Inspection Reports for Abode Care of Monroeville
2560 STROSCHEIN ROAD,, MONROEVILLE, PA, 15146
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
37 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
687% worse than Pennsylvania average
Pennsylvania average: 4.7 deficiencies/yearDeficiencies per year
36
27
18
9
0
Census
Latest occupancy rate
53% occupied
Based on a May 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Census: 35
Capacity: 66
Deficiencies: 0
Date: May 22, 2025
Visit Reason
The inspection was conducted as a licensing inspection by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing, with the reason stated as 'Fine'.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Residents Served: 35
License Capacity: 66
Current Residents in Hospice: 9
Resident Support Staff Hours: 0
Total Daily Staff: 61
Waking Staff: 46
Residents Age 60 or Older: 64
Residents Diagnosed with Mental Illness: 3
Residents Diagnosed with Intellectual Disability: 1
Residents with Mobility Need: 26
Residents with Physical Disability: 1
Inspection Report
Complaint Investigation
Census: 35
Capacity: 66
Deficiencies: 4
Date: May 15, 2025
Visit Reason
The inspection was a partial, unannounced complaint investigation conducted on 05/15/2025 to review provisional compliance at Abode Care of Monroeville.
Complaint Details
The inspection was triggered by a complaint and was provisional in nature. The plan of correction was fully implemented as of 06/30/2025.
Findings
The inspection identified multiple deficiencies including unlocked resident records accessible in a conference room, residents smoking in unauthorized areas contrary to the facility's smoking policy, incorrect medication labeling, and incomplete documentation in a resident's support plan regarding use of a Hoyer lift. Plans of correction were accepted and implemented by 06/30/2025.
Deficiencies (4)
Resident records were unlocked, unattended, and accessible in the conference room cabinet.
Residents were observed smoking directly in front of the main entrance door despite a no smoking sign and designated smoking area elsewhere.
Medication label did not match physician's orders regarding dosage and administration times.
Resident's support plan did not indicate how the home was addressing the use of a Hoyer lift for safe transfers.
Report Facts
License Capacity: 66
Residents Served: 35
Current Hospice Residents: 5
Residents Age 60 or Older: 34
Residents Diagnosed with Mental Illness: 4
Residents Diagnosed with Intellectual Disability: 2
Residents with Mobility Need: 26
Residents with Physical Disability: 1
Total Daily Staff: 61
Waking Staff: 46
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director | Responsible for securing records, conducting staff training on HIPAA confidentiality, reviewing smoking policy, and ensuring ongoing compliance. | |
| Director of Wellness | Reviewed medication administration records, provided education to Med Techs, revised resident support plans, and responsible for ongoing compliance. | |
| Marketing Director | Inadvertently left conference room door unlocked where resident records were accessible. | |
| Regional Director | Re-educated Executive Director on record confidentiality. | |
| Maintenance Director | Installed a canopy in the designated smoking area following resident council request. |
Inspection Report
Complaint Investigation
Census: 35
Capacity: 66
Deficiencies: 2
Date: Apr 1, 2025
Visit Reason
The inspection was conducted as a complaint and incident investigation, unannounced, to review allegations and compliance at the facility.
Complaint Details
The visit was complaint-related involving an allegation of verbal abuse by a direct care staff person against a resident. The allegation was substantiated by Protective Services notification. The facility initially failed to implement an approved plan of supervision but later corrected the issue.
Findings
The inspection found a violation related to improper handling of an abuse allegation involving a staff member, and a maintenance issue with a keypad on an emergency exit door alarm. Plans of correction were submitted and accepted for both violations.
Deficiencies (2)
Failure to immediately develop and implement an approved plan of supervision or suspend a staff person involved in an alleged verbal abuse incident.
Keypad on the emergency exit door alarm was missing the key for the number three, preventing the alarm from being silenced without entering a code.
Report Facts
License Capacity: 66
Residents Served: 35
Current Residents in Hospice: 6
Residents Diagnosed with Mental Illness: 3
Residents Diagnosed with Intellectual Disability: 1
Residents with Mobility Need: 27
Residents with Physical Disability: 1
Residents Age 60 or Older: 35
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Direct care staff person A | Assistant Director of Wellness | Named in verbal abuse allegation and plan of supervision violation. |
| Executive Director | Educated Director of Wellness on plan of supervision procedures and responsible for ongoing compliance. | |
| Director of Wellness | Responsible for implementing plan of supervision and ongoing compliance. | |
| Maintenance Director | Notified of keypad malfunction and responsible for maintenance repairs. | |
| Maintenance Supervisor | Responsible for daily checks to ensure equipment repairs. |
Inspection Report
Renewal
Census: 36
Capacity: 66
Deficiencies: 26
Date: Jan 15, 2025
Visit Reason
The inspection was conducted as a renewal inspection combined with complaint and provisional interim reviews, including follow-up on plans of correction and enforcement.
Complaint Details
The inspection included complaint investigations related to allegations of resident abuse by staff person A, failure to report abuse timely, and improper supervision. The complaints were substantiated with repeat violations noted.
Findings
The facility was found to have multiple violations including resident abuse reporting failures, improper supervision, environmental hazards, medication administration issues, and deficiencies in staff training and documentation. A provisional license was issued with a requirement to correct all violations by specified dates.
Deficiencies (26)
Failure to immediately report suspected abuse of a resident and delayed reporting to the Area Agency on Aging.
Staff person A continued to work unsupervised despite allegations of abuse and lack of proper supervision.
Resident #1 was verbally and physically abused by staff person A, including leaving resident in soiled brief and failure to provide care.
Resident #2's mattress was concaved and sunken, and a new mattress was not provided despite multiple reports.
Resident #9's mattress cover was stained and torn.
Resident #11's medication administration record was incomplete and lacked documentation of medication administration times.
Resident privacy coding was improperly posted, revealing residents' names.
Hot water temperature exceeded 120°F in resident bathrooms.
Trash receptacles in kitchen were uncovered, allowing penetration of insects and rodents.
Fire drills were not conducted monthly, and fire safety inspections were not documented.
Emergency procedures were not posted in a conspicuous place.
Criminal background checks were not completed timely for new staff hires.
Direct care staff lacked required qualifications and training documentation.
Administrator and staff failed to complete required orientation and competency-based training.
Resident contracts were not completed or reviewed prior to admission.
Quality management plan was not established or documented.
Smoking area was improperly located and not posted with required signage.
Resident #12 was served inappropriate diet inconsistent with medical orders.
Menus were not posted weekly in a conspicuous place.
Food items were not labeled or dated properly; leftover food was improperly stored.
Thermometer was missing in food storage freezer.
Furniture and equipment were in disrepair, including missing towel bars and damaged bathroom doors.
Portable space heaters were found in resident rooms, which is prohibited.
Fire drill records indicated no drills conducted for several months.
Evacuation times exceeded regulatory limits and no maximum evacuation time was established.
Resident medical evaluations did not include medication regimens as required.
Report Facts
License Capacity: 66
Census: 36
Fine Amount: 180
Fine Class: 2
Number of Staff: 52
Waking Staff: 39
Resident Served: 36
Residents with Mobility Need: 16
Inspection Report
Renewal
Census: 36
Capacity: 66
Deficiencies: 18
Date: Oct 25, 2024
Visit Reason
The inspection was conducted as part of a renewal, complaint, provisional, and interim review of the Abode Care of Monroeville facility, including multiple licensing inspections and follow-up submissions.
Complaint Details
The inspection included complaint investigations related to resident abuse, mistreatment, and failure to report incidents timely. The complaint was substantiated with findings of abuse by staff person A towards resident #1 and failures in supervision and reporting.
Findings
The facility was found to have multiple violations including resident abuse reporting failures, improper supervision, fire safety deficiencies, medication administration errors, and environmental hazards. A second provisional license was issued with a requirement to correct all violations by specified dates.
Deficiencies (18)
Failure to immediately report suspected abuse of a resident and failure to supervise staff involved in abuse allegations.
Resident #1 was verbally and physically abused by staff person A, with delayed reporting to protective services.
Resident #1 left in soiled brief for extended periods and mistreated by staff person A.
Resident #1 was subjected to verbal abuse and humiliation by staff person A.
Resident #2's mattress was concaved and sunken, not properly supporting the resident.
Resident #9's mattress cover was stained and torn.
Resident #11 had incomplete medication administration records and missing diagnoses in assessments.
Hot water temperature exceeded 120°F in resident bathroom areas.
Fire drills were not conducted monthly and evacuation times exceeded standards.
Emergency procedures were not posted in a conspicuous place.
Trash receptacles in kitchen were uncovered and improperly maintained.
Furniture and equipment, including towel bars and bathroom door hardware, were in disrepair.
Direct care staff lacked required training and documentation for orientation, competency, and annual training topics.
Criminal background checks were incomplete for some staff members.
Resident records were not kept confidential and privacy coding was improperly displayed.
Resident #10 medication administration errors with Diclofenac Sodium gel were documented.
Portable space heaters were found in resident rooms, which is prohibited.
The home lacked a current written description of services and activities provided.
Report Facts
License Capacity: 66
Census: 36
Fine Amount: 180
Fine Mandated Correction Days: 5
Staff Total Daily: 52
Waking Staff: 39
Resident Served: 36
Residents with Mobility Need: 16
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Juliet Marsala | Deputy Secretary | Signed the letter issuing the second provisional license. |
| Unnamed Administrator | Administrator | Named in multiple findings related to abuse reporting, supervision, and corrective actions. |
| Staff person A | Involved in abuse and mistreatment allegations towards resident #1. | |
| Staff person B | Provided care to resident #1 and involved in abuse investigation. | |
| Staff person E | Did not receive required training in 2024 staff training year. | |
| Executive Director | Responsible for implementing corrective actions and training. | |
| Maintenance Director | Responsible for fire safety compliance and maintenance corrective actions. | |
| Admissions Director | Responsible for admissions contracts and compliance. | |
| DON | Director of Nursing | Involved in medication administration corrective actions and staff training. |
| ADON | Assistant Director of Nursing | Involved in medication administration corrective actions and staff training. |
Inspection Report
Renewal
Census: 36
Capacity: 66
Deficiencies: 34
Date: Oct 25, 2024
Visit Reason
The inspection was conducted as part of a renewal, complaint, provisional, and interim review of the Abode Care of Monroeville facility, including follow-up on previous violations and enforcement actions.
Complaint Details
The inspection was complaint-related due to allegations of resident abuse and mistreatment, failure to report abuse timely, and failure to comply with previous plans of correction. The complaint was substantiated with repeat violations noted.
Findings
The facility was found to have multiple violations including resident abuse reporting failures, improper supervision, environmental hazards, medication administration errors, and deficiencies in staff training and documentation. A provisional license was issued with a plan of correction required to address these issues.
Deficiencies (34)
Failure to immediately report suspected abuse of a resident and failure to supervise staff involved in abuse allegations.
Resident #1 was verbally and physically abused by staff person A; failure to report timely to protective services.
Resident #1 left in soiled brief for extended periods; staff failed to provide adequate care.
Resident #1 was verbally abused and staff person A was placed on probationary status with supervision.
Resident #2's mattress was concaved and sunken; no replacement provided despite multiple reports.
Resident #9's mattress cover was stained and torn; linens were not properly maintained.
Resident #10 medication administration errors with Diclofenac Sodium gel; documentation and monitoring deficiencies.
Resident #6's medical evaluation did not include a medication regimen.
Resident privacy coding was improperly posted, exposing resident names.
Trash receptacles uncovered in kitchen; food safety violations noted.
Hole in ceiling and drywall damage in A Hall behind reception area.
Hot water temperatures exceeded 120°F in resident bathrooms.
Emergency procedures and fire safety inspections were not properly documented or posted.
Fire drills were not conducted monthly; last drill was in August 2024.
Staff training plans for 2025 were not developed or documented.
Direct care staff lacked required qualifications and training documentation.
Portable space heaters were found in resident rooms, violating policy.
Resident #12 was served inappropriate diet items contrary to prescribed mechanical soft diet.
Food safety violations including unlabeled leftovers and improper food storage.
Resident #1 was left in a soiled brief for extended periods; staff failed to provide adequate care.
Resident #1 was verbally abused and staff person A was placed on probationary status with supervision.
Resident #6's medical evaluation did not include a medication regimen.
Resident #10 medication administration errors with Diclofenac Sodium gel; documentation and monitoring deficiencies.
Resident privacy coding was improperly posted, exposing resident names.
Trash receptacles uncovered in kitchen; food safety violations noted.
Hole in ceiling and drywall damage in A Hall behind reception area.
Hot water temperatures exceeded 120°F in resident bathrooms.
Emergency procedures and fire safety inspections were not properly documented or posted.
Fire drills were not conducted monthly; last drill was in August 2024.
Staff training plans for 2025 were not developed or documented.
Direct care staff lacked required qualifications and training documentation.
Portable space heaters were found in resident rooms, violating policy.
Resident #12 was served inappropriate diet items contrary to prescribed mechanical soft diet.
Food safety violations including unlabeled leftovers and improper food storage.
Report Facts
License Capacity: 66
Residents Served: 36
Current Residents: 7
Total Daily Staff: 52
Waking Staff: 39
Fine Amount: 180
Fine Per Resident Per Day: 5
Fine Mandated Correction Days: 5
Inspection Report
Complaint Investigation
Census: 36
Capacity: 66
Deficiencies: 4
Date: Sep 20, 2024
Visit Reason
The inspection was conducted as a complaint and incident investigation at Abode Care of Monroeville.
Complaint Details
The visit was complaint-related and substantiated by findings including a verbal dispute between staff and resident, and other violations related to resident rights and documentation.
Findings
The inspection found multiple deficiencies including unsigned resident contracts, lack of signed statements acknowledging receipt of resident rights, a verbal dispute involving staff disrespecting a resident, and failure to document resident education on the right to refuse medication. Corrective actions were implemented including staff termination, policy reinforcement, and contract addendums.
Deficiencies (4)
Resident-home agreement was not signed by the resident.
No signed statement in resident record acknowledging receipt of resident rights and complaint procedures.
Verbal dispute where direct care staff person A verbally disrespected a resident and refused to provide care.
No documentation that resident had been educated on the right to question or refuse a medication if the resident believes there may be a medication error.
Report Facts
License Capacity: 66
Residents Served: 36
Current Hospice Residents: 7
Residents with Mobility Need: 18
Residents 60 Years or Older: 36
Residents Diagnosed with Mental Illness: 2
Residents Diagnosed with Intellectual Disability: 1
Residents with Physical Disability: 2
Total Daily Staff: 54
Waking Staff: 41
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Administrator involved in corrective actions including attempts to obtain resident signatures and terminating staff person A. | |
| Direct Care Staff Person A | Staff member involved in verbal dispute with resident and subsequently terminated. | |
| Direct Care Staff Person B | Witnessed verbal dispute between staff person A and resident. |
Inspection Report
Complaint Investigation
Census: 35
Capacity: 66
Deficiencies: 13
Date: May 1, 2024
Visit Reason
The inspection was conducted as a complaint investigation following allegations of mistreatment or abuse of residents, failure to submit and comply with an acceptable plan of correction, and other regulatory violations at Abode Care of Monroeville.
Complaint Details
The complaint involved allegations of abuse including staff verbally abusing residents, providing residents with alcohol and marijuana, failure to report incidents timely to the Department and Area Agency on Aging, and inappropriate sexual behaviors between residents. Staff members involved were terminated. The facility failed to immediately suspend staff involved in abuse allegations and failed to report incidents timely.
Findings
Multiple violations were found including abuse of residents, failure to report incidents timely, use of plastic cutlery regularly, incomplete medication administration records, improper food storage and labeling, unsecured medications, and confidentiality breaches. Several staff members were terminated due to abuse allegations. Plans of correction were submitted but many were not implemented by the follow-up dates.
Deficiencies (13)
Staff person screamed at resident during care and incident was not reported timely.
Resident verbally abused by staff member.
Plastic cutlery used regularly by residents during meals.
Medication administration records missing staff initials for multiple doses.
Menus not posted for at least one week in advance.
Medication and syringes not kept locked; medications found unsecured in resident room.
Resident abuse incidents involving staff providing alcohol and marijuana to residents and verbal abuse not reported timely.
Resident sexually inappropriate behaviors not documented in support plan.
Resident treated without dignity and respect; staff wrote messages on resident's meal containers causing discomfort.
Trash lids left open allowing exposure to insects and rodents.
Unlabeled and undated leftover food items found in kitchen refrigerator and freezer.
Food items stored in unsealed containers in dry food storage room.
Dented cans of food present in dry food storage room.
Report Facts
License Capacity: 66
Residents Served: 35
Staffing Hours: 57
Waking Staff: 43
Fine Amount: 185
Census at Inspection: 37
Total Daily Staff: 65
Waking Staff: 49
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff person A | Dietary Aide | Named in abuse and incident reporting violations involving verbal abuse and providing alcohol and marijuana to residents. |
| Staff person E | Named in verbal abuse violation for calling resident a 'whore' and yelling obscenities. | |
| Juliet Marsala | Deputy Secretary, Office of Long-term Living | Signed enforcement and licensing correspondence. |
Inspection Report
Complaint Investigation
Census: 35
Capacity: 66
Deficiencies: 13
Date: May 1, 2024
Visit Reason
The inspection was conducted as a complaint investigation following allegations of mistreatment, abuse, and noncompliance with regulations at Abode Care of Monroeville.
Complaint Details
The complaint involved allegations of abuse including verbal abuse, providing residents with alcohol and marijuana, failure to report incidents timely, and sexually inappropriate behaviors between residents. The investigation confirmed these allegations and found additional violations related to resident care and facility management.
Findings
Multiple violations were found including abuse of residents, failure to report incidents timely, improper medication administration documentation, use of plastic cutlery regularly, unlabeled and undated food items, unsecured medications, and inadequate supervision of staff involved in abuse allegations. Several repeat violations were noted.
Deficiencies (13)
Staff person A screamed at resident #1 during care and failed to report the incident timely.
Resident #1 was verbally abused by staff person A.
Plastic cutlery was used regularly by residents during meals.
Menus were not posted for the required one week in advance.
Medication administration records lacked staff initials for multiple medications and dates.
Staff person A provided alcohol and marijuana to residents #1 and #2 and failed to report timely.
Staff person E verbally abused resident #4 and failed to report timely.
Residents #4 and #5 engaged in sexually inappropriate behavior not documented in support plans.
An empty medication card with resident information was found on the ground near the dumpster.
Medications and syringes were found unsecured in resident #6's room.
Food items were unlabeled, undated, unsealed, or outdated in the kitchen and storage areas.
Dumpster lids were left open allowing exposure of trash.
Resident #7 had messages written on meal containers making them uncomfortable.
Report Facts
License Capacity: 66
Residents Served: 35
Staffing Hours: 57
Waking Staff: 43
Fine Amount: 185
Fine Duration Days: 5
Inspection Report
Complaint Investigation
Census: 33
Capacity: 66
Deficiencies: 1
Date: Feb 22, 2024
Visit Reason
The inspection was conducted as a complaint investigation following a complaint received by the Pennsylvania Department of Human Services.
Complaint Details
The complaint was substantiated as the investigation confirmed verbal abuse by staff person A towards a resident. Staff person A was placed on supervision and corrective actions were directed and implemented.
Findings
The investigation found that a staff person verbally abused a resident by attempting to forcibly remove the resident's call bell pendant, causing distress to the resident. A plan of correction was implemented including supervision of the staff member, staff re-education on resident rights and de-escalation, and ongoing monitoring.
Deficiencies (1)
A resident was verbally abused by staff person A who attempted to forcibly remove the resident's call bell pendant, causing the resident to become upset and feel bullied.
Report Facts
License Capacity: 66
Residents Served: 33
Current Hospice Residents: 4
Staffing Hours: 50
Waking Staff: 38
Duration of Supervision: 3
Inspection Report
Complaint Investigation
Census: 36
Capacity: 66
Deficiencies: 0
Date: Jan 3, 2024
Visit Reason
The inspection was conducted as a complaint investigation at the facility ABODE CARE OF MONROEVILLE on January 3, 2024.
Complaint Details
The inspection was complaint-related, but no deficiencies were found and no follow-up was required.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
License Capacity: 66
Residents Served: 36
Current Hospice Residents: 7
Resident Support Staff: 48
Waking Staff: 36
Residents 60 Years or Older: 36
Residents Diagnosed with Mental Illness: 2
Residents Diagnosed with Intellectual Disability: 1
Residents with Mobility Need: 12
Residents with Physical Disability: 1
Inspection Report
Plan of Correction
Census: 38
Capacity: 66
Deficiencies: 11
Date: Nov 28, 2023
Visit Reason
The inspection was conducted as a result of a renewal and complaint review of the facility on 11/28/2023 and 11/30/2023.
Findings
The submitted plan of correction was determined to be fully implemented following the inspection. Multiple deficiencies were identified including issues with record confidentiality, written contracts, surfaces, furniture and equipment, resident rights, support plans, standardized forms, and record content, all of which were addressed with corrective actions.
Deficiencies (11)
Wellness office containing resident records and narcotic count sheet binders was unlocked, unattended, and accessible.
Resident #1's written contract did not include the date the contract was executed.
Emergency exit door in activity room did not latch or fully close; fire exit doors between hallway B and C did not fully close, leaving a gap of approximately 1 inch.
Freezer had several inches of ice buildup in the dry storage area.
Resident #1 has not been educated on the right to refuse medication if a medication error is suspected.
Resident #2 has not been educated on the right to refuse medication if a medication error is suspected.
Resident #3 has not been educated on the right to refuse medication if a medication error is suspected.
Resident #4 has not been educated on the right to refuse medication if a medication error is suspected.
Resident #4's support plan does not include a phone number to contact the hospice agency.
Residents 1, 2, 3, and 4 medical evaluations were not completed on the Department's current standardized form.
Resident #4's most recent photo in record is outdated.
Report Facts
License Capacity: 66
Residents Served: 38
Current Residents in Hospice: 7
Residents Diagnosed with Mental Illness: 2
Residents with Mobility Need: 18
Residents with Physical Disability: 1
Residents Age 60 or Older: 38
Inspection Report
Follow-Up
Census: 35
Capacity: 66
Deficiencies: 7
Date: May 4, 2023
Visit Reason
The inspection was conducted as a follow-up to verify the implementation of a previously submitted plan of correction related to complaints and incidents at the facility.
Complaint Details
The inspection was complaint-related, triggered by incidents including an assault and police presence at the facility. The complaint was substantiated as deficiencies were found in incident reporting and other areas.
Findings
The submitted plan of correction was determined to be fully implemented. The report details multiple deficiencies that were corrected, including incident reporting, sanitary conditions, medication storage procedures, resident assessments, support plan revisions, discharge and transfer documentation, and record content.
Deficiencies (7)
Failure to report incidents to the Department within 24 hours as required.
Unsanitary conditions in designated smoking areas with large accumulations of cigarette butts posing a fire hazard.
Failure to properly implement procedures for safe storage and accountability of medications and controlled substances, including incomplete narcotic count sign-in/out sheets.
Resident assessment not completed within 15 days of admission; resident lacks personal needs account and financial management documentation.
Support plan not revised to address significant behavioral changes and new hospice orders for a resident.
Resident discharge and transfer records lacked dates, reasons, and destination information.
Resident record did not include date of death or official death certificate for a resident who died in the home.
Report Facts
License Capacity: 66
Residents Served: 35
Current Residents in Hospice: 8
Residents with Mobility Need: 11
Residents Diagnosed with Mental Illness: 2
Residents Diagnosed with Intellectual Disability: 2
Residents with Physical Disability: 1
Inspection Report
Complaint Investigation
Census: 34
Capacity: 66
Deficiencies: 0
Date: Jan 20, 2023
Visit Reason
The inspection was conducted as a complaint investigation with an unannounced partial inspection on 01/20/2023.
Complaint Details
The inspection was triggered by a complaint; no deficiencies were found and no follow-up was required.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Total Daily Staff: 57
Waking Staff: 43
Resident Support Staff: 0
Residents Served: 34
License Capacity: 66
Current Hospice Residents: 6
Residents Diagnosed with Mental Illness: 1
Residents Diagnosed with Intellectual Disability: 0
Residents with Mobility Need: 23
Residents with Physical Disability: 2
Residents Age 60 or Older: 34
Residents Receiving Supplemental Security Income: 0
Inspection Report
Complaint Investigation
Census: 35
Capacity: 66
Deficiencies: 1
Date: Oct 19, 2022
Visit Reason
The inspection was conducted as a complaint investigation and incident review, including an unannounced partial inspection on 10/19/2022 with an exit conference on 11/23/2022.
Complaint Details
The visit was complaint-related due to an incident where staff member A independently transferred resident #1 who required two-person assistance, leading to a fall and hospital admission. The plan of correction was fully implemented as of 12/23/2022.
Findings
The investigation found a violation related to improper assistance during resident transfer, resulting in a resident fall and hospitalization. The facility implemented a plan of correction including staff re-education, supervision, and ongoing monitoring to ensure compliance with assistance requirements.
Deficiencies (1)
Failure to provide required two-person assistance during resident transfer, resulting in resident fall and hospitalization.
Report Facts
License Capacity: 66
Residents Served: 35
Current Hospice Residents: 7
Residents 60 Years or Older: 35
Residents with Mobility Need: 19
Total Daily Staff: 54
Waking Staff: 41
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Margliotti | Submitted the plan of correction on 12/22/2022 | |
| Larry Mazza | Reviewer of plan of correction |
Inspection Report
Renewal
Census: 18
Capacity: 66
Deficiencies: 9
Date: May 2, 2022
Visit Reason
The inspection was conducted as a renewal inspection of the facility's license.
Findings
The inspection identified multiple deficiencies including combustible storage near heat sources, fire safety inspection and drill issues, evacuation times exceeding limits, menu change notification failures, medication labeling and administration errors, and undated posted menus. Plans of correction were accepted and implemented for all deficiencies.
Deficiencies (9)
3 cardboard boxes were stored on the floor of the pantry approximately 5" from the gas hot water heater.
The home’s most recent fire safety inspection and fire drill conducted by a fire safety expert was completed on 4/13/22; however, the previous fire safety inspection and fire drill was completed on 5/21/19.
Fire drill evacuation times exceeded 2 minutes, 30 seconds on multiple dates without documentation from a fire safety expert indicating a maximum safe evacuation time exceeding 2 minutes, 30 seconds.
On 5/2/22, a grilled ham and swiss cheese sandwich was listed on the menu for lunch; however, pasta with meat sauce was served instead without advance notice posted.
Resident #1's medication pharmacy label did not match prescribed dosage and instructions for administration.
Resident #2’s glucometer was not set to the current date and time.
Resident #1’s medication administration record (MAR) did not match physician orders regarding frequency of administration.
The current 2 weeks of menus were posted but were undated (repeat violation).
Resident #1 was administered medication in each eye daily since 4/1/22 contrary to prescriber’s orders (repeat violation).
Report Facts
License Capacity: 66
Residents Served: 18
Evacuation Time: 242
Evacuation Time: 255
Evacuation Time: 220
Staffing: 28
Waking Staff: 21
Inspection Report
Follow-Up
Census: 25
Capacity: 66
Deficiencies: 10
Date: Jan 14, 2022
Visit Reason
The inspection was a follow-up visit conducted on 01/14/2022 to review the submitted plan of correction related to a prior complaint and incident at the facility.
Complaint Details
The visit was complaint-related, triggered by allegations of resident abuse and incidents involving staff. The complaint was substantiated with multiple violations found.
Findings
The inspection found multiple deficiencies including failure to timely report suspected resident abuse, inadequate supervision plans for staff involved in abuse allegations, incomplete medical evaluations, medication administration errors, improper resident confinement practices during COVID-19 quarantine, incomplete resident assessments, and unsecured resident records. The facility submitted plans of correction which were accepted and deemed fully implemented.
Deficiencies (10)
Failure to immediately report suspected abuse of a resident to the local Area Agency on Aging.
Failure to immediately develop and implement a plan of supervision or suspend staff person involved in alleged abuse incident.
Failure to report the incident to the Department within 24 hours.
Residents denied access to telephone in privacy during COVID-19 quarantine; no cordless phones available for resident use.
Resident medical evaluation missing information on special health or dietary needs.
Failure to administer prescribed medications at prescribed times.
Prohibited seclusion practices by staff closing resident's bedroom door to prevent exit during quarantine.
Resident initial assessment missing contact information for mental health services.
Resident additional assessment not updated to reflect increased supervision needs due to behavioral issues.
Resident records unsecured and accessible to unauthorized persons.
Report Facts
License Capacity: 66
Residents Served: 25
Current Hospice Residents: 8
Residents Age 60 or Older: 24
Residents with Mobility Need: 12
Residents with Physical Disability: 1
Medication Missed: 2
Inspection Report
Complaint Investigation
Census: 27
Capacity: 66
Deficiencies: 3
Date: Sep 29, 2021
Visit Reason
The inspection was conducted as a complaint investigation with an unannounced partial inspection to review compliance and follow-up on a submitted plan of correction.
Complaint Details
The inspection was complaint-driven and included an exit conference on 10/01/2021. The submitted plan of correction was reviewed and found fully implemented by 10/28/2021.
Findings
The inspection found deficiencies including failure to issue refunds upon resident death as required by law, staff sleeping during night shifts violating awake staff requirements, and unqualified staff administering medications without completing required training.
Deficiencies (3)
Failure to issue refund to resident's personal representative or guardian after resident's death in accordance with the Elder Care Payment Restitution Act.
Staff members routinely took naps or dozed off during the 11:00 pm to 7:00 am shift, requiring residents to rouse sleeping staff.
Staff person A administered PRN medications without successfully completing the Department-approved medication administration course.
Report Facts
License Capacity: 66
Residents Served: 27
Current Hospice Residents: 6
Residents Age 60 or Older: 26
Residents with Mobility Need: 13
Residents with Physical Disability: 1
Total Daily Staff: 40
Waking Staff: 30
Inspection Report
Monitoring
Census: 33
Capacity: 66
Deficiencies: 15
Date: Jul 16, 2021
Visit Reason
The visit was a monitoring inspection to review compliance with regulations and follow up on previous corrective actions.
Findings
The facility was found to have multiple deficiencies related to compliance with health and safety laws, resident personal equipment, sanitary conditions, staff communication, emergency preparedness, and medication management. Corrective actions were implemented and documented, with some violations later withdrawn.
Deficiencies (15)
Numerous staff were observed without wearing face coverings as required by the Pennsylvania Department of Health order.
No carbon monoxide detectors were present near the home's gas furnace.
Resident-home contracts were not completed for some residents after a legal entity change.
Pennsylvania criminal background check was not completed timely for a staff member.
Resident #3's bed enablers lacked covers and one half-rail was loose, posing an entrapment hazard.
A urinal was left hanging and partially full on resident #3's bed enabler for several hours.
Resident #4's bathroom door was missing its door handle.
The home lacked a communication system enabling staff to immediately contact others in emergencies.
Emergency telephone numbers were not posted on or near telephones in hallways A and C.
The porch railing on the wooden fire escape ramp was detached and spindles were not securely attached.
One deck board on the wooden fire escape ramp was raised approximately 2 inches, posing a tripping hazard.
No thermometer was present in the small white chest freezer containing frozen foods.
A dog belonging to residents #5 and #6 lived in the home despite home rules prohibiting pets.
Numerous empty medication cards with pharmacy labels were unlocked and unattended on top of the medication cart.
Resident #3's bottle of Fluticasone Propionate was unlocked and unattended on top of the medication cart.
Report Facts
License Capacity: 66
Residents Served: 33
Staffing Hours: 47
Waking Staff: 35
Residents Served: 27
Staffing Hours: 39
Waking Staff: 29
Inspection Report
Routine
Census: 27
Capacity: 66
Deficiencies: 14
Date: May 20, 2021
Visit Reason
The inspection was a provisional, full, unannounced licensing inspection conducted by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing on 05/20/2021.
Findings
The inspection identified multiple deficiencies including failure to comply with mask mandates, lack of carbon monoxide detectors, incomplete resident-home contracts, delayed criminal background checks, unsafe resident equipment, sanitary issues, missing emergency phone numbers, unsecured porch railings, tripping hazards on exterior decks, absence of freezer thermometers, presence of unauthorized pets, and outdated posted menus. Plans of correction were accepted for all deficiencies with specified completion dates.
Deficiencies (14)
Numerous staff persons, including Director of Resident Care, were observed without wearing face coverings as required by the Pennsylvania Department of Health.
No carbon monoxide detectors were present near the home's gas furnace located next to the common living and dining rooms. Repeat violation from 10/26/2020.
New resident-home contracts were not completed for residents #1 and #2 following a legal entity change.
Staff member B was hired before completion of Pennsylvania criminal background check, which was delayed until 2/8/21.
No covers on resident #3's two half-rail bed enablers, posing possible entrapment hazard; left half-rail bed enabler loose and unsecured.
A urinal approximately 1/6th full with urine was hanging on resident #3's half-rail bed enabler for several hours.
Resident #4's bathroom door was missing its door handle.
The home did not have a system of communication enabling staff to immediately contact others for emergency assistance; home served 26 residents.
Emergency telephone numbers, including nearest hospital and fire department, were not posted on or near telephones in hallways A and C.
Porch railing on wooden fire escape ramp outside hallway C emergency exit was detached approximately 2 inches from the wall and about 40 railing spindles were not securely attached.
One deck board on the wooden fire escape ramp outside hallway C emergency exit was raised approximately 2 inches, posing a tripping hazard.
No thermometer was present in the small white chest freezer in the food storage room containing frozen foods.
A dog belonging to residents #5 and #6 lived in the home despite home rules prohibiting pets.
The only menu posted in a conspicuous and public place was dated 5/16/21 through 5/22/21, not meeting weekly posting requirements.
Report Facts
License Capacity: 66
Residents Served: 27
Current Hospice Residents: 6
Residents Diagnosed with Mental Illness: 1
Residents with Mobility Need: 12
Residents with Physical Disability: 1
Residents Age 60 or Older: 27
Total Daily Staff: 39
Waking Staff: 29
Inspection Report
Renewal
Deficiencies: 0
Date: Apr 15, 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 or deficiencies were identified as a result of this inspection.
Inspection Report
Renewal
Deficiencies: 0
Date: Mar 5, 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.
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