Inspection Reports for Alexandria Manor II
313 S. WALNUT ST.,, BATH, PA, 18014
Back to Facility ProfileInspection Report Summary
The most recent inspection on September 18, 2025, identified one deficiency involving resident glucometers being plugged into electrical outlets and placed on the conference room floor, which was promptly corrected with education and audits initiated. Earlier inspections showed a pattern of multiple deficiencies related mainly to medication management, staffing adequacy, sanitary conditions, record confidentiality, and food storage, with several repeat issues over time. Complaint investigations were generally unsubstantiated except for substantiated abuse allegations in early 2024 that led to enforcement actions including license revocation and issuance of provisional licenses. Enforcement actions included fines and license restrictions due to abuse incidents and failure to implement timely corrective plans, but more recent inspections indicate corrective measures were accepted and plans of correction were implemented. The facility’s inspection history shows some improvement in addressing prior deficiencies, though medication management and sanitary conditions have been recurring themes.
Deficiencies (last 6 years)
Deficiencies (over 6 years)
45.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
864% worse than Pennsylvania average
Pennsylvania average: 4.7 deficiencies/yearDeficiencies per year
32
24
16
8
0
Census
Latest occupancy rate
67% occupied
Based on a September 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Plan of Correction
Census: 52
Capacity: 78
Deficiencies: 1
Date: Sep 18, 2025
Visit Reason
The inspection was conducted as a complaint and interim review, unannounced, to evaluate compliance and the submitted plan of correction.
Complaint Details
The inspection was complaint-related and interim in nature. The plan of correction was fully implemented and compliance was maintained.
Findings
The submitted plan of correction was determined to be fully implemented. The main deficiency involved sanitary conditions where three resident glucometers were found plugged into electrical outlets and lying on the conference room floor, which was corrected promptly with education and ongoing audits initiated.
Deficiencies (1)
Three resident glucometers were observed plugged into electrical outlets and lying on the conference room floor.
Report Facts
License Capacity: 78
Residents Served: 52
Current Hospice Residents: 2
Total Daily Staff: 57
Waking Staff: 43
Number of glucometers observed: 3
Audit duration: 90
Audit frequency after 90 days: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Personal Care Home administrator | Named in relation to removing glucometers, auditing, and providing education on sanitary conditions |
Inspection Report
Renewal
Census: 50
Capacity: 78
Deficiencies: 12
Date: Jul 17, 2025
Visit Reason
The inspection was conducted as a full, unannounced visit for renewal, complaint, and provisional reasons, including follow-up on a plan of correction submission.
Findings
The inspection identified multiple deficiencies including failure to timely report a fire alarm incident, breaches in record confidentiality, inadequate staffing for resident needs and evacuation, unsecured poisonous materials, unsanitary conditions, lack of working landline telephones in key areas, improper food storage and labeling, incomplete medical evaluations, medication storage and documentation errors, and incomplete or unsigned resident support plans. Plans of correction were accepted with education and audits scheduled to ensure ongoing compliance.
Deficiencies (12)
Failure to report fire alarm incident to the department within 24 hours.
Resident records were accessible to unauthorized persons and inspection binders contained privacy coding.
Inadequate staffing to safely evacuate residents, including insufficient staff for Hoyer lift transfers.
Poisonous materials were unlocked and accessible to residents.
Unsanitary conditions including feces on carpet and residue in showers.
Lack of working, non-coin operated landline telephones in second-floor kitchenette and common areas.
Unlabeled and unsealed leftover food items in kitchen storage.
Dented can of food found in dry storage area.
Resident medical evaluations missing required information or not current.
Blood glucose readings not properly documented on Medication Administration Record.
Resident support plan did not specify type of bath and did not reflect resident preferences.
Resident refused to sign support plan but no notation of refusal was documented.
Report Facts
Inspection Dates: 3
Residents Served: 50
License Capacity: 78
Staffing: 54
Waking Staff: 41
Residents with Mobility Need: 4
Residents with Physical Disability: 2
Hospice Residents: 1
Evacuation Time: 13
Fire Drill Evacuation Time: 9.3
Blood Glucose Reading: 244
Blood Glucose MAR Reading: 263
Inspection Report
Renewal
Census: 50
Capacity: 78
Deficiencies: 13
Date: Jul 17, 2025
Visit Reason
The inspection was conducted as part of a renewal, complaint, and provisional review of Alexandria Manor II on July 17, 21, and 25, 2025.
Findings
The facility was found to be in compliance with 55 Pa. Code Ch. 2600 after corrections were made. Several deficiencies were identified including late incident reporting, record confidentiality breaches, inadequate staffing for resident needs, sanitary condition issues, non-functional landline telephones, improper food storage, incomplete medical evaluations, and support plan documentation issues. Plans of correction were submitted and accepted with ongoing monitoring and education.
Deficiencies (13)
Late reporting of fire alarm incident on 7/3/25 to the Department until 7/25/25.
Resident records were accessible to unauthorized persons and privacy coding was improperly posted.
Inadequate staffing to safely evacuate residents and to assist with Hoyer lift transfers as required.
Poisonous materials were unlocked and accessible to residents in storage and beauty salon areas.
Unsanitary conditions including feces on carpet, black residue and used towels in showers.
Non-working landline telephones in common areas and kitchenettes.
Unlabeled and unsealed leftover food items in kitchen storage.
Dented can of beef broth found in kitchen dry storage.
Resident medical evaluation missing height and weight information.
Missing prior or updated annual medical evaluations for two residents.
Blood glucose reading documentation discrepancy for Resident #5.
Support plan for Resident #1 did not specify type of bath and did not reflect resident's shower preferences.
Resident #4 refused to sign support plan but no notation of refusal was documented.
Report Facts
Inspection dates: 3
License capacity: 78
Residents served: 50
Residents with mobility needs: 4
Residents requiring assist of 2 for Hoyer lift: 1
Staffing: 54
Waking staff: 41
Evacuation time: 13
Fire drill evacuation time: 9.3
Number of residents 60 years or older: 49
Number of residents with physical disability: 2
Number of residents with hospice: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jacqueline Burns | Personal Care Home Administrator | Named as responsible for ongoing compliance and monitoring multiple deficiencies including incident reporting, staffing, sanitary conditions, phone system, and support plans. |
Inspection Report
Complaint Investigation
Census: 59
Capacity: 78
Deficiencies: 0
Date: Apr 15, 2025
Visit Reason
The inspection was conducted as a complaint investigation during an unannounced partial licensing inspection on 04/15/2025.
Complaint Details
The inspection was complaint-related, but no deficiencies or citations were found, indicating no substantiated issues.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
License Capacity: 78
Residents Served: 59
Total Daily Staff: 65
Waking Staff: 49
Residents Diagnosed with Mental Illness: 1
Residents with Mobility Need: 6
Residents 60 Years of Age or Older: 59
Inspection Report
Census: 50
Capacity: 78
Deficiencies: 0
Date: Feb 25, 2025
Visit Reason
The inspection was conducted as a partial, unannounced visit due to an incident at the facility.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Residents Served: 50
License Capacity: 78
Current Hospice Residents: 2
Total Daily Staff: 54
Waking Staff: 41
Residents Receiving Supplemental Security Income: 50
Residents Age 60 or Older: 50
Residents with Mobility Need: 4
Inspection Report
Census: 54
Capacity: 78
Deficiencies: 0
Date: Feb 20, 2025
Visit Reason
The inspection was conducted as a licensing inspection by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing on 02/20/2025.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Total Daily Staff: 58
Waking Staff: 44
Residents Served: 54
License Capacity: 78
Current Hospice Residents: 2
Residents 60 Years of Age or Older: 54
Residents with Mobility Need: 4
Inspection Report
Complaint Investigation
Census: 49
Capacity: 78
Deficiencies: 0
Date: Jan 30, 2025
Visit Reason
The inspection was conducted as a complaint investigation with partial, unannounced visits on 01/30/2025, 01/31/2025, and 02/10/2025.
Complaint Details
The inspection was complaint-related, but no deficiencies or regulatory citations were found, indicating no substantiated issues.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
License Capacity: 78
Residents Served: 49
Current Residents in Hospice: 3
Total Daily Staff: 53
Waking Staff: 40
Inspection Report
Complaint Investigation
Census: 58
Capacity: 78
Deficiencies: 0
Date: Nov 26, 2024
Visit Reason
The inspection was conducted as a complaint and incident investigation with a partial, unannounced visit on 11/26/2024 and an off-site exit conference on 12/06/2024.
Complaint Details
The inspection was complaint-related and incident-based, with no deficiencies found and no follow-up required.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
License Capacity: 78
Residents Served: 58
Current Hospice Residents: 4
Total Daily Staff: 62
Waking Staff: 47
Inspection Report
Enforcement
Census: 46
Capacity: 78
Deficiencies: 18
Date: Oct 29, 2024
Visit Reason
The inspection was conducted due to licensing inspections on August 13, 2024, and October 29, 2024, which found violations. The Department refused to renew the certificate of compliance due to serious violations and failure to submit an acceptable plan of correction, issuing a second provisional license instead.
Complaint Details
The inspection was complaint-related due to an allegation of physical and verbal abuse by Resident #1 against Staff Person A on 7/25/24. The home failed to immediately develop a supervision plan or suspend the staff involved and did not report the incident immediately to the Department's regional office.
Findings
Multiple violations were found including improper posting of licensing summaries, unlocked poisonous materials, outdated food items, incomplete medical evaluations, unsecured medications, improper storage and calibration of glucometers, and failure to immediately report and supervise staff involved in abuse allegations. Several violations were repeated from prior inspections. Plans of correction were accepted but many were not implemented by the follow-up date.
Deficiencies (18)
The binder containing the current Licensing Inspection Summaries was stored in a cabinet and not accessible to residents or the public.
The 2nd floor kitchenette door was propped open with poisonous materials accessible to residents not assessed to avoid them.
Outdated or unlabeled food items were found in the second floor kitchenette refrigerator and main kitchen.
Medical evaluation for Resident #1 did not indicate ability to self-administer medications.
A bottle of eye drops prescribed for Resident #2 was found unlocked and unattended in the office near the main kitchen.
Medication administration records documented blood sugar readings not found in residents' glucometers; one glucometer was not calibrated to correct date/time.
Staff failed to immediately develop a supervision plan or suspend Staff Person A after an abuse allegation by Resident #1.
Incident of abuse was not reported immediately to the Department’s Northeast Regional Office.
Privacy coding sheets with resident and staff names were left attached to Licensing Inspection Summaries posted publicly.
Cleaning cart with poisonous materials was left unattended and accessible to residents not assessed to avoid them.
Trash receptacles in kitchen and bathrooms were uncovered.
Interior light at exit stairwell from 2nd floor was not working.
Carpeting on stairwell landing was covered in dry leaves.
Food items in second floor kitchenette refrigerator and main kitchen were uncovered and not dated.
Freezer in second floor kitchenette lacked a thermometer.
Food storage cabinet contained opened and unsealed items.
Combustible materials (dish towels and socks) found behind dryer in laundry room.
Resident #2's annual medical evaluation was incomplete or missing dates.
Report Facts
License Capacity: 78
Residents Served: 46
Fine Amount: 138
Fine Correction Date: 15
Inspection Report
Enforcement
Census: 46
Capacity: 78
Deficiencies: 18
Date: Oct 29, 2024
Visit Reason
The inspection was conducted due to licensing inspections on August 13, 2024, and October 29, 2024, resulting in violations found. The Department refused to renew the certificate of compliance due to serious violations and failure to submit an acceptable plan of correction, issuing a second provisional license based on an acceptable plan to correct violations.
Complaint Details
The inspection was complaint-related due to an allegation of physical and verbal abuse by Resident #1 toward Staff Person A on 7/25/24. The home failed to immediately develop a supervision plan or suspend the staff involved and did not report the incident immediately to the Department’s Northeast Regional Office.
Findings
Multiple violations were found including improper posting of licensing summaries, unlocked poisonous materials, outdated food items, incomplete medical evaluations, unsecured medications, improper storage and calibration of glucometers, failure to implement supervision plans after abuse allegations, untimely incident reporting, confidentiality breaches, uncovered trash receptacles, inadequate lighting, and combustible storage hazards. Some violations were repeated from prior inspections. Plans of correction were accepted with proposed completion dates, but many were not implemented as of the last follow-up.
Deficiencies (18)
The binder containing the home’s current Licensing Inspection Summaries was stored in a cabinet and not accessible to residents or the general public.
The 2nd floor kitchenette door was propped open with poisonous materials accessible to residents not assessed to avoid them.
Outdated or unlabeled food items found in the second floor kitchenette refrigerator and main kitchen.
Medical evaluation for Resident #1 did not indicate ability to self-administer medications.
A bottle of eye drops prescribed for Resident #2 was found unlocked and unattended in an office near the main kitchen.
Medication administration records documented blood sugar readings not found in residents’ glucometers; one glucometer was not calibrated to correct date/time.
Failure to immediately develop and implement a plan of supervision or suspend Staff Person A after an allegation of abuse by Resident #1.
Incident of abuse was not reported immediately to the Department’s Northeast Regional Office.
Privacy Coding Sheets with resident and staff names were left attached to Licensing Inspection Summaries posted in a public area.
Cleaning products with poison control instructions were left unlocked and accessible on the second floor.
Trash receptacles in kitchen and bathrooms were uncovered.
Interior light at exit stairwell from 2nd floor new section was not working.
Carpeting on stairwell landing near room 201 was covered in dry leaves.
Food items in second floor kitchenette and main kitchen were uncovered or not dated.
Freezer in second floor kitchenette lacked a thermometer.
Food storage cabinet contained opened and unsealed items.
Combustible materials (dish towels and socks) found behind dryer in second floor laundry room.
Resident #2's annual medical evaluation was incomplete or missing dates.
Report Facts
License Capacity: 78
Residents Served: 46
Fine Amount: 138
Staffing Hours: 50
Waking Staff: 38
Inspection Report
Follow-Up
Census: 58
Capacity: 78
Deficiencies: 3
Date: Jun 18, 2024
Visit Reason
The inspection was a partial, unannounced follow-up visit conducted due to an incident at the facility.
Findings
The facility was found to have deficiencies related to incomplete medical evaluations, unsecured medications and syringes, and failure to follow prescriber's orders. The submitted plan of correction was accepted and fully implemented by the follow-up date.
Deficiencies (3)
Resident #1's medical evaluation did not contain the resident's medical diagnosis or medications.
Medications and syringes were not kept locked; medication cards were observed unattended on a desk accessible to residents.
Failure to follow prescriber's orders: Resident #1 was not administered prescribed medication because it was not available in the home.
Report Facts
License Capacity: 78
Residents Served: 58
Total Daily Staff: 62
Waking Staff: 47
Hospice Current Residents: 4
Residents 60 Years or Older: 58
Residents with Mobility Need: 4
Inspection Report
Follow-Up
Census: 54
Capacity: 78
Deficiencies: 3
Date: May 29, 2024
Visit Reason
The inspection was a partial, unannounced follow-up visit conducted on 05/29/2024 to review the submitted plan of correction related to previous deficiencies and to ensure continued compliance.
Findings
The submitted plan of correction was determined to be fully implemented. The report details repeated medication-related deficiencies including storage procedures, medication record keeping, and following prescriber's orders, with corrective actions accepted and implemented by early July 2024.
Deficiencies (3)
The home did not have the PRN medication available to administer as ordered.
Staff person did not initial the residents’ electronic Medication Administration Records due to technical issues and did not document medication administrations in any other manner.
Resident did not receive prescribed medications and testing as ordered; medications were missed due to unavailability and residents leaving the facility without taking medications.
Report Facts
License Capacity: 78
Residents Served: 54
Total Daily Staff: 59
Waking Staff: 44
Hospice Residents: 2
Residents 60 Years or Older: 53
Residents with Mental Illness: 1
Residents with Mobility Need: 5
Inspection Report
Plan of Correction
Census: 58
Capacity: 78
Deficiencies: 3
Date: May 10, 2024
Visit Reason
The inspection was a follow-up review of the facility's submitted plan of correction related to medication storage and administration violations.
Findings
The facility was found to have repeated medication-related deficiencies including improper labeling and storage of medications, failure to administer medications as ordered, and failure to follow prescriber's orders. The submitted plan of correction was determined to be fully implemented as of the follow-up inspection.
Deficiencies (3)
Medication stored in the medication cart without pharmacy label and not labeled with resident's name and date opened. Repeated violation.
Medication was initialed as administered but could not be found during audit. Repeated violation.
Failure to follow prescriber's orders including missed medication administration and administering medication despite hold parameters. Repeated violation.
Report Facts
License Capacity: 78
Residents Served: 58
Total Daily Staff: 62
Waking Staff: 47
Current Hospice Residents: 4
Inspection Report
Follow-Up
Census: 53
Capacity: 78
Deficiencies: 5
Date: Mar 27, 2024
Visit Reason
The inspection was a follow-up review conducted on 03/27/2024 to verify the implementation of a previously submitted plan of correction for the facility.
Findings
The submitted plan of correction was determined to be fully implemented with continued compliance required. Deficiencies related to facility maintenance and medication management were addressed with corrective actions and staff education.
Deficiencies (5)
The C outside exit door in the 100 hallway had a hole in the bottom left corner of the door weatherstripping, approximately 1 inch by 1 inch.
Resident #1's medication label did not include the parameter to hold the medication for systolic blood pressure less than a specified value.
Resident #1's medication administration record (MAR) did not include a diagnosis or purpose for the medication.
Resident #2's MAR indicated medication was administered after it was discontinued and no longer available.
Resident #1, #3, and #4 had medications not administered or held without proper documentation or physician orders indicating parameters for holding medications.
Report Facts
License Capacity: 78
Residents Served: 53
Total Daily Staff: 58
Waking Staff: 44
Residents Receiving Supplemental Security Income: 3
Residents Age 60 or Older: 52
Residents Diagnosed with Mental Illness: 1
Residents with Mobility Need: 5
Hospice Residents: 4
Inspection Report
Complaint Investigation
Census: 70
Capacity: 78
Deficiencies: 0
Date: Mar 19, 2024
Visit Reason
The inspection was conducted as a complaint investigation with unannounced partial inspection dates on 03/19/2024 and 03/20/2024.
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: 78
Residents Served: 70
Total Daily Staff: 80
Waking Staff: 60
Residents Receiving Supplemental Security Income: 4
Residents 60 Years or Older: 66
Residents Diagnosed with Mental Illness: 4
Residents Diagnosed with Intellectual Disability: 3
Residents with Mobility Need: 10
Residents with Physical Disability: 2
Inspection Report
Enforcement
Census: 49
Capacity: 78
Deficiencies: 6
Date: Feb 15, 2024
Visit Reason
The visit was conducted as a monitoring inspection following licensing inspections on January 23, 2024, and February 15, 2024, due to serious violations including mistreatment or abuse of residents. The Department revoked the previous certificate of compliance and issued a first provisional license based on an acceptable plan of correction.
Complaint Details
The inspection was complaint-related, triggered by allegations of abuse involving staff members A and B toward resident #1. The complaint included video evidence. The Department conducted a partial complaint incident inspection on January 23, 2024. The complaint was substantiated based on video evidence and investigation findings.
Findings
The inspection found serious violations related to abuse and mistreatment of a resident by staff members, failure to follow medication administration protocols, and deficiencies in support plan documentation. Video evidence showed staff abusing a resident and improper medication administration. Plans of correction and supervision were submitted but not fully implemented by the follow-up dates.
Deficiencies (6)
Failure to immediately develop and implement a plan of supervision or suspend staff involved in alleged abuse; staff members involved in abuse were allowed to return to work without a supervised plan.
Resident was physically abused by staff member A, including slapping and pushing, as evidenced by video.
Resident's morning medication was not administered properly; medication was thrown to the floor and resident unable to self-medicate.
Failure to record the date/time of medication administration accurately; medication administration record falsely documented medication was given.
Failure to follow prescriber's orders regarding medication administration; resident's refusal and inability to self-medicate not properly managed.
Support plan for resident was not signed by the resident nor documented refusal or inability to sign; plan was only signed by a family member.
Report Facts
License Capacity: 78
Residents Served: 49
Fine Amount Per Day: 147
Fine Per Resident Per Day: 3
Mandated Correction Days: 15
Total Daily Staff: 53
Waking Staff: 40
Residents Receiving Hospice: 3
Residents Age 60 or Older: 49
Residents with Mobility Need: 4
Inspection Report
Enforcement
Census: 49
Capacity: 78
Deficiencies: 5
Date: Feb 15, 2024
Visit Reason
The visit was conducted as a monitoring inspection and a complaint investigation related to allegations of abuse and mistreatment of residents, specifically involving staff members and resident #1.
Complaint Details
The complaint investigation was triggered by a video and allegations of abuse involving staff members A and B and resident #1. The complaint was substantiated based on video evidence and interviews. Staff members were suspended and reassigned during the investigation.
Findings
The inspection found serious violations including abuse of resident #1 by staff members, failure to follow medication administration protocols, and incomplete support plan signatures. The facility's certificate of compliance was revoked and a provisional license was issued based on an acceptable plan of correction.
Deficiencies (5)
Failure to immediately develop and implement a plan of supervision or suspend staff involved in alleged abuse of resident #1.
Resident #1 was physically abused by staff member A, including slapping and pushing, as evidenced by video.
Resident #1's morning medication was not administered properly; medication was thrown to the floor and documentation was falsified.
Failure to follow prescriber's orders for resident #1's medication administration.
Support plan for resident #1 was not signed by the resident nor documented for refusal or inability to sign.
Report Facts
License Capacity: 78
Residents Served: 49
Fine Amount Per Day: 147
Fine Per Resident Per Day: 3
Mandated Correction Date: 15
Total Daily Staff: 53
Waking Staff: 40
Current Residents in Hospice: 3
Residents Age 60 or Older: 49
Residents with Mobility Need: 4
Inspection Report
Complaint Investigation
Census: 49
Capacity: 78
Deficiencies: 4
Date: Jan 12, 2024
Visit Reason
The inspection was conducted as a complaint investigation with an unannounced partial inspection on 01/12/2024 to review compliance and follow up on a plan of correction submission.
Complaint Details
The inspection was complaint-driven, conducted as a partial unannounced visit on 01/12/2024 with a follow-up plan of correction submission required.
Findings
The facility was found to have multiple deficiencies related to medical evaluation documentation, medication storage, and support plans, particularly concerning immunization documentation, medication labeling, and policies regarding medical marijuana use. The submitted plan of correction was accepted and fully implemented by early March 2024.
Deficiencies (4)
Resident documentation of medical evaluation did not indicate whether the resident was up to date on immunizations.
Resident had a prescription medication that was not labeled with the date opened as required by the manufacturer's instructions.
The home did not have a policy regarding the use of medical marijuana by residents who self-administer it.
Resident's support plan did not address the resident's use of medical marijuana.
Report Facts
License Capacity: 78
Residents Served: 49
Total Daily Staff: 53
Waking Staff: 40
Hospice Residents: 3
Residents 60 Years or Older: 47
Residents with Mobility Need: 4
Inspection Report
Follow-Up
Census: 47
Capacity: 78
Deficiencies: 3
Date: Nov 21, 2023
Visit Reason
The inspection visit on 11/21/2023 was conducted as a partial, unannounced follow-up related to complaint and monitoring reasons to verify the implementation of the submitted plan of correction.
Complaint Details
The inspection was complaint-related and included monitoring. The plan of correction submitted by the facility was determined to be fully implemented.
Findings
The facility was found to have fully implemented the plan of correction. However, deficiencies were noted including failure to post the License Inspection Summary conspicuously, a strong odor of urine in the 2nd floor common area, and uncovered trash receptacles in resident rooms. All issues were addressed with corrective actions implemented by 12/13/2023.
Deficiencies (3)
The home did not have the License Inspection Summary posted conspicuously as required.
A strong odor of urine was noted in the 2nd floor common area just outside the elevator. Repeat violation from 9/6/23.
In resident room 15, a trash can containing soiled briefs was found with no lid on it. Repeat violation from 9/6/23 and 10/12/23.
Report Facts
License Capacity: 78
Residents Served: 47
Current Residents in Hospice: 5
Total Daily Staff: 51
Waking Staff: 38
Inspection Report
Follow-Up
Census: 42
Capacity: 78
Deficiencies: 11
Date: Oct 12, 2023
Visit Reason
The inspection was a partial, unannounced visit conducted for complaint, incident, and monitoring reasons.
Findings
The facility was found to have multiple repeat violations including improper posting of the current license, unsigned resident contracts, privacy violations due to unauthorized removal of a camera, incomplete staff training documentation, uncovered trash receptacles, incomplete first aid kits, improper food storage, undated leftover food, missing annual medical evaluations, unsecured medications, and incomplete resident support plans. Plans of correction were accepted and implemented by December 13, 2023.
Deficiencies (11)
The home's current provisional license was posted on the bulletin board near the entrance but was covered with the ombudsman poster.
Resident #1's contract was not signed by the resident.
Resident #2 resides alone in a semi-private room and had a nanny camera installed which was removed without permission.
The home did not have documentation that staff persons A, B, and C completed the required annual trainings in 2022.
Trash cans in the kitchenette and bathroom lacked lids and contained soiled briefs.
First aid kits were missing tweezers, tape, gauze, thermometer, scissors, and bandages.
Several cardboard boxes of canned foods and bottles of teriyaki sauce were stored directly on the pantry floor.
Frozen hash brown patties and frozen pies were stored in the freezer without dates or labels.
Resident #3 and #4 had missing or outdated Documentation of Medical Evaluation forms.
Several packets of aspirin were found in the first aid kit stored on the kitchen counter, not locked.
Resident #5's support plan was unsigned and undated; Resident #4's support plan was undated.
Report Facts
License Capacity: 78
Residents Served: 42
Hospice Current Residents: 3
Residents Age 60 or Older: 42
Residents with Mobility Need: 4
Total Daily Staff: 46
Waking Staff: 35
Inspection Report
Complaint Investigation
Census: 43
Capacity: 78
Deficiencies: 0
Date: Oct 5, 2023
Visit Reason
The inspection was conducted as a complaint investigation at the facility on 10/05/2023.
Complaint Details
The inspection was a complaint investigation, but no deficiencies or citations were found, indicating no substantiated issues.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Residents Served: 43
License Capacity: 78
Current Residents in Hospice: 3
Total Daily Staff: 47
Waking Staff: 35
Residents Age 60 or Older: 43
Residents with Mobility Need: 4
Inspection Report
Renewal
Census: 39
Capacity: 78
Deficiencies: 32
Date: Sep 6, 2023
Visit Reason
The inspection was a provisional licensing inspection conducted on September 6-7, 2023, to evaluate compliance with 55 Pa. Code Chapter 2600 relating to Personal Care Homes, leading to the issuance of a regular license.
Findings
The facility was found to be in compliance overall but had multiple deficiencies including missing postings, incomplete medical evaluations, medication administration issues, sanitary condition concerns, and record storage problems. Corrective actions and staff trainings were implemented with ongoing audits planned.
Deficiencies (32)
The home did not post the License Inspection Summary report dated 6/5/23.
Resident funds refund was delayed beyond 30 days after discharge.
Missing criminal background check documentation for a staff member.
Direct care staff person lacked required high school diploma, GED, or active registry.
Administrator lacked documentation of 24 hours annual training for 2022.
Direct care staff did not complete required direct care competency testing timely.
Staff persons D, E, and F did not complete required annual training in 2022.
Staff persons D, E, and F did not complete required annual training content including fire safety.
Poisonous materials (deodorant and mouth rinse) were accessible to a resident unable to safely use them.
Sanitary conditions were poor with urine odor, mold in shower, and spilled food in refrigerator.
Trash receptacles in kitchen and bathroom were uncovered or improperly maintained.
Hole in flooring posed a tripping hazard.
Emergency telephone numbers were not posted near resident #3's phone.
First aid kit was missing tweezers, tape, and a thermometer.
Resident #4's room lacked an operable lamp or accessible bedside lighting.
A used washcloth was found hanging in a common bathroom shower.
Leftover food items in refrigerators and cabinets were not labeled or dated.
Lint was accumulated in lint traps of all dryers in basement laundry room.
Combustible materials (cigarette butts and dried leaves) were found near storm drain in parking lot.
Initial and annual medical evaluations were incomplete or missing required information for residents #3 and #5.
Annual medical evaluation for resident #6 was outdated; resident #3's annual evaluation was undated.
Resident #3 was not assessed for ability to self-administer medications but had medications in room.
Staff person G had only one medication administration observation documented during annual training.
Insulin pen and inhaler for residents #7 and #9 were not dated when opened.
Medication labels for residents #7 and #8 did not reflect current prescribed dosages or instructions.
Glucometer for resident #9 was not calibrated to correct date and time.
Medication administration record for resident #8 lacked diagnosis for Diclofenac sodium gel.
Medication for resident #7 was marked administered when it was not in the medication cart.
Medication for resident #8 was held despite heart rate being above prescribed threshold.
Annual resident assessments (RASP) for residents #3, #6, and #10 were missing dates or outdated.
Annual RASP for resident #3 was not signed by resident or assessor.
Resident records were stored in unlocked offices and accessible to unauthorized persons.
Report Facts
License Capacity: 78
Residents Served: 39
Current Residents in Hospice: 3
Residents with Mobility Need: 5
Total Daily Staff: 44
Waking Staff: 33
Inspection Dates: 2
Medication Administration Observation: 1
Inspection Report
Follow-Up
Census: 39
Capacity: 78
Deficiencies: 29
Date: Sep 6, 2023
Visit Reason
The inspection was a full, unannounced provisional review conducted on 09/06/2023 and 09/07/2023 to verify compliance with licensing regulations and the implementation of a submitted plan of correction.
Findings
The facility was found to have multiple deficiencies including issues with posting current licenses, resident funds refunds, staff qualifications and training, sanitary conditions, medication administration and storage, medical evaluations, and record storage. The submitted plan of correction was determined to be fully implemented with ongoing compliance required.
Deficiencies (29)
The home did not post the current license inspection summary in a conspicuous location.
Resident funds refund was not issued within 30 days of discharge.
Lack of documentation of criminal background check for a staff member.
Direct care staff person lacked required high school diploma, GED, or active registry status.
Administrator did not have documentation of 24 hours of annual training for 2022.
Direct care staff did not complete required direct care competency testing timely.
Staff persons did not complete required annual training topics in 2022.
Poisonous materials were not locked and accessible to a resident who cannot safely use or avoid them.
Sanitary conditions were poor with odors, mold, and unclean refrigerators noted.
Trash receptacles in kitchen and bathroom were uncovered or improperly maintained.
Hole in flooring posed a tripping hazard.
Emergency telephone numbers were not posted near resident room phones.
First aid kit was missing tweezers, tape, and a thermometer.
Resident room lacked an operable lamp or accessible bedside lighting.
Use of a common towel was observed in a common bathroom.
Leftover food items in refrigerators and cabinets were not labeled or dated.
Lint was not removed from dryers as required.
Combustible materials and cigarette butts were improperly stored near heat sources.
Medical evaluations (DME) for residents were incomplete or missing required information.
Resident self-administration medication assessments were incomplete; medications found in resident rooms without assessment.
Medication administration training for a staff member was incomplete with only one observation.
Medications belonging to residents were not dated when opened.
Pharmacy labels on resident medications did not match prescribed orders.
Medication storage devices were not properly calibrated.
Medication records lacked diagnosis or purpose for medications.
Medication administration records had missing or inaccurate date/time entries.
Prescriber's orders were not consistently followed regarding medication administration parameters.
Resident additional assessments (RASP) were incomplete, missing dates, or signatures.
Resident records were stored unsecured and accessible to unauthorized persons.
Report Facts
License Capacity: 78
Residents Served: 39
Total Daily Staff: 44
Waking Staff: 33
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff person A | Lack of documentation of criminal background check | |
| Staff person B | Personal Care Aide | Did not have required high school diploma, GED, or active registry; delayed direct care competency testing |
| Staff person C | Administrator | Did not have documentation of 24 hours of annual training for 2022 |
| Staff person D | Did not complete required annual training topics in 2022 | |
| Staff person E | Did not complete required annual training topics in 2022 | |
| Staff person F | Did not complete required annual training topics in 2022 | |
| Staff person G | Med Tech | Medication administration training included only one observation |
Inspection Report
Complaint Investigation
Census: 49
Capacity: 78
Deficiencies: 0
Date: Jun 2, 2023
Visit Reason
The inspection was conducted as a complaint investigation with unannounced partial inspections on 06/02/2023, 06/05/2023, and 06/16/2023.
Complaint Details
The inspection was complaint-related and no deficiencies were found, indicating no substantiated issues.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Inspection dates: 3
Total Daily Staff: 56
Waking Staff: 42
Resident Census: 49
Licensed Capacity: 78
Residents 60 Years or Older: 49
Residents with Mobility Need: 7
Current Residents in Hospice: 4
Inspection Report
Follow-Up
Census: 48
Capacity: 78
Deficiencies: 4
Date: May 23, 2023
Visit Reason
The inspection was a partial, unannounced follow-up visit conducted to review the submitted plan of correction for previously cited deficiencies.
Findings
The submitted plan of correction was determined to be fully implemented, with ongoing compliance required. Multiple violations related to posting of license, medication administration, storage procedures, and following prescriber's orders were noted as repeat violations but were addressed with corrective actions.
Deficiencies (4)
The home did not have their current provisional license posted in the home as required, nor the License Inspection Summary report posted as required.
Resident #1's blood glucose readings were inconsistently documented and not found in the glucometer as required, indicating improper storage and documentation procedures.
Resident #1's medication administration records showed discrepancies in date/time documentation and medication delivery was not properly approved or documented.
Resident #1's medication was not administered as ordered due to unavailability, and medications were administered despite blood glucose or blood pressure readings that should have held the medication, violating prescriber's orders.
Report Facts
Licensed Capacity: 78
Residents Present: 48
Total Daily Staff: 56
Waking Staff: 42
Residents with Mobility Need: 8
Inspection Report
Follow-Up
Census: 47
Capacity: 78
Deficiencies: 18
Date: Mar 29, 2023
Visit Reason
The inspection was an interim, unannounced partial inspection conducted on March 29-30, 2023, to review compliance with licensing regulations and follow up on previous violations.
Findings
Multiple violations were found including issues with criminal background checks, direct care training, locking poisonous materials, sanitary conditions, emergency telephone postings, refrigerator/freezer temperatures, annual medical evaluations, smoking area guidelines, medication administration, medication storage, medication labeling, refusal of medication documentation, following prescriber's orders, preadmission screening, resident assessments, and resident record content. Directed plans of correction were issued with specified completion dates.
Deficiencies (18)
Direct care staff members did not have timely Pennsylvania State Police Criminal Background checks completed.
Direct care staff members did not complete the Department-approved direct care competency course and were working unsupervised.
Poisonous materials were not kept locked and inaccessible to residents; a bottle of mouthwash was accessible to a resident who could not safely handle it.
Sanitary conditions were not maintained; dried feces was found on and around the toilet in a resident's room.
Emergency telephone numbers were not posted on or near the telephone in the dining room.
The freezer/refrigerator did not contain thermometers as required.
Resident's annual medical evaluation was overdue.
Smoking occurred on a non-designated 2nd floor balcony, creating fire safety hazards.
Medication administration was improper; medications were left on a nightstand when residents were sleeping.
Medications and syringes were not locked; a tube of arthritis cream was found unlocked and accessible.
Resident's medications were not properly labeled with pharmacy labels including dosage instructions.
Storage procedures for medications were not properly implemented; blood glucose readings were not accurately recorded.
Refusals of prescribed medications were not documented or reported to prescribers as required.
Prescriber's orders were not followed; medications were administered despite contraindications and blood glucose readings were missed.
Preadmission screening did not document if the home could meet resident needs or if the resident could safely use and avoid poisons.
Resident initial assessments were not completed within 15 days of admission.
Resident annual assessments were overdue.
Resident records were incomplete, missing social security numbers, identifying marks, photographs, emergency contacts, physician information, and medical insurance information.
Report Facts
Residents Served: 47
License Capacity: 78
Staffing Hours - Total Daily Staff: 52
Staffing Hours - Waking Staff: 39
Hospice Current Residents: 5
Residents Diagnosed with Mental Illness: 1
Residents Diagnosed with Intellectual Disability: 1
Residents with Mobility Need: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Juliet Marsala | Deputy Secretary, Office of Long-term Living | Signed the letter regarding licensing and enforcement actions |
Inspection Report
Complaint Investigation
Census: 36
Capacity: 78
Deficiencies: 0
Date: Feb 9, 2023
Visit Reason
The inspection was conducted as a complaint investigation with multiple inspection dates including on-site and off-site visits.
Complaint Details
The inspection was complaint-related, but no deficiencies or citations were found, and follow-up was not required.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Inspection Dates: 4
Total Daily Staff: 41
Waking Staff: 31
Residents Served: 36
License Capacity: 78
Current Hospice Residents: 3
Inspection Report
Complaint Investigation
Census: 36
Capacity: 78
Deficiencies: 0
Date: Jan 10, 2023
Visit Reason
The inspection was conducted as a complaint investigation with an unannounced partial inspection on 01/10/2023 at Alexandria Manor II.
Complaint Details
The inspection was complaint-related, but no deficiencies or citations were found, indicating no substantiated issues.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Total Daily Staff: 41
Waking Staff: 31
Residents Served: 36
Licensed Capacity: 78
Residents Diagnosed with Mental Illness: 1
Residents Diagnosed with Intellectual Disability: 1
Residents with Mobility Need: 5
Residents with Physical Disability: 1
Residents Age 60 or Older: 36
Residents Receiving Supplemental Security Income: 0
Current Residents in Hospice: 3
Inspection Report
Renewal
Census: 25
Capacity: 78
Deficiencies: 27
Date: Aug 16, 2022
Visit Reason
The inspection was conducted for renewal, complaint, and incident reasons as part of the Pennsylvania Department of Human Services licensing inspections on August 16 and 17, 2022.
Findings
Multiple violations were found related to resident confidentiality, compliance with laws, staff qualifications and training, medication administration, facility maintenance, and record keeping. Several deficiencies were noted as repeat violations. Plans of correction were submitted with varying implementation statuses.
Deficiencies (27)
Resident records and X-ray orders were stored outside the Administrator’s office door, allowing unauthorized access to confidential medical information.
The carbon monoxide detector battery in the facility's kitchen was last changed on 5/5/21, not complying with annual battery change requirements.
Resident #1's contract did not include the right to refuse medications if they feel the medication is given in error.
Direct care staff member B did not have a Pennsylvania State Police Criminal Background Check completed.
Direct care staff member B did not have a high school diploma, GED, or active registry status on the Pennsylvania nurse aide registry.
No staff certified in First Aid and CPR were present from 6:30 pm to 6:30 am on 8/13 and 8/14/22.
Direct care staff members A and B did not complete general fire safety training on or before their first workday.
Direct care staff members A and B did not complete training in resident rights, emergency medical plan, mandatory abuse reporting, and reporting of incidents within the first 40 hours worked.
A spray bottle of OdoBan was found unlocked in a resident room, posing a poisoning hazard.
The bathroom fan in a resident room was not operable.
The ceiling of the 2nd floor medication room was water stained with a black raised substance.
Emergency telephone numbers were not posted on or near telephones in resident rooms and hallways.
Two couches in the TV lounge had large patches of leather missing.
Refrigerators in the dry goods room lacked thermometers at the time of inspection.
The front emergency exit was blocked by patio chairs, obstructing egress.
Four fabric chairs were located in the designated smoking area, posing a fire hazard.
The upcoming week's menu was not posted and available for residents to review.
Direct care staff member C's 2022 annual medication practicum had only 2 MAR reviews completed; staff member A did not complete initial medication training upon rehire.
Medication trained staff were not always following required medication administration procedures; medications were sometimes left on bedside tables or seats.
Medications were removed from original containers and placed in baggies for residents leaving the building.
Resident #3's Vitamin D3 bottle did not have the resident's name on it.
Resident #3's PRN albuterol inhaler was not available; Resident #4's glucometer was not calibrated correctly and blood glucose readings were inconsistently documented.
Resident #5's 8 am and 8 pm medications were not initialed as administered on multiple dates; MAR contained incorrect blood glucose notes.
Resident #3 refused medications on 8/6/22 but prescriber was not notified.
Resident #4's blood glucose readings at 8 pm were not completed on multiple dates; Resident #3 did not receive prescribed medication on 8/16/22 at 8 pm.
The activity calendar posted was outdated, showing June 2022 on 8/16/22.
Resident #4's records did not include identifiable marks.
Report Facts
License Capacity: 78
Residents Served: 25
Resident Support Staff: 4
Total Daily Staff: 33
Waking Staff: 25
Current Hospice Residents: 2
Deficiencies cited: 27
Inspection Report
Complaint Investigation
Census: 25
Capacity: 78
Deficiencies: 5
Date: Jun 8, 2022
Visit Reason
The inspection was conducted as a complaint investigation with multiple review dates from 06/08/2022 to 06/23/2022 to assess compliance and corrective actions at Alexandria Manor II.
Complaint Details
The inspection was complaint-driven, with the reason explicitly stated as 'Complaint' and multiple on-site and off-site review dates. The submitted plan of correction was determined to be fully implemented.
Findings
The inspection identified several deficiencies including sanitary conditions with urine odor in resident rooms, inoperable bed functions, lack of timely support plan revisions, incomplete medical/dental support plans, and missing current resident photographs. Plans of correction were accepted and implemented with follow-up submissions confirming compliance.
Deficiencies (5)
Sanitary conditions with heavy odor of urine in resident rooms.
Resident bed does not properly operate; function to move bed up or down is inoperable.
Support plan not revised within 30 days upon completion of assessment or changes in resident needs.
Support plan does not document medical, dental, vision, hearing, mental health or other behavioral care services as required.
Resident record did not include a current photograph no more than 2 years old.
Report Facts
Inspection Dates: 5
Residents Served: 25
License Capacity: 78
Staffing Hours - Total Daily Staff: 31
Staffing Hours - Waking Staff: 23
Inspection Report
Complaint Investigation
Census: 26
Capacity: 78
Deficiencies: 2
Date: Mar 31, 2022
Visit Reason
The inspection was conducted as a complaint investigation with an unannounced partial review on 03/31/2022.
Complaint Details
The visit was complaint-related as stated under Inspection Information with reason 'Complaint'.
Findings
The inspection found deficiencies related to incomplete initial assessment and support plan for resident #1, which were later corrected and fully implemented as of 01/20/2023.
Deficiencies (2)
An assessment was not completed for resident #1 within 15 days of admission.
Resident #1's initial support plan was not completed within 30 days of admission.
Report Facts
License Capacity: 78
Residents Served: 26
Hospice Current Residents: 2
Residents Diagnosed with Mental Illness: 1
Residents Diagnosed with Intellectual Disability: 1
Residents with Mobility Need: 5
Residents with Physical Disability: 2
Inspection Report
Complaint Investigation
Census: 29
Capacity: 78
Deficiencies: 4
Date: Mar 3, 2022
Visit Reason
The inspection was conducted as a complaint investigation following allegations including sexual abuse and treatment concerns at the facility.
Complaint Details
The visit was complaint-related, triggered by allegations including sexual abuse by a staff person and concerns about treatment of residents. The complaint was substantiated with findings of violations.
Findings
The inspection found deficiencies related to failure to timely submit a supervision plan for a staff member involved in an allegation of sexual abuse, improper treatment of a resident by staff, and incomplete resident support plans addressing behavioral issues. Plans of correction were submitted and reviewed with some requiring resubmission and follow-up.
Deficiencies (4)
Failure to immediately submit a plan of supervision or notice of suspension for a staff person involved in an allegation of sexual abuse.
Staff directed emergency services to take a resident to the farthest hospital with the longest wait time, showing lack of dignity and respect.
Resident support plan did not include documented verbally and physically abusive behaviors or plan to address them.
Resident support plan did not include resident's diagnoses or plan to meet needs relative to diagnoses.
Report Facts
License Capacity: 78
Residents Served: 29
Current Hospice Residents: 2
Total Daily Staff: 33
Waking Staff: 25
Inspection Report
Routine
Deficiencies: 0
Date: Feb 23, 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 or deficiencies were identified as a result of this inspection.
Inspection Report
Complaint Investigation
Census: 30
Capacity: 78
Deficiencies: 2
Date: Jan 26, 2022
Visit Reason
The inspection was conducted as a complaint investigation with a partial, unannounced visit on 01/26/2022 and an exit conference on 02/02/2022.
Complaint Details
The visit was complaint-related, triggered by a complaint. The plan of correction was accepted and fully implemented as of the follow-up dates.
Findings
The submitted plan of correction was found to be fully implemented. Deficiencies included lack of a 2021 annual medical evaluation for a resident and incomplete documentation of behavioral care services in the resident's support plan, which were corrected during the inspection.
Deficiencies (2)
Resident #1’s most recent medical evaluation was missing; no record of an evaluation for 2021.
Resident #1’s support plan did not address aggressive and inappropriate behaviors, including urinating in a cup and throwing urine at people.
Report Facts
License Capacity: 78
Residents Served: 30
Current Residents in Hospice: 4
Residents 60 Years or Older: 30
Residents Diagnosed with Mental Illness: 1
Residents Diagnosed with Intellectual Disability: 1
Residents with Mobility Need: 5
Residents with Physical Disability: 0
Inspection Report
Plan of Correction
Census: 29
Capacity: 78
Deficiencies: 17
Date: Oct 25, 2021
Visit Reason
The inspection was conducted for renewal, complaint, and incident reasons as part of a full, unannounced review of the facility.
Findings
The submitted plan of correction was reviewed and determined to be fully implemented. Several deficiencies were identified related to resident contracts, death of a resident procedures, lighting, food storage, fire extinguisher inspection, medical evaluations, medication administration, labeling, storage procedures, resident records, trash receptacles, and notification to the fire department.
Deficiencies (17)
Resident #6's contract was not signed by the resident.
Refund was not issued timely following the death of Resident #6.
Residents in rooms 14 and 21 did not have an operable lamp or other source of lighting that could be turned on at bedside.
Coffee cake in 2nd floor refrigerator was not labeled with the date it was opened.
Fire extinguisher in '2 old hallway' lacked a tag indicating the date of last inspection.
Resident #5 did not have a medical evaluation in 2020.
The home did not have posted menus in a public and conspicuous area for the current and upcoming week.
Staff person C's annual medication re-certification did not indicate the date re-certification was completed.
Resident #3's medication administration record and pill pack had conflicting medication frequencies.
Resident #1 and #2's glucometers were not calibrated to the correct time and date; medication administration records were not properly maintained; narcotic counts were inaccurate and not properly signed.
Resident #7's medication records showed missed medications and incomplete documentation; narcotic count sheet discrepancies were noted.
Resident #3 participated in support plan development but did not sign the support plan.
Resident #6's preadmission screening was not completed more than 30 days prior to admission.
Resident #3's record lacked race, weight, eye color, religion, identifying remarks, and a dated picture; Resident #4's picture was more than 2 years old.
A large trash can on the 2nd floor was overflowing and not covered.
Soup in the 2nd floor refrigerator was stored with a spoon inside and the lid was not securely tightened.
The home failed to notify the local fire department of the home's address, bedroom locations, and evacuation assistance needs; census and oxygen use data were inconsistent.
Report Facts
License Capacity: 78
Residents Served: 29
Current Residents in Hospice: 3
Residents Age 60 or Older: 29
Residents Diagnosed with Mental Illness: 1
Residents Diagnosed with Intellectual Disability: 1
Residents with Mobility Need: 6
Residents with Physical Disability: 0
Total Daily Staff: 35
Waking Staff: 26
Inspection Report
Follow-Up
Census: 28
Capacity: 78
Deficiencies: 1
Date: Sep 16, 2021
Visit Reason
The inspection was a follow-up review of the submitted plan of correction for the facility, conducted on 09/16/2021 as a result of an incident.
Findings
The submitted plan of correction was determined to be fully implemented, with ongoing compliance required. The main deficiency involved documentation in the resident's support plan regarding behavioral needs, which was updated during the inspection and subsequently monitored.
Deficiencies (1)
The resident's support plan did not document how behavioral needs would be met.
Report Facts
License Capacity: 78
Residents Served: 28
Current Residents in Hospice: 2
Total Daily Staff: 34
Waking Staff: 26
Residents with Mobility Need: 6
Residents Diagnosed with Mental Illness: 1
Residents Diagnosed with Intellectual Disability: 1
Residents 60 Years of Age or Older: 28
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Anne Graziano | Signed letter confirming plan of correction implementation |
Inspection Report
Plan of Correction
Census: 31
Capacity: 78
Deficiencies: 1
Date: Sep 15, 2021
Visit Reason
The inspection was conducted as a complaint investigation with a partial unannounced inspection on 09/15/2021, followed by a plan of correction submission and review.
Complaint Details
The inspection was complaint-related, with the plan of correction fully implemented and compliance maintained.
Findings
The submitted plan of correction was found to be fully implemented. A specific deficiency was noted regarding the resident support plan not being updated to reflect wound care for a resident, which was corrected immediately during the inspection.
Deficiencies (1)
Resident Assessment and Support Plan for Resident 1 was not updated to show that the resident receives wound care.
Report Facts
License Capacity: 78
Residents Served: 31
Current Residents in Hospice: 2
Residents Age 60 or Older: 31
Residents Diagnosed with Mental Illness: 1
Residents Diagnosed with Intellectual Disability: 1
Residents with Mobility Need: 6
Resident Support Staff: 0
Total Daily Staff: 37
Waking Staff: 28
Inspection Report
Renewal
Deficiencies: 0
Date: May 6, 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
Renewal
Census: 41
Capacity: 78
Deficiencies: 25
Date: Oct 8, 2020
Visit Reason
The inspection was a full, unannounced licensing inspection conducted on October 8, 2020, as part of the renewal process for Alexandria Manor II, a Personal Care Home.
Findings
The facility was found to be in compliance with 55 Pa. Code Ch. 2600 after corrections were made. Several deficiencies were identified related to licensing postings, record confidentiality, fire safety orientation, sanitary conditions, medication management, and fire safety equipment, all of which had directed plans of correction implemented.
Deficiencies (25)
License Inspection Summary reports dated 1/7/20 and 2/20/20 were not posted in the home as required; provisional license was not posted.
Narcotic logs were located on the side of the medication cart in an unsecured area, containing confidential resident information.
Direct care staff member did not complete first day fire safety orientation until 2/24/20.
An unlabeled jug of detergent was found in the 2nd floor laundry room.
Food garbage, wrappers, and a plastic spoon were observed on the floor of the 2nd floor common area and stairwell.
Trash cans with food garbage were uncovered in the memory care section kitchenette area.
Hot water temperature in the first floor handicapped bathroom sink measured 133°F, exceeding the 120°F limit.
Beds in rooms 20 and 21 had no operable bedside lighting.
Bathroom across from room H2 lacked paper towels or a hand drying mechanism.
Boxes of watermelons and bananas were stored directly on the floor in the 1st floor pantry.
Two gallon jugs of milk were left out on a table and counter in the 2nd floor kitchenette.
Plastic bags of rice and wheat cereal were found opened but not sealed in the 2nd floor kitchenette cupboards; an uncovered cup of ice cream was found in the freezer.
Lint was found in lint traps of dryers in the 2nd floor and lower level laundry areas, posing a fire hazard.
Exit labeled #5 was blocked with a medication cart, chair, and walker, obstructing egress.
Emergency evacuation diagrams in the lower level did not indicate location of pull stations or fire extinguishers.
The home did not have a notice to the local fire department regarding address, bedrooms, and evacuation assistance.
Fire extinguishers on the second floor had expired inspection tags dated 7/20/20.
Fire drills during sleeping hours were not conducted within the required 6-month interval.
Medications were found unlocked on the medication cart and in a resident's room.
Resident #2's pharmacy label on liquid Tylenol did not indicate the medication name.
Resident #2's miralax and Tylenol bottles did not have the resident's name on them.
Resident #3's narcotic count sheet showed 83 pills when only 79 were available; Resident #1's glucometer was not calibrated correctly.
Resident #4's sliding scale of insulin was not noted on the medication administration record (MAR).
Resident #1's medication was administered despite heart rate and blood glucose readings indicating it should have been held.
Resident Assessment and Support Plans for residents #1, #5, and #6 were not signed nor documented refusal to sign.
Report Facts
License Capacity: 78
Residents Served: 41
Staffing Hours: 48
Waking Staff: 36
Current Residents on Hospice: 4
Residents Age 60 or Older: 40
Residents with Mobility Need: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jacqueline Burns | Administrator | Named in facility information section |
| Jamie Buchenauer | Deputy Secretary | Signed licensing letter and certificate |
| Ryan Yankowy | Lead Inspector | Lead inspector for the October 8, 2020 inspection |
| Amy Deluca | Department Representative | On-site inspector for the October 8, 2020 inspection |
| Anne Graziano | Lead Reviewer | Reviewer for follow-up document submissions |
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