Inspection Reports for Adult Living at Rosebrook
723 SOUTH PIKE ROAD,, SARVER, PA, 16055
Back to Facility ProfileInspection Report Summary
The most recent inspection on September 17, 2025, found a deficiency related to a cockroach infestation linked to a resident’s motorized wheelchair and bedroom, with the facility’s corrective plan fully implemented. Earlier inspections showed a pattern of deficiencies involving resident safety, medication management, food storage, emergency preparedness, and reporting incidents, all addressed through accepted plans of correction. Complaint investigations mostly resulted in deficiencies related to assistance with activities of daily living and timely incident reporting, with no enforcement actions or fines listed in the available reports. Most complaints were either unsubstantiated or resolved through corrective actions. The inspection history shows ongoing attention to compliance with some recurring issues, but corrective measures have been consistently accepted and implemented.
Deficiencies (last 5 years)
Deficiencies (over 5 years)
6.4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
36% worse than Pennsylvania average
Pennsylvania average: 4.7 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
83% occupied
Based on a September 2025 inspection.
Occupancy over time
Inspection Report
Complaint Investigation
Census: 83
Capacity: 100
Deficiencies: 1
Date: Sep 17, 2025
Visit Reason
The inspection was conducted as a complaint investigation following reports of infestation and other concerns at the facility.
Complaint Details
The visit was complaint-driven and the plan of correction submitted by the facility was fully implemented and accepted.
Findings
The inspection found evidence of cockroach infestation linked to a resident's motorized wheelchair and resident bedroom. The facility implemented a plan of correction including pest control treatments and monitoring, which was determined to be fully implemented.
Deficiencies (1)
Evidence of cockroach infestation found in resident's motorized wheelchair and bedroom.
Report Facts
License Capacity: 100
Residents Served: 83
Current Residents in Hospice: 10
Residents Diagnosed with Mental Illness: 11
Residents with Mobility Need: 30
Residents Age 60 or Older: 83
Resident Support Staff Hours: 0
Total Daily Staff Hours: 113
Waking Staff Hours: 85
Inspection Report
Renewal
Census: 82
Capacity: 100
Deficiencies: 6
Date: Feb 11, 2025
Visit Reason
The inspection was conducted as a renewal inspection of the Adult Living at Rosebrook facility to assess compliance with licensing requirements.
Findings
The inspection identified several deficiencies including privacy issues with bathroom doors, outdated food items, lack of emergency drinking water supply, improper fire drill scheduling, incorrect exit sign directions, and incomplete resident support plans. All deficiencies had plans of correction accepted and were implemented by early March 2025.
Deficiencies (6)
The door to the bathroom labelled “spa” on the 2nd floor had a cloth curtain that did not provide total privacy, leaving a 2 inch gap and allowing full visibility of the toilet from the hallway.
There was a dented 8lb can of grape jelly and a dented 4 lb can of salmon located in the dry storage pantry.
The home did not have the emergency drinking water on-site nor a current and valid contractual agreement for a 3-day supply of drinking water for 82 residents.
Fire drills were not held on different days and times as required; specifically, 4 staff participated in fire drills during overnight shifts on 3/26/24 and 9/26/24.
Exit signs on the 2nd floor near bedrooms 220 and 210 indicated directions leading to a bathroom and a bedroom without exits.
Resident #1’s support plan did not address the resident's verbal and physical behaviors nor refusals related to bathing.
Report Facts
Residents served: 82
License capacity: 100
Staff total daily: 114
Waking staff: 86
Emergency water supply gallons required: 246
Water ordered: 300
Fire drill staff participants: 4
Inspection Report
Renewal
Census: 79
Capacity: 100
Deficiencies: 7
Date: Jan 4, 2024
Visit Reason
The inspection was conducted as a renewal inspection of the Adult Living at Rosebrook facility to review compliance with licensing requirements.
Findings
The inspection found several deficiencies including lack of a carbon monoxide alarm near a gas furnace, unplugged bedside lamp for a resident, unsealed food items in the kitchen, outdated fire safety inspection and drill, medication labeling discrepancies, and an undated preadmission screening form. All deficiencies had plans of correction submitted and were determined to be fully implemented.
Deficiencies (7)
No carbon monoxide alarm near the gas-operated furnace in the mechanical room located on the 5 West Wing.
Resident #1 does not have access to a source of light that can be turned on/off at bedside; the lamp was unplugged.
The 14 cups of tartar sauce in the kitchen's walk-in cooler were opened and unsealed.
Plastic zip-lock bag with approximately 20 waffles in the kitchen's walk-in freezer was opened and unsealed.
The last fire safety inspection and fire drill conducted by a fire safety expert was on 5/31/23; the previous inspection and drill was conducted on 3/23/22.
Resident #2's prescription medication labels indicate take orally or rectally, which does not match the prescribed directions.
Resident #3's preadmission screening form was not dated when completed.
Report Facts
License Capacity: 100
Residents Served: 79
Current Residents on Hospice: 5
Residents Diagnosed with Mental Illness: 5
Residents Aged 60 or Older: 78
Residents with Mobility Need: 23
Residents Receiving Supplemental Security Income: 0
Residents Diagnosed with Intellectual Disability: 0
Residents with Physical Disability: 0
Total Daily Staff: 102
Waking Staff: 77
Inspection Report
Complaint Investigation
Census: 77
Capacity: 100
Deficiencies: 0
Date: May 16, 2023
Visit Reason
The inspection was conducted as a complaint and incident investigation during an unannounced partial inspection.
Complaint Details
The inspection was triggered by a complaint and incident, but no deficiencies or citations were found.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Residents Served: 77
License Capacity: 100
Current Hospice Residents: 3
Residents 60 Years or Older: 76
Residents Diagnosed with Mental Illness: 4
Residents with Mobility Need: 19
Inspection Report
Renewal
Census: 84
Capacity: 100
Deficiencies: 7
Date: Jan 3, 2023
Visit Reason
The inspection was conducted as a renewal and complaint investigation visit to assess compliance with licensing regulations and to verify the implementation of a previously submitted plan of correction.
Complaint Details
The inspection included a complaint investigation as part of the renewal visit. The report does not explicitly state the substantiation status of the complaint.
Findings
Multiple deficiencies were identified including improper storage of poisonous materials, unlabeled soap in shared bathrooms, food stored on the floor, unlabeled and undated leftover food, unsafe smoking area receptacles, and medication administration errors. All deficiencies had plans of correction accepted and were reported as implemented by April 11, 2023.
Deficiencies (7)
A 500ml clear, unlabeled spray bottle containing PINE SOL cleaning solution was found on the cleaning cart.
An unlabeled green bar of soap was found in the 1st floor spa bathroom shower area.
Food items including soda, flavored water, and juice bottles were stored on the floor of the basement activity storage closet.
Unlabeled and undated one-gallon bags containing leftover food were stored in the refrigerator.
Multiple cigarette butts were found in two plastic, non fire safe receptacles at the designated smoking area.
More than 10 capsules of a discontinued medication were found in the medication cart.
Resident #2 was administered 3 units of Humalog insulin when 6 units were prescribed according to sliding scale orders.
Report Facts
License Capacity: 100
Residents Served: 84
Staffing Hours: 98
Waking Staff: 74
Hospice Residents: 2
Residents with Mental Illness: 5
Residents with Mobility Need: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| DON | Director of Nursing | Removed discontinued medication from medication cart and re-educated staff on medication regulations. |
| Administrator | Re-educated staff on multiple regulations including poisonous materials storage, soap labeling, food storage, smoking area guidelines, and medication administration. | |
| Head of Dietary Department | Disposed of unlabeled and undated leftover food and was re-educated on labeling and dating leftover food. | |
| Med Tech | Re-educated on following prescriber's orders after insulin administration error. |
Inspection Report
Plan of Correction
Census: 75
Capacity: 100
Deficiencies: 1
Date: May 10, 2022
Visit Reason
The inspection was a partial, unannounced visit conducted on 05/10/2022 due to an incident at the facility involving a resident fall near a staircase.
Findings
The report details a resident fall incident where a resident in a wheelchair fell down stairs, resulting in hospitalization. The facility was aware of the hazard due to a previous similar incident. A plan of correction was implemented including resident safety assessments, installation of gates at stairways, staff education, and approval by local code enforcement.
Deficiencies (1)
Resident #1 was left unattended near a staircase and fell down the stairs resulting in injury and hospitalization.
Report Facts
License Capacity: 100
Residents Served: 75
Total Daily Staff: 87
Waking Staff: 65
Residents Diagnosed with Mental Illness: 10
Residents 60 Years or Older: 74
Residents with Mobility Need: 12
Inspection Report
Renewal
Deficiencies: 0
Date: Apr 29, 2022
Visit Reason
The inspection was conducted as a licensing inspection by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing.
Findings
No regulatory citations were identified as a result of this inspection.
Inspection Report
Renewal
Deficiencies: 0
Date: Feb 17, 2022
Visit Reason
The inspection was conducted as a licensing inspection of the Adult Living at Rosebrook facility on 02/17/2022 and 03/01/2022.
Findings
No regulatory citations were identified as a result of this inspection.
Inspection Report
Complaint Investigation
Census: 79
Capacity: 100
Deficiencies: 2
Date: Feb 2, 2022
Visit Reason
The inspection was conducted as a complaint investigation triggered by an indicator, with an unannounced partial inspection on 02/02/2022 and 02/03/2022.
Complaint Details
The inspection was complaint-driven, with the reason stated as 'Complaint, Indicator'.
Findings
The inspection found deficiencies related to inadequate assistance with activities of daily living and incomplete additional resident assessments. The facility submitted a plan of correction which was accepted and later determined to be fully implemented.
Deficiencies (2)
Resident #1 left the dining room without assistance or reminder and fell down stairs while self-propelling a wheelchair, indicating failure to provide required assistance with activities of daily living.
Resident #1's support plan lacked a plan to meet supervision needs despite the resident requiring minimal supervision and potential confusion in unfamiliar settings.
Report Facts
License Capacity: 100
Residents Served: 79
Total Daily Staff: 93
Waking Staff: 70
Residents 60 Years or Older: 78
Residents Diagnosed with Mental Illness: 10
Residents with Mobility Need: 14
Inspection Report
Renewal
Census: 82
Capacity: 100
Deficiencies: 5
Date: Nov 3, 2021
Visit Reason
The inspection was a renewal inspection conducted on 11/03/2021 and 11/04/2021 to assess compliance with licensing requirements for Adult Living at Rosebrook.
Findings
The inspection identified several deficiencies including failure to report an incident within 24 hours, presence of a potential entrapment hazard on a resident's bed, sanitary condition issues with shared glucometer use, damaged window screens, and lack of operable bedside lighting. Plans of correction were accepted and implemented with staff training and repairs completed.
Deficiencies (5)
Failure to report an incident involving resident #1 to the Department within 24 hours.
Presence of an enabler bar on resident #2's bed with an opening posing a potential entrapment hazard.
Resident #3's glucometer was used to test resident #1's blood sugar, violating sanitary conditions.
Screen in resident #4's bedroom window had a 2" x 4" hole.
No operable lamp or other source of lighting at resident #3's bedside.
Report Facts
License Capacity: 100
Residents Served: 82
Total Daily Staff: 92
Waking Staff: 69
Residents Diagnosed with Mental Illness: 7
Residents with Mobility Need: 10
Residents 60 Years or Older: 81
Inspection Report
Complaint Investigation
Census: 83
Capacity: 100
Deficiencies: 3
Date: Jul 28, 2021
Visit Reason
The inspection was conducted as a complaint and incident investigation at the Adult Living at Rosebrook facility on 07/28/2021.
Complaint Details
The complaint involved an allegation that on 7/25/2021, resident #1 was hit by a staff member. The allegation was not reported in accordance with the Older Adults Protective Services Act until 7/27/2021, and the incident was not reported to the Department until 7/26/2021 at 8:00 p.m.
Findings
The inspection found violations related to delayed reporting of suspected resident abuse, failure to report incidents within required timeframes, and incomplete documentation in the resident's support plan regarding wandering behaviors and exit-seeking. Plans of correction were accepted and implemented.
Deficiencies (3)
Failure to immediately report suspected abuse of a resident as required by the Older Adult Protective Services Act.
Failure to report the incident or condition to the Department’s personal care home regional office or complaint hotline within 24 hours.
Resident's support plan did not document how wandering and exit-seeking behaviors would be met.
Report Facts
License Capacity: 100
Residents Served: 83
Current Hospice Residents: 1
Residents 60 Years or Older: 82
Residents Diagnosed with Mental Illness: 11
Residents with Mobility Need: 15
Inspection Report
Renewal
Capacity: 100
Deficiencies: 0
Date: Mar 1, 2021
Visit Reason
This document serves as a certificate of compliance and license renewal for the Personal Care Home 'Adult Living at Rosebrook' following the renewal application submitted on November 18, 2020.
Findings
A regular license is issued in response to the renewal application. The Department will conduct an onsite inspection within the next twelve months to ensure compliance with applicable regulations.
Report Facts
Maximum capacity: 100
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary | Signed letter regarding license renewal and inspection requirements |
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