Inspection Reports for
South Mountain Memory Care
201 Seventh St, Emmaus, PA 18049, PA, 18049
Back to Facility Profile22 Reports
Inspection Report — Oct 2, 2025
Renewal
Date: Oct 2, 2025
Visit Reason
The inspection was conducted as a renewal visit to assess compliance with licensing requirements for South Mountain Memory Care.
Findings
The facility had multiple deficiencies including improper storage of poisonous materials, outdated food items, medication storage and record issues, and missing directions for key-locking devices. All deficiencies were addressed with plans of correction and were reported as implemented by follow-up dates.
Citations (5)
82a Poisonous materials were found stored in an unlabeled spray bottle in a supply closet near the North hallway exit. This was a repeat violation from 10/1/24.
103i Outdated or dented food cans were found in the kitchen storage, including a #10 can of Great Northern beans and a 16 oz can of mushroom pieces.
185a The home failed to implement proper storage procedures for medications; a resident’s Lorazepam pill was taped to keep it in place.
187a Medication records did not accurately reflect frequency of administration; a resident’s Clobetetasol cream directions were inconsistent between notes and MAR.
233c Directions for operating key-locking devices were not posted near exit doors on the North and South wings. This was a repeat violation from 10/1/24.
Report Facts
Residents Served: 24
Current Hospice Residents: 5
Total Daily Staff: 48
Waking Staff: 36
Inspection Report — Jan 29, 2025
Date: Jan 29, 2025
Visit Reason
The inspection was an unannounced partial licensing inspection conducted as an interim review by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Residents Served: 23
Current Residents in Hospice: 6
Total Daily Staff: 46
Waking Staff: 35
Inspection Report — Oct 1, 2024
Renewal
Date: Oct 1, 2024
Visit Reason
The inspection was conducted as a renewal inspection of the South Mountain Memory Care facility to assess compliance with licensing requirements.
Findings
The inspection identified multiple deficiencies including improper posting of current license documents, confidentiality breaches with resident records, lack of staff CPR/First Aid certification during a shift, missing annual training topics for staff, unsafe storage of poisonous materials, furniture and equipment hazards, food safety violations, fire safety equipment and drill deficiencies, medication record inaccuracies, and incomplete resident support plans. All deficiencies had plans of correction accepted and were implemented by March 20, 2025.
Citations (17)
Binder containing previous year’s License Inspection Summary reports was not stored in a public and conspicuous area.
Confidential resident information found in unlocked cabinet in dining area.
No staff on third shift had current First Aid and CPR training certification.
Staff did not receive required annual training on medication self-administration.
Staff did not receive required annual fire safety training by a fire safety expert.
Laundry detergent pods stored in a clear container without original label.
Bed rail in room 109 was not securely fastened and was very loose.
Container of ice cream found uncovered and unlabeled in freezer.
No fire extinguisher stored in the basement of the home.
Fire extinguisher in laundry area had expired inspection tag marked 'FAIL'.
No documentation of fire drills from December 2023 through August 2024.
Fire safety inspection and supervised fire drill not conducted annually as required.
No documentation of fire drill during sleeping hours every six months.
Incorrect documentation of blood glucose readings on Medication Administration Record.
Medication records missing documentation of vital signs used to determine medication holds.
No code posted near keypad used to open exit gate for outdoor garden area.
Resident Assessment Support Plan did not reflect resident's inability to safely avoid poisonous materials or use of bedside mobility device.
Report Facts
Residents Served: 24
Current Hospice Residents: 3
Total Daily Staff: 48
Waking Staff: 36
Inspection Report — Dec 13, 2023
Renewal
Date: Dec 13, 2023
Visit Reason
The inspection was an unannounced full renewal inspection conducted to review compliance with licensing requirements and verify the submitted plan of correction.
Findings
The facility was found to have multiple deficiencies including failure to post the current license and inspection summary conspicuously, unlocked poisonous materials accessible to residents, missing light bulbs in bedside lamps, inaccuracies in medication storage procedures, and incomplete support plan documentation. All deficiencies had accepted plans of correction which were fully implemented by the follow-up dates.
Citations (5)
The most recent license inspection summary and Chapter 2600 regulations were not posted in a conspicuous area but were found in a binder behind a piano.
A can of Clorox Disinfectant Spray was found unlocked in a kitchen cupboard accessible to residents, posing a poisoning hazard.
The bedside lamp in Resident room 105 was missing a light bulb with no other source of illumination near the bed.
Review of Resident #1's glucometer showed discrepancies with the MAR indicating inaccurate blood sugar levels due to human error.
The Resident Assessment Support Plan (RASP) for Resident #1 did not indicate the resident’s date of admission.
Report Facts
Residents Served: 23
Current Residents in Hospice: 3
Residents Age 60 or Older: 23
Residents with Mobility Need: 23
Residents with Physical Disability: 1
Staffing Hours - Resident Support Staff: 1
Staffing Hours - Total Daily Staff: 47
Staffing Hours - Waking Staff: 35
Inspection Report — Sep 13, 2022
Plan of Correction
Date: Sep 13, 2022
Visit Reason
The visit was conducted to review the submitted plan of correction for the facility following a prior inspection.
Findings
The submitted plan of correction was determined to be fully implemented, and continued compliance must be maintained.
Inspection Report — Aug 8, 2022
Follow-Up
Date: Aug 8, 2022
Visit Reason
The visit was a partial, unannounced follow-up inspection triggered by an incident involving an allegation of sexual assault by a staff member on a resident.
Complaint Details
The visit was complaint-related due to an allegation of sexual assault by Staff Member A on Resident #1. The staff member was suspended and terminated after investigations by the facility, police, and other agencies. Preliminary findings noted no physical evidence, but later evidence from a specimen kit led to an arrest. The facility cooperated fully with investigations and retrained staff on resident rights.
Findings
The facility was found to have fully implemented the submitted plan of correction related to the abuse allegation. The staff member involved was suspended and terminated following internal and external investigations, with no physical evidence found to support the claim initially. The facility retrained staff on resident rights and maintained compliance with abuse reporting policies.
Citations (1)
A resident may not be neglected, intimidated, physically or verbally abused, mistreated, subjected to corporal punishment or disciplined in any way.
Report Facts
Residents Served: 21
Resident Support Staff: 21
Total Daily Staff: 63
Waking Staff: 47
Inspection Report — Jun 24, 2022
Routine
Date: Jun 24, 2022
Visit Reason
The inspection was conducted as part of the Pennsylvania Department of Human Services, Bureau of Human Service Licensing routine licensing inspections on 06/24/2022 and 07/01/2022.
Findings
No regulatory citations were identified as a result of this inspection.
Inspection Report — Feb 22, 2022
Routine
Date: Feb 22, 2022
Visit Reason
The inspection was conducted as part of licensing inspections by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing on multiple dates in February 2022.
Findings
No regulatory citations were identified as a result of the inspections conducted on 02/04/2022, 02/07/2022, 02/10/2022, and 02/22/2022 at the facility.
Report Facts
Inspection dates: 4
Inspection Report — Dec 14, 2021
Routine
Date: Dec 14, 2021
Visit Reason
The inspection was conducted as a routine licensing inspection by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Notice — Aug 27, 2021
Date: Aug 27, 2021
Visit Reason
The document serves as a renewal notification and license issuance for South Mountain Memory Care, a Personal Care Home, confirming receipt of the renewal application and advising of the requirement for an annual onsite inspection within the next twelve months.
Findings
No inspection findings are reported in this document; it is an administrative notice confirming license renewal and outlining the Department's inspection requirements.
Report Facts
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary, Office of Long-term Living | Signed the renewal notification letter |
Inspection Report — Aug 3, 2021
Renewal
Date: Aug 3, 2021
Visit Reason
The inspection was conducted as a renewal inspection of the South Mountain Memory Care facility to assess compliance with licensing requirements.
Findings
The inspection found deficiencies related to refund procedures following a resident's death, improper food storage, and missing documentation of resident education regarding the right to refuse medication. Plans of correction were accepted and implemented for all deficiencies.
Citations (3)
Refund to resident's estate after death was not prorated correctly according to the Elder Care Payment Restitution Act.
An uncovered bowl of oatmeal was found in the kitchen freezer, violating food storage requirements.
Records for several residents did not include documentation that they were educated about their right to question or refuse medications.
Report Facts
Residents Served: 25
Monthly Bill: 6365
Residents Missing Education Documentation: 16
Staffing: 50
Waking Staff: 38
Inspection Report — Jun 24, 2021
Routine
Date: Jun 24, 2021
Visit Reason
The inspection was conducted as a licensing inspection by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing.
Findings
No regulatory citations were identified as a result of this inspection.
Inspection Report — Oct 28, 2020
Complaint Investigation
Date: Oct 28, 2020
Visit Reason
The inspection was conducted as a complaint investigation to review compliance with staffing and resident support requirements at South Mountain Memory Care.
Complaint Details
The visit was complaint-related and substantiated by findings of insufficient staffing and inaccurate resident support plan documentation.
Findings
The facility was found to have insufficient staffing to meet the needs of residents, particularly during night shifts, with several residents requiring two-person assists. The facility submitted a plan of correction and hired additional staff to address these issues, and the resident support plan for an immobile resident was revised and accepted.
Citations (2)
Staffing was inadequate to meet resident needs, with only 2 Personal Care Aides on duty from 11pm to 7am on 10/17 and 10/18 despite 19 residents in the secured dementia unit and 5 requiring two-person assist.
The resident assessment and support plan (RASP) for Resident 1 inaccurately indicated minimal assistance needed, but the resident is immobile and requires staff assistance for transfers and evacuation.
Report Facts
Residents Served: 19
Current Residents: 3
Personal Care Aides on Night Shift: 2
Residents Requiring 2-Person Assist: 5
Staffing Hours: 43
Resident Support Staff: 5
Waking Staff: 32
Inspection Report — Oct 14, 2020
Follow-Up
Date: Oct 14, 2020
Visit Reason
The visit was a follow-up inspection to verify the implementation of a previously submitted plan of correction at South Mountain Memory Care.
Findings
The facility had previously been cited for issues related to unobstructed egress and incomplete medical evaluations. The plan of correction for the magnetic locking system installation was implemented by 12/9/2020. The medical evaluation documentation for Resident #1 was corrected and audited for completeness.
Citations (2)
2600 121a. Stairways, hallways, doorways, passageways and egress routes must be unlocked and unobstructed. The laundry room door was locked by a key operating lock but must be locked with a magnetic lock and unobstructed.
2600 141a. A resident must have a medical evaluation within 60 days prior to admission or within 30 days after admission. Resident #1's medical evaluation dated 9/14/20 did not include pulse rate, health status, or cognitive functioning.
Report Facts
Residents Served: 20
Current Hospice Residents: 3
Notice — Aug 6, 2020
Date: Aug 6, 2020
Visit Reason
This document serves as a renewal notification and license issuance for South Mountain Memory Care LLC to operate a Personal Care Home. It also informs the facility that an annual onsite inspection will be conducted within the next twelve months.
Findings
No inspection findings are reported in this document. It confirms the issuance of a regular license following the renewal application.
Report Facts
Inspection Report — Jul 7, 2020
Routine
Date: Jul 7, 2020
Visit Reason
The inspection visits were routine licensing inspections conducted by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing on multiple dates from April 24, 2020 through July 7, 2020.
Findings
No regulatory citations were identified as a result of these inspections.
Inspection Report — Sep 26, 2019
Renewal
Date: Sep 26, 2019
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 Ch. 2600 for South Mountain Memory Care.
Findings
The inspection identified violations related to medication labeling and storage procedures. The facility submitted plans of correction addressing these issues with partial implementation noted as of October 16, 2019.
Citations (2)
2600.184b: Resident #1's Bayer Aspirin 81mg was not labeled with the resident's name. This was a repeated violation from 8-10-18.
2600.185a: The home did not properly maintain the Medication Administrator Record for resident #2 due to incorrect transcription of blood glucose test results. This was a repeated violation from 2-22-19.
Report Facts
Residents Served: 26
Current Hospice Residents: 4
Total Daily Staff: 52
Waking Staff: 39
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joan Matura | Director of Wellness | Named in medication labeling and storage procedure findings |
Inspection Report — Jun 6, 2019
Renewal
Date: Jun 6, 2019
Visit Reason
The document is a renewal application and license issuance for South Mountain Memory Care LLC to operate a Personal Care Home. The Department will conduct an onsite inspection within the next twelve months as part of the annual inspection requirement.
Findings
This document does not contain inspection findings but confirms the issuance of a regular license following the renewal application and outlines the Department's plan to conduct an inspection within twelve months.
Report Facts
Inspection Report — Feb 22, 2019
Complaint Investigation
Date: Feb 22, 2019
Visit Reason
The inspection was conducted as a complaint investigation at South Mountain Memory Care to assess compliance with 55 Pa. Code Chapter 2600 for Personal Care Homes.
Complaint Details
The inspection was triggered by a complaint. The violations found were related to staff training, resident medical and cognitive preadmission screenings, and glucometer calibration and documentation.
Findings
Multiple violations were found including incomplete direct care staff training, improper calibration and documentation of resident glucometers, incomplete preadmission screening, delayed medical evaluations, and incomplete cognitive preadmission screening. Plans of correction were submitted and partially implemented as of March 19, 2019.
Citations (5)
55 Pa.Code §2600 - Staff person A did not complete the department-approved direct care training course and competency test.
55 Pa.Code §2600 - Glucometers for Residents #1 and #2 were not calibrated to the correct date and time, resulting in inaccurate blood glucose documentation.
55 Pa.Code §2600 - Resident #3's preadmission screening was not completed within the required timeframe prior to admission.
55 Pa.Code §2600 - Resident #3's medical evaluation by a qualified professional was not completed within 60 days prior to admission.
55 Pa.Code §2600 - Resident #3's cognitive preadmission screening was not completed within 72 hours prior to admission as required.
Report Facts
Number of Residents Served: 16
Total Daily Staff: 32
Waking Staff: 24
Number of Current Hospice Residents: 2
Number of Hospice Residents in Past Year: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Colleen McCabe | Administrator | Named as legal entity representative and signer of plan of correction |
| Kristin DeVries | Inspector | Conducted the inspection on-site |
| Vanessa Mendez | Inspector | Conducted the inspection on-site |
Inspection Report — Aug 10, 2018
Annual Inspection
Date: Aug 10, 2018
Visit Reason
The inspection was an annual licensing inspection conducted by the Department's Bureau of Human Services Licensing on August 10, 2018, including renewal and incident reasons.
Findings
Multiple violations of 55 Pa. Code Chapter 2600 related to Personal Care Homes were found, including resident abuse, facility maintenance issues, documentation errors, medication labeling, and safety concerns. Plans of correction were submitted and partially implemented as of August 22, 2018.
Citations (9)
55 Pa.Code §2600.42(b) Resident #1 pushed Resident #2 twice causing Resident #2 to fracture the left humerus. Staff were unable to prevent the second incident.
55 Pa.Code §2600.121(a) The exit door in the North Wing did not open due to weather stripping swelling with humidity and was fixed at inspection.
55 Pa.Code §2600.132(c) Fire drill logs showed discrepancies in exit used and resident counts during drills, indicating user error in documentation.
55 Pa.Code §2600.141(a)(2) Resident #2's medical evaluation was a faxed copy, not a photocopy, with transcription errors disputed by the facility.
55 Pa.Code §2600.184(b) OTC medications in the med cart were unlabeled and lacked identification of the resident to whom they belonged.
55 Pa.Code §2600.224(a) Resident #1's pre-admission screening was completed late, indicating user error in documentation.
55 Pa.Code §2600.232(d) The North wing exit door led to an unsecured area with no magnetic locking device, posing a safety risk to residents.
55 Pa.Code §2600.234(a) Resident #2 was admitted without a timely support plan; Resident #1's readmission documentation was also delayed.
55 Pa.Code §2600.251(b) Resident #2's RASP record contained correction tape over entries and repeated phone numbers due to electronic software errors.
Report Facts
Staffing: 25
Staffing: 20
Number of Deficiencies: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Victoria B. Snyder | Administrator | Named as responsible staff for multiple violations and plans of correction |
| Amy Deluca | Department representative conducting the inspection |
Notice — Apr 27, 2018
Date: Apr 27, 2018
Visit Reason
The document serves as a response to a request for a waiver of specific Pennsylvania Code regulations related to admission, medical evaluation, and reportable incidents for South Mountain Memory Care LLC.
Findings
The waiver is granted under specified conditions, including the use of alternative forms for reportable incidents and medical evaluations. The waiver remains effective as long as conditions are met and will be reviewed annually during inspections.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jacqueline L. Rowe | Director | Signed the waiver approval letter. |
Inspection Report — Mar 8, 2018
Original Licensing
Date: Mar 8, 2018
Visit Reason
The inspection was conducted as a licensing inspection for a new facility that was not yet serving four or more residents.
Findings
The facility was found to be in substantial compliance with regulations but had violations that needed correction. Two violations were documented related to snow removal and exit door locking mechanisms.
Citations (2)
55 Pa.Code §2600.100(b): The exit ramp from the north side rear was covered with snow, obstructing safe egress. Snow was removed on 3/9/18 and staff were instructed to ensure all exits are cleared after snowfall.
55 Pa.Code §2600.233(c): Directions for operating the home's locking mechanism were incorrectly posted with the code 201201 instead of the correct code 123123. New responsibilities were assigned to prevent future errors.
Report Facts
Number of Residents Served: 2
Total Daily Staff: 4
Waking Staff: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Victoria Snyder | Executive Director | Named as legal entity representative signing plan of correction on violations |
| Ryan Novak | Inspector | Conducted the on-site inspection on 3/8/2018 |
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