Inspection Report
Follow-Up
Census: 39
Capacity: 100
Deficiencies: 2
Feb 20, 2025
Visit Reason
The visit was a partial, unannounced follow-up inspection to review the submitted plan of correction for the facility.
Findings
The facility was found to have fully implemented the submitted plan of correction related to annual training and medication administration compliance. The report details two specific violations regarding annual falls and accident prevention training and medication course certification, both of which were corrected with ongoing monitoring plans.
Deficiencies (2)
| Description |
|---|
| No documentation was available on site that Staff A completed Falls and Accident Prevention for the 2024 training year. |
| Staff Member A’s certification to pass medications expired and they were not recertified until after continuing to pass medication out of compliance. |
Report Facts
Residents Served: 39
License Capacity: 100
Current Hospice Residents: 6
Total Daily Staff: 63
Waking Staff: 47
Inspection Report
Renewal
Census: 44
Capacity: 100
Deficiencies: 17
Dec 3, 2024
Visit Reason
The inspection was conducted as a renewal visit with an incident review, including unannounced full inspections on 12/03/2024 and 12/12/2024.
Findings
The facility was found to have multiple regulatory violations including failure to report an abuse allegation, lack of physician certification for hospice residents during fire drills, insufficient overnight staffing for evacuation, incomplete staff training, missing rabies vaccinations for house cats, inadequate fire drill records, missing exit signs, outdated menus, unsecured medications, and incomplete resident records. Plans of correction were accepted and many were implemented by early 2025.
Deficiencies (17)
| Description |
|---|
| Failed to report an allegation of abuse to the Licensing Department involving resident #1. |
| No written physician certification for hospice residents #2 and #3 exempting them from fire drill evacuation. |
| Insufficient overnight staffing to evacuate all residents during fire emergencies on 11/30/2024 and 12/1/2024. |
| Staff members A and B did not complete required training topics including infection control and meeting resident needs for 2023. |
| Two house cats lacked current rabies vaccination certificates. |
| Fire drill records from 2/16/24 through 11/25/24 did not indicate exit routes used. |
| No written fire safety expert letter for extended evacuation time; fire drills exceeded 2 minutes 30 seconds. |
| Residents #2 and #3 were not evacuated during fire drills from 6/26/24 to 11/25/24 without physician certification. |
| Exit signs missing in dining room egress routes during inspection on 12/3/2024. |
| Menus were not posted one week in advance; November 2024 menu was still posted on 12/3/24. |
| Medications and syringes were unlocked and accessible in resident #4's room on 12/12/24. |
| OTC medications in medication cart were not labeled with resident names. |
| Resident #4's prescribed medication Famotidine 20mg was not available at time of inspection. |
| Resident #5's medication administration lacked documentation of vital signs prior to administration on 11/15/24 and 11/16/24. |
| Staff Members A and B administered medications with expired certifications. |
| Residents #6 and #7 did not have preadmission screening forms completed by the home. |
| Resident #6's record lacked identifying marks, eye color, hair color, and religious affiliation documentation. |
Report Facts
License Capacity: 100
Census: 44
Residents requiring assistance to evacuate: 26
Staff on overnight shift: 2
Residents on hospice: 3
Staff total daily: 70
Waking staff: 53
Inspection Report
Follow-Up
Census: 52
Capacity: 100
Deficiencies: 1
Aug 28, 2024
Visit Reason
The inspection visit on 08/28/2024 was a partial, unannounced follow-up inspection triggered by an incident at the facility.
Findings
The facility was found to have implemented the submitted plan of correction related to a medication administration error where a staff member accidentally administered medications to the wrong resident. The error was monitored with no adverse effects reported, and additional staff education and monitoring were put in place.
Deficiencies (1)
| Description |
|---|
| Staff Person “A” accidentally administered medications to the wrong resident, violating the requirement to follow prescriber's orders. |
Report Facts
License Capacity: 100
Residents Served: 52
Current Residents in Hospice: 9
Residents Age 60 or Older: 52
Residents with Mobility Need: 29
Total Daily Staff: 81
Waking Staff: 61
Inspection Report
Census: 51
Capacity: 100
Deficiencies: 0
Apr 24, 2024
Visit Reason
The inspection was a partial, unannounced visit conducted due to an incident at the facility on 04/24/2024.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
License Capacity: 100
Residents Served: 51
Current Residents in Hospice: 3
Resident Support Staff: 78
Waking Staff: 59
Residents Age 60 or Older: 51
Residents with Mobility Need: 27
Inspection Report
Follow-Up
Census: 55
Capacity: 100
Deficiencies: 1
Jan 24, 2024
Visit Reason
The inspection visit on 01/24/2024 was a partial, unannounced follow-up inspection related to an incident at the facility.
Findings
The submitted plan of correction was determined to be fully implemented. A staff member was found to have intentionally provoked a resident to take a video of the resident's behavior when agitated, resulting in the staff member's suspension and termination. Current employees were re-educated on managing aggressive behaviors and abuse reporting.
Deficiencies (1)
| Description |
|---|
| Staff person 'A' intentionally provoked a resident to use their cell phone to take a video of the resident's behavior when agitated, violating the requirement that a resident be treated with dignity and respect. |
Report Facts
License Capacity: 100
Residents Served: 55
Current Residents in Hospice: 10
Total Daily Staff: 65
Waking Staff: 49
Residents 60 Years or Older: 55
Residents with Mobility Need: 10
Inspection Report
Follow-Up
Census: 55
Capacity: 100
Deficiencies: 1
Dec 12, 2023
Visit Reason
The inspection visit on 12/12/2023 was a partial, unannounced follow-up inspection triggered by an incident at the facility.
Findings
The submitted plan of correction related to an abuse incident involving a staff member punching a resident was reviewed and determined to be fully implemented. Continued compliance is required.
Deficiencies (1)
| Description |
|---|
| On 12/4/23, a resident was punched in the chest by a staff member, resulting in bruising; the staff member was suspended and terminated following investigation. |
Report Facts
License Capacity: 100
Residents Served: 55
Current Residents in Hospice: 10
Residents Age 60 or Older: 55
Residents with Mobility Need: 16
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff Member A | Named in abuse incident involving punching a resident and subsequent termination | |
| Staff Member B | Witnessed abuse incident involving Staff Member A |
Inspection Report
Renewal
Census: 58
Capacity: 100
Deficiencies: 8
Nov 7, 2023
Visit Reason
The inspection was an unannounced full renewal inspection conducted on 11/07/2023 to review compliance with licensing requirements and verify the implementation of the submitted plan of correction.
Findings
The facility was found to have multiple deficiencies including missing criminal background checks, incomplete annual staff training documentation, lack of operable bedside lamps, expired rabies vaccination for resident pets, combustible materials near heat sources, missing medications, incomplete preadmission screening forms, and incomplete resident record content. All deficiencies had plans of correction accepted and were reported as implemented by 01/02/2024.
Deficiencies (8)
| Description |
|---|
| No documentation that a Pennsylvania State Police Criminal Background Check was completed for Staff Member A. |
| No documentation that staff members B and C completed required annual training for 2022. |
| An operable lamp or other source of lighting was not found at the bedside in room 104. |
| The rabies vaccination for pet cat for residents 1 and 2 expired 9/14/22. |
| A white sock was found lying over the dryer vent in the resident’s laundry room, posing a possible fire hazard. |
| Resident #6's PRN medication Bisacodyl suppositories 10mg was not available in the home at the time of inspection. |
| Preadmission Screening forms for Residents #3, #4, and #5 did not indicate if the residents' needs could be met in a Personal Care Home. |
| Resident records for Residents #1, #3, #4, and #5 did not contain any information regarding identifying marks. |
Report Facts
License Capacity: 100
Residents Served: 58
Total Daily Staff: 74
Waking Staff: 56
Current Residents in Hospice: 11
Residents Age 60 or Older: 58
Residents with Mobility Need: 16
Residents with Physical Disability: 1
Inspection Report
Follow-Up
Census: 50
Capacity: 100
Deficiencies: 5
Mar 30, 2023
Visit Reason
The inspection was a partial, unannounced follow-up visit triggered by an incident to review the submitted plan of correction for previous deficiencies.
Findings
The facility was found to have fully implemented the submitted plan of correction addressing multiple deficiencies including abuse, treatment of residents, annual medical evaluations, additional assessments, and support plan documentation. Continued compliance and auditing were recommended.
Deficiencies (5)
| Description |
|---|
| Resident #1 was neglected and physically moved against their will despite resistance, constituting abuse. |
| Staff violated the dignity of Resident #2 by yelling at them in the dining room. |
| A new Durable Medical Equipment (DME) was not completed by the physician for Resident #1. |
| A significant change assessment and support plan was not completed for Resident #1 after hospice admission. |
| Hospice services for Resident #2 were not noted in their assessment and support plan. |
Report Facts
License Capacity: 100
Residents Served: 50
Current Hospice Residents: 10
Residents Age 60 or Older: 50
Residents with Mobility Need: 16
Total Daily Staff: 66
Waking Staff: 50
Inspection Report
Renewal
Census: 56
Capacity: 100
Deficiencies: 17
Sep 27, 2022
Visit Reason
The inspection was conducted as a renewal and complaint investigation to assess compliance with regulatory requirements.
Findings
The inspection identified multiple deficiencies including delayed incident reporting, breaches in record confidentiality, delays in assistance with activities of daily living, contract signing delays, sanitary condition issues, safety hazards, medication administration errors, and incomplete resident records. Plans of correction were accepted and implemented with ongoing audits and education planned.
Complaint Details
The inspection included a complaint investigation component, as indicated by the reason for visit including 'Complaint'. Specific substantiation status is not stated.
Deficiencies (17)
| Description |
|---|
| Delayed reporting of medication errors and resident death to the Department. |
| Medication administration record binder was accessible to anyone walking by, breaching confidentiality. |
| Residents waited over an hour for call bell assistance despite needing help with activities of daily living. |
| Resident did not sign the resident-home contract within 24 hours of admission. |
| Resident's glucometer had dried blood on it, indicating poor sanitary conditions. |
| Emergency exit door near room 108 was covered with cobwebs, leaves, and bugs. |
| Residents in certain rooms did not have operable bedside lamps or lighting. |
| Food items in dry storage and freezer were not properly sealed or dated. |
| Exit door near a specified room would not open easily, preventing immediate egress. |
| A fire drill was not conducted in July 2022. |
| Fire drill evacuation times exceeded the 8-minute limit on two occasions. |
| Resident medical evaluation did not indicate resident's weight. |
| Medication Administration Record (MAR) transcription errors of blood glucose readings for multiple residents. |
| Resident's MAR documented incorrect blood glucose reading resulting in incorrect insulin administration. |
| Preadmission screening forms were completed outside the regulated timeframe for some residents. |
| Resident assessments were completed outside the required 15-day timeframe for some residents. |
| Resident records lacked eye and hair color information. |
Report Facts
License Capacity: 100
Residents Served: 56
Staffing Hours: 79
Waking Staff: 59
Completion Dates: Multiple dates ranging from 2022-12-01 to 2023-04-28
Inspection Report
Follow-Up
Census: 55
Capacity: 100
Deficiencies: 1
Sep 19, 2022
Visit Reason
The inspection was an unannounced partial review conducted due to an incident at the facility, with follow-up visits to verify the submitted plan of correction.
Findings
A staff person was found to have yelled at a resident to 'Shut up,' violating the requirement to treat residents with dignity and respect. The staff person was removed, suspended, and ultimately terminated. The facility submitted and implemented a plan of correction including staff re-education on resident rights and dignity.
Deficiencies (1)
| Description |
|---|
| Staff person yelled at resident to 'Shut up,' failing to treat resident with dignity and respect. |
Report Facts
Resident census: 55
Total licensed capacity: 100
Inspection Report
Renewal
Census: 53
Capacity: 100
Deficiencies: 12
Sep 14, 2021
Visit Reason
The inspection was a renewal inspection conducted on 09/14/2021 and 09/15/2021 to review compliance with licensing requirements.
Findings
The inspection identified multiple deficiencies including failure to post current license and inspection summaries, failure to report a resident abuse incident timely, unsigned resident contracts, insufficient staff CPR/First Aid training coverage, incomplete staff training topics, exterior hazards, improper food labeling, lack of emergency procedure submission, incomplete medical evaluations, medication record errors, delayed resident assessments, and incomplete support plans. Plans of correction were accepted and implemented for all deficiencies.
Deficiencies (12)
| Description |
|---|
| The home did not have the current license posted and did not post license inspection summaries dated 2/17/21 and 8/31/20 as required. |
| Resident #1 swung a cane and hit resident #2; the incident was not reported to the area agency on aging or the department's regional office timely. |
| Contracts for residents #3 and #4 were not signed by the residents. |
| On 9/5/21 and 9/11/21, there were shifts with insufficient staff certified in First Aid and CPR; the home requires at least 2 certified staff per shift. |
| Staff person A did not have required training on meeting the needs of residents as described in preadmission screening, support plan, and medical evaluation for the 2019 training year. |
| Sidewalk near exit door by room 108 was obstructed by overgrown lavender plants. |
| Activity area refrigerator had unlabeled and undated foil wrapped soft pretzels stored in the freezer. |
| The home did not have documentation that emergency procedures were reviewed and submitted to the local emergency management agency in 2020. |
| Resident #1's medical evaluation incorrectly indicated need for secure dementia care; the resident no longer required it. |
| Medication record for resident #5 included PRN medications not currently ordered and not in the medication cart. |
| Resident #4 did not have an initial assessment completed within 15 days of admission. |
| Resident #1's support plan did not list the significant change reason or hospice caregiver services. |
Report Facts
License Capacity: 100
Residents Served: 53
Current Residents on Hospice: 6
Residents Age 60 or Older: 53
Residents with Mobility Need: 23
Total Daily Staff: 76
Waking Staff: 57
Deficiencies Cited: 12
Inspection Report
Complaint Investigation
Census: 53
Capacity: 100
Deficiencies: 4
Aug 18, 2021
Visit Reason
The inspection was conducted as a complaint investigation related to incidents of resident abuse and other regulatory concerns at the facility.
Findings
The investigation found multiple violations including failure to immediately report suspected abuse, physical abuse and rough handling of residents, use of manual restraints, and failure to update resident support plans to reflect anxiety diagnoses and related care needs. Staff members involved were suspended or terminated, and corrective actions including staff education and audits were implemented.
Complaint Details
The complaint investigation substantiated incidents where staff held resident #1's arms to provide care causing bruising, and staff member E was observed providing rough and aggressive care to resident #2. Delays in reporting these incidents were noted. Staff involved were suspended and/or terminated. Follow-up audits and education were planned to ensure compliance.
Deficiencies (4)
| Description |
|---|
| Failure to immediately report suspected abuse of residents. |
| Physical abuse and rough handling of residents during care. |
| Use of manual restraint by holding resident's arms during care. |
| Failure to update resident support plan to reflect anxiety diagnosis and care needs. |
Report Facts
License Capacity: 100
Residents Served: 53
Current Residents in Hospice: 7
Residents with Mobility Need: 21
Completion Date for Abuse Plan of Correction: Nov 19, 2021
Completion Date for Abuse Audit: Nov 12, 2021
Completion Date for Manual Restraint Audit: Nov 12, 2021
Completion Date for Support Plan Audit: Nov 12, 2021
Inspection Report
Renewal
Deficiencies: 0
Jun 30, 2021
Visit Reason
The inspection was conducted as a licensing inspection by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing on 06/30/2021 for the facility Amity Place.
Findings
No regulatory citations were identified as a result of this licensing inspection.
Inspection Report
Complaint Investigation
Census: 51
Capacity: 100
Deficiencies: 2
Jun 7, 2021
Visit Reason
The inspection was conducted as a complaint investigation and incident review at Amity Place on 06/07/2021.
Findings
The inspection found deficiencies related to medical evaluation and preadmission screening for Resident #1, including failure to complete a medical evaluation within the required timeframe and lack of a preadmission screening form. The submitted plan of correction was accepted and fully implemented.
Complaint Details
The visit was complaint-related with the reason stated as Complaint, Incident. The deficiencies pertain to Resident #1's medical evaluation and preadmission screening documentation.
Deficiencies (2)
| Description |
|---|
| Resident #1's documented medical evaluation was not completed within 60 days prior to admission or within 30 days after admission. |
| Resident #1's preadmission screening form was not completed within 30 days prior to admission and could not be found in the resident's record. |
Report Facts
License Capacity: 100
Residents Served: 51
Current Residents in Hospice: 2
Resident Support Staff Hours: 68
Total Daily Staff: 136
Waking Staff: 102
Residents with Mobility Need: 17
Inspection Report
Follow-Up
Census: 51
Capacity: 100
Deficiencies: 2
Mar 11, 2021
Visit Reason
The visit was a follow-up inspection to verify that the previously submitted plan of correction was fully implemented following an incident-related partial inspection.
Findings
The facility was found to have implemented the plan of correction related to enabler bars attached to residents' beds, ensuring they were covered to prevent entrapment. The support plan for Resident #1 was updated to document the use and placement of the enabler bar. Ongoing audits and staff training were established to maintain compliance.
Deficiencies (2)
| Description |
|---|
| Residents #1 and #2 had enabler bars attached to their beds that were not covered to protect from possible entrapment. |
| Resident #1's support plan did not indicate the placement of the enabler bar or the reason for its use. |
Report Facts
Residents Served: 51
License Capacity: 100
Current Hospice Residents: 4
Total Daily Staff: 59
Waking Staff: 44
Residents with Mobility Need: 8
Residents Age 60 or Older: 51
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Care Services Manager | Named as responsible for covering enabler bars, conducting audits, and updating support plans | |
| Executive Director | Provided education to Care Services Manager and staff on relevant regulations |
Inspection Report
Plan of Correction
Census: 55
Capacity: 100
Deficiencies: 1
Feb 17, 2021
Visit Reason
The inspection was a partial, unannounced incident review conducted on 02/17/2021 to evaluate compliance and the implementation of a submitted plan of correction.
Findings
The report found a violation where a staff member was overheard making disrespectful comments to a resident requiring toileting assistance. The plan of correction was accepted, the employee was no longer employed, and staff re-education and ongoing resident interviews were planned to ensure dignity and respectful treatment.
Deficiencies (1)
| Description |
|---|
| Staff person A was overheard telling resident #1 that they shouldn't drink because then they have to go to the bathroom too much; resident #1 requires assistance with toileting. |
Report Facts
Residents Served: 55
License Capacity: 100
Staffing Hours - Total Daily Staff: 55
Staffing Hours - Waking Staff: 41
Hospice Current Resident Count: 13
Inspection Report
Renewal
Deficiencies: 0
Feb 5, 2021
Visit Reason
The document summarizes the results of multiple licensing inspections conducted by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing, at the facility on various dates in January and February 2021.
Findings
No regulatory citations were identified as a result of the inspections conducted on the specified dates.
Report Facts
Inspection dates: 7
Inspection Report
Routine
Deficiencies: 0
Jan 28, 2021
Visit Reason
The inspection was conducted as a routine licensing inspection by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing.
Findings
No regulatory citations were identified as a result of this inspection.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Michele Moskalczyk | Human Services Licensing Supervisor | Signed the inspection report. |
Document
Capacity: 100
Deficiencies: 0
Aug 31, 2021
Visit Reason
The document includes a Certificate of Compliance granting permission to operate a Personal Care Home and a letter acknowledging receipt of a renewal application with notice of an upcoming annual inspection within the next twelve months.
Findings
No inspection findings are reported; the documents confirm issuance of a regular license and state that an annual inspection will be conducted within the next twelve months.
Report Facts
Maximum capacity: 100
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary, Office of Long-term Living | Signed the renewal letter |
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