueline L. Rowe | Director | Signed the denial letter. |
Notice — May 23, 2017
Date: May 23, 2017
Visit Reason
The document is a response to a waiver request for allowing three residents to reside in one bedroom in a licensed secured dementia care unit. The Department of Human Services is denying the waiver request based on regulatory requirements.
Findings
The Department denied the waiver request because there is no alternative for providing an equivalent level of health, safety, and well-being protection for residents. The purpose of the regulation is to reduce agitation and injury risk due to aggressive behaviors.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jacqueline L. Rowe | Director | Signed the denial letter. |
| Kevin Brumbach | Enforcement Manager | Listed as contact for appeal process. |
Inspection Report — Jan 10, 2017
Renewal
Date: Jan 10, 2017
Visit Reason
The inspection was a renewal licensing inspection conducted to assess compliance with 55 Pa.Code Chapter 2600 for Personal Care Homes.
Findings
The facility was found to be in substantial compliance with regulations but had several violations noted on the License Inspection Summary that required correction. The violations involved issues such as emergency phone numbers, snow removal, medical evaluations, medication labeling, and locked egress signage.
Citations (9)
Regulation 2600.91: Emergency phone numbers posted near resident room 109 were incorrect and did not include the Personal Care Home Complaint Hotline number.
Regulation 2600.100(b): The gate leading from the secured dementia care courtyard was blocked by 1-2 inches of snow and did not open completely.
Regulation 2600.141(a)(2): Medical evaluations for residents #1 and #2 did not include required information on body positioning or mobility needs.
Regulation 2600.183(d): A topical ointment prescribed for resident #6 was expired since 12/2006 and was disposed of on the day of inspection.
Regulation 2600.184(a): A bottle of Hydrocortisone lotion and a tube of Triple Antibiotic ointment were not labeled or dated; a jar of Equate Vaporizing Rub was also not labeled or dated.
Regulation 2600.2600: The Ducolax 10 mg suppositories prescribed for resident #7 were not on hand as required.
Regulation 2600.187(a): Resident #3's medication administration record did not indicate how many units of Novolog insulin were administered at 12:00 pm on 1/7/17.
Regulation 2600.231(c): The door from the dining room to the secured dementia care unit did not have directions or code posted to operate the magnetic locking device.
Regulation 2600.234(a): The assessment and support plan for resident #5 did not include the required summary and determination of the assessment upon admission.
Report Facts
Residents in Secured Dementia Care Unit: 19
Supplemental Security Income Recipients: 4
Residents Age 60 or Older: 69
Residents with Mobility Need: 19
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tracy Shingara | PCHA | Administrator named in multiple plan of correction signatures related to violations. |
| Julienne Rushin | Department representative on-site during inspection. | |
| Jesse Hummel | Department representative on-site during inspection. |
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