Inspection Report
Renewal
Census: 84
Capacity: 99
Deficiencies: 17
Apr 2, 2025
Visit Reason
The inspection was conducted as a renewal inspection of the facility license, with an unannounced full inspection on 04/02/2025 and 04/03/2025.
Findings
The inspection identified multiple deficiencies including privacy signage, staff training plan content, locking of poisonous materials, sanitary conditions, trash receptacle issues, elevator certification, food labeling and storage, emergency procedures posting, fire extinguisher inspection, menu posting, first aid kit contents, medication management, and medication storage and procedures. All deficiencies had plans of correction accepted and were implemented by June 5, 2025.
Deficiencies (17)
| Description |
|---|
| Video cameras on home exits and entrances record 24 hours but signage does not state cameras are recording. |
| Staff training plan does not include dates, locations, and times. |
| Unlocked, unattended poisonous materials accessible to residents in memory care unit room 119 and hallway. |
| Dirt buildup on memory care kitchenette sink. |
| Half full, uncovered, unattended trash can in 2nd floor kitchenette. |
| Metal signs and boxes located outside of dumpster area. |
| No current certificate of operation for elevators; last expired January 31, 2025. |
| Unlabeled, undated bags of Tots, sweet potatoes, and french fries in main kitchen freezer. |
| Refrigerator/freezer temperatures not properly maintained; no thermometers in some freezers; memory care kitchenette freezer at 26°F. |
| Emergency procedures not posted in a conspicuous and public place. |
| Fire extinguishers not inspected since March 2024; expired in March 2025. |
| Menu for week of 4/6/2025 not posted. |
| Expired hand sanitizer in first aid kit on transportation bus. |
| Resident had medications not listed on Medication Administration Record. |
| Loose pills found in memory care medication cart; expired insulin pen found. |
| Medications prescribed to resident not available in the home. |
| Discrepancy in narcotic pill count documentation during medication cart audit. |
Report Facts
License Capacity: 99
Residents Served: 84
Secured Dementia Care Unit Capacity: 32
Residents Served in Dementia Care Unit: 27
Total Daily Staff: 111
Waking Staff: 83
Inspection Report
Follow-Up
Census: 84
Capacity: 99
Deficiencies: 3
Mar 27, 2025
Visit Reason
The inspection visit was conducted as a follow-up to review the submitted plan of correction related to a complaint and incident at the facility.
Findings
The facility was found to have fully implemented the submitted plan of correction addressing deficiencies including resident elopement risk, unsecured egress routes, and medication administration documentation. Continued compliance is required.
Complaint Details
The visit was complaint-related and incident-driven, involving a resident with a history of wandering who eloped from the secured dementia care unit and was found off-site. The complaint was substantiated with findings of safety risks and procedural deficiencies.
Deficiencies (3)
| Description |
|---|
| Resident eloped from the secured dementia care unit through a broken window, exposing safety risks due to lack of fencing and unsecured windows. |
| Exit door at Stairway 3 would not open after delayed release bar was held for 30 seconds, blocking egress. |
| Medication administration record did not include initials of staff who administered medication at 6 am on a specific date. |
Report Facts
License Capacity: 99
Residents Served: 84
Secured Dementia Care Unit Capacity: 32
Secured Dementia Care Unit Residents Served: 26
Hospice Current Residents: 5
Residents Age 60 or Older: 84
Residents with Mobility Need: 27
Residents Diagnosed with Intellectual Disability: 1
Inspection Report
Follow-Up
Census: 84
Capacity: 99
Deficiencies: 2
Mar 19, 2025
Visit Reason
The inspection visit on 03/19/2025 was conducted as a partial, unannounced review due to an incident, focusing on follow-up of a previously submitted plan of correction.
Findings
The submitted plan of correction was determined to be fully implemented as of the follow-up review. Two deficiencies were noted related to support plan signatures and key-locking device instructions, both of which were corrected by 04/07/2025.
Deficiencies (2)
| Description |
|---|
| Resident participated in the development of the support plan but did not sign the support plan. |
| Incorrect instructions were posted next to exit doors in multiple stairwells and at the main gate in the Memory Care area patio. |
Report Facts
License Capacity: 99
Residents Served: 84
Secured Dementia Care Unit Capacity: 32
Secured Dementia Care Unit Residents Served: 26
Hospice Current Residents: 5
Residents Age 60 or Older: 84
Residents with Intellectual Disability: 1
Residents with Mobility Need: 27
Inspection Report
Plan of Correction
Census: 81
Capacity: 99
Deficiencies: 2
Feb 18, 2025
Visit Reason
The inspection was a partial, unannounced review conducted due to an incident at the facility on 02/18/2025.
Findings
The submitted plan of correction was found to be fully implemented. Deficiencies included failure to complete a Pennsylvania State Criminal Background Check for a staff member and incomplete resident assessments following behavior changes.
Deficiencies (2)
| Description |
|---|
| Staff A, a Direct Care Staff member, did not have a completed PA State Criminal Background Check and an FBI check was not requested by the date of hire. |
| Resident had a behavior change with increased agitation; the assessment noted the change but did not indicate the resident's needs or service plan, with relevant sections left blank. |
Report Facts
License Capacity: 99
Residents Served: 81
Secured Dementia Care Unit Capacity: 32
Secured Dementia Care Unit Residents Served: 27
Hospice Current Residents: 8
Residents Age 60 or Older: 81
Residents with Intellectual Disability: 1
Residents with Physical Disability: 2
Residents with Mobility Need: 27
Inspection Report
Follow-Up
Census: 79
Capacity: 99
Deficiencies: 1
Jan 13, 2025
Visit Reason
The inspection was a partial, unannounced visit conducted as a follow-up to verify the implementation of a previously submitted plan of correction related to a complaint or incident.
Findings
The submitted plan of correction was determined to be fully implemented, with the Memory Care Director having removed and locked up unlocked poisonous materials accessible to residents. Continued compliance must be maintained.
Complaint Details
The inspection was triggered by a complaint or incident. The plan of correction was accepted and fully implemented as of the inspection date.
Deficiencies (1)
| Description |
|---|
| Pantene shampoo and Ivory body wash were unlocked, unattended, and accessible to residents, including one resident not assessed as capable of recognizing and using poisons safely. |
Report Facts
Residents Served: 79
License Capacity: 99
Secured Dementia Care Unit Capacity: 32
Residents Served in Memory Care Unit: 28
Current Hospice Residents: 10
Residents Age 60 or Older: 79
Residents with Mobility Need: 27
Residents with Physical Disability: 2
Residents Diagnosed with Intellectual Disability: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Memory Care Director | Responsible for removing and locking up poisonous materials and re-educating staff on proper storage |
Inspection Report
Monitoring
Census: 73
Capacity: 99
Deficiencies: 3
Oct 17, 2024
Visit Reason
The visit was a monitoring inspection conducted on 10/17/2024 to review the facility's compliance status and the implementation of the submitted plan of correction.
Findings
The submitted plan of correction was determined to be fully implemented as of 10/17/2024. Deficiencies related to medication administration documentation, storage procedures, and following prescriber's orders were identified and corrected with education and auditing plans put in place.
Deficiencies (3)
| Description |
|---|
| Resident readings were incorrectly documented in the resident's medication administration record (MAR) at multiple times. |
| Medication administration record did not include the initials of the staff person who administered a prescribed medication on 10/9/2024 at 7:00 pm. |
| Medications prescribed to residents were not available in the home at the time of inspection. |
Report Facts
License Capacity: 99
Residents Served: 73
Secured Dementia Care Unit Capacity: 32
Secured Dementia Care Unit Residents Served: 22
Hospice Current Residents: 8
Resident Support Staff: 96
Waking Staff: 72
Inspection Report
Complaint Investigation
Census: 80
Capacity: 99
Deficiencies: 9
Aug 14, 2024
Visit Reason
The inspection was conducted as a complaint investigation with unannounced partial review visits on 08/14/2024, 08/15/2024, and 08/16/2024 to assess compliance and the implementation of a plan of correction.
Findings
The facility was found to have multiple deficiencies including improper use of chemical restraints, incomplete staff training in medication self-administration and dementia care, incomplete medical evaluations, medication storage and labeling issues, and inadequate resident assessments related to frequent falls. The submitted plan of correction was fully implemented by 11/04/2024.
Complaint Details
The inspection was triggered by a complaint as indicated by the reason for inspection being 'Complaint'.
Deficiencies (9)
| Description |
|---|
| Resident was administered a medication as a chemical restraint to control behaviors, which is prohibited. |
| Direct care staff person did not receive training in medication self-administration during training year 2023. |
| Staff person did not receive training in the Older Adult Protective Services Act or in falls and accident prevention during training year 2023. |
| Resident medical evaluation did not include health status. |
| Medication found in medication cart was past disposal date per manufacturer's instructions. |
| Prescription medication was changed without a change sticker on the prescription bubble pack. |
| Discrepancy in controlled substance count in medication bubble pack versus controlled substance register. |
| Resident assessment did not address the service need of frequent falls or indicate how this service need will be met. |
| Direct care staff person working in secured dementia care unit had only 2.5 hours of training in dementia care during 2023 training year instead of required 6 hours. |
Report Facts
Residents Served: 80
License Capacity: 99
Residents Served in Secured Dementia Care Unit: 24
Capacity of Secured Dementia Care Unit: 32
Current Hospice Residents: 14
Residents Age 60 or Older: 80
Residents with Intellectual Disability: 1
Residents with Physical Disability: 3
Residents with Mobility Need: 31
Resident Falls Since January 2024: 19
Inspection Report
Follow-Up
Census: 90
Capacity: 99
Deficiencies: 7
Jul 15, 2024
Visit Reason
The inspection visit was conducted as a partial, unannounced review triggered by complaint and monitoring reasons.
Findings
The facility was found to have multiple deficiencies including issues with resident privacy policies, incomplete criminal background checks for staff, inadequate staff training in medication administration and fire safety, furniture and equipment maintenance problems, improper labeling and return of residents' clothing, and medication administration errors. The submitted plan of correction was determined to be fully implemented as of the inspection date.
Complaint Details
The visit was complaint-related and monitoring in nature, as indicated by the inspection reason.
Deficiencies (7)
| Description |
|---|
| The home's policy required residents to request authorization and provide written consent for electronic monitoring devices, which was found to inhibit residents' rights to install hidden cameras without community permission. |
| A staff member's criminal background check was not completed until after hire. |
| Direct care staff did not receive required training on medication self-administration and meeting residents' needs as described in their assessment plans during 2023. |
| Staff person did not receive required training in fire safety and the Older Adult Protective Services Act during 2023. |
| Air conditioning units in multiple resident rooms were inoperable for extended periods and not promptly replaced. |
| Residents' clothing items were not labeled properly in the laundry room, risking loss or misplacement. |
| A resident was administered double the prescribed dose of Vitamin D3 for over a month, except on two days. |
Report Facts
License Capacity: 99
Residents Served: 90
Secured Dementia Care Unit Capacity: 32
Secured Dementia Care Unit Residents Served: 28
Current Hospice Residents: 11
Residents with Mobility Need: 32
Residents 60 Years or Older: 90
Residents with Physical Disability: 1
Inspection Report
Complaint Investigation
Census: 85
Capacity: 99
Deficiencies: 6
Jun 3, 2024
Visit Reason
The inspection was conducted as a partial, unannounced visit due to a complaint and incident reported at the facility.
Findings
The inspection found multiple violations including failure to timely report abuse incidents, verbal and physical abuse by a resident's spouse, lack of privacy during medication administration, improper treatment of residents, and incomplete preadmission screening and support plan signatures. Plans of correction were accepted and implemented by November 18, 2024.
Complaint Details
The visit was complaint-related due to allegations of abuse by a resident's spouse, including physical and verbal abuse, which were substantiated by observations of bruising and resident statements. Staff failed to report the incident timely and did not address ongoing concerns.
Deficiencies (6)
| Description |
|---|
| Failure to report an incident of abuse to the Department within 24 hours. |
| Resident subjected to verbal and physical abuse by spouse; bruising noted and concerns unaddressed. |
| Resident treated without dignity and respect; staff rummaged through belongings and ignored resident's request to lower TV volume. |
| Lack of privacy during medication administration in the wellness office with multiple residents present. |
| Preadmission screening form completed after resident admission date. |
| Support plan developed without required signatures from participants. |
Report Facts
Residents Served: 85
License Capacity: 99
Secured Dementia Care Unit Capacity: 32
Secured Dementia Care Unit Residents Served: 29
Hospice Current Residents: 11
Residents Age 60 or Older: 85
Residents with Mobility Need: 31
Residents Diagnosed with Intellectual Disability: 1
Inspection Report
Complaint Investigation
Census: 89
Capacity: 99
Deficiencies: 2
Apr 3, 2024
Visit Reason
The inspection was conducted as a complaint and incident investigation at Arbor Terrace Exton on April 3, 2024.
Findings
Two deficiencies were identified: one involving improper treatment of a resident by a staff member, and another related to incomplete resident record content, specifically the absence of incident reports in individual resident records. Both deficiencies had plans of correction implemented by May 15, 2024.
Complaint Details
The inspection was complaint-driven and included an incident investigation. The staff member involved in the resident treatment violation was suspended and subsequently terminated. The complaint was substantiated with corrective actions taken.
Deficiencies (2)
| Description |
|---|
| Staff member A woke a resident by removing their cover and telling them to get up for coffee despite the resident not wanting to get up, without physical contact but without assisting the resident. |
| Resident record did not include a record of incident reports for the individual resident; reportable incidents involving staff investigations were kept separately in the Business Office. |
Report Facts
License Capacity: 99
Residents Served: 89
Memory Care Unit Capacity: 32
Memory Care Unit Residents Served: 29
Hospice Residents: 12
Residents Age 60 or Older: 95
Residents with Mobility Need: 34
Residents Diagnosed with Intellectual Disability: 1
Inspection Report
Complaint Investigation
Census: 90
Capacity: 99
Deficiencies: 7
Jan 23, 2024
Visit Reason
The inspection was conducted as a complaint investigation following an unannounced partial inspection on 01/23/2024.
Findings
The facility was found to have multiple violations including failure to provide adequate heating as contracted, indoor temperatures below required minimums, use of prohibited portable space heaters creating safety hazards, and incomplete resident medical evaluations lacking emergency and allergy information. All cited deficiencies had accepted plans of correction with implementation dates by 03/01/2024.
Complaint Details
The inspection was complaint-driven, with a follow-up plan of correction submission required and reviewed. The complaint involved heating issues and safety concerns related to portable space heaters.
Deficiencies (7)
| Description |
|---|
| Failure to provide heating to residents in the dining room and to a resident for at least two weeks as contracted in the resident-home contract. |
| Indoor temperature in resident-used areas was below 70°F, specifically the dining room was colder than 62°F. |
| Portable space heaters were used without proper protective guards, posing risk of resident contact with hot surfaces. |
| Portable space heater placed in dining room between tables near a resident walker, creating a trip hazard and discomfort. |
| Portable space heaters obstructed bedroom doorway and living room hallway egress routes. |
| Use of five portable space heaters in the facility, which are prohibited. |
| Resident medical evaluations did not include medical information pertinent to diagnosis, emergency treatment, and allergies. |
Report Facts
License Capacity: 99
Residents Served: 90
Residents in Secured Dementia Care Unit: 26
Residents with Mobility Need: 30
Current Hospice Residents: 8
Staffing Hours - Total Daily Staff: 120
Staffing Hours - Waking Staff: 90
Number of Portable Space Heaters Found: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Evelyn Perez | Lead Inspector | Conducted the on-site inspection on 01/23/2024. |
Inspection Report
Follow-Up
Census: 85
Capacity: 99
Deficiencies: 6
Oct 5, 2023
Visit Reason
The inspection was a partial, unannounced visit conducted due to a complaint and incident at the facility.
Findings
The inspection identified multiple deficiencies related to training records, locking poisonous materials, medication storage, medication administration, and original container requirements. The facility submitted a plan of correction which was determined to be fully implemented as of the follow-up review.
Complaint Details
The inspection was triggered by a complaint and incident as stated in the inspection information section.
Deficiencies (6)
| Description |
|---|
| Training record did not include location of training, training source, or length of training completed. |
| Poisonous materials (toothpaste with warning label) were unlocked and accessible to a resident not assessed as safe to handle them. |
| Resident #2's medications were stored unlocked in a bedroom drawer. |
| Medication administration steps were not properly completed; medication was left on bathroom counter and not administered immediately. |
| Medication was pre-poured and left in a disposable cup in another resident's bathroom without their awareness. |
| Medication was pre-poured and stored improperly on bathroom counter contrary to manufacturer instructions. |
Report Facts
License Capacity: 99
Residents Served: 85
Secured Dementia Care Unit Capacity: 32
Secured Dementia Care Unit Residents Served: 26
Hospice Current Residents: 8
Residents Age 60 or Older: 85
Residents with Mobility Need: 33
Residents Diagnosed with Intellectual Disability: 1
Inspection Report
Census: 69
Capacity: 99
Deficiencies: 0
Jun 22, 2023
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 during this inspection.
Report Facts
License Capacity: 99
Residents Served: 69
Memory Care Unit Capacity: 32
Memory Care Unit Residents Served: 22
Residents Age 60 or Older: 69
Residents Diagnosed with Intellectual Disability: 1
Residents with Mobility Need: 27
Inspection Report
Renewal
Census: 71
Capacity: 99
Deficiencies: 18
May 10, 2023
Visit Reason
The inspection was conducted as a licensing inspection including renewal, complaint, and provisional reasons on May 10 and 11, 2023.
Findings
The facility was found to be in compliance overall, but several deficiencies were cited related to contract signatures, furniture and equipment maintenance, food labeling, unobstructed egress, medication administration training and procedures, preadmission screening, assessments, support plan signatures, and record keeping. All deficiencies had plans of correction submitted and were implemented by July 25, 2023.
Deficiencies (18)
| Description |
|---|
| Resident-home contracts for three residents were not signed by the residents. |
| The stopper in the bathroom sink in room 109 was broken, causing drainage issues. |
| An unlabeled, undated plastic container of salad was found in the third-floor tavern refrigerator. |
| Two patio chairs and a patio table blocked egress from the Memory Care sunroom. |
| Staff person A administered medications without completing required medication administration training. |
| The glucometer for resident 4 was not calibrated to the correct time; a glucometer reading for resident 5 was not recorded on the Medication Administration Record. |
| Staff person A administered medications without completing the Department-approved medication administration course. |
| Staff person A checked blood glucose level without completing required medication administration and diabetic education. |
| Medication administration training record for staff person B lacked date, source, trainer name, and documentation of successful completion. |
| Resident 6’s preadmission screening form did not include a determination that the resident's needs could be met by the home. |
| Preadmission screening forms for residents 2 and 7 were completed outside the required timeframe. |
| Resident 3’s and resident 6’s assessments did not include all diagnoses. |
| Resident 7’s additional assessment did not include all diagnoses. |
| Resident 2 participated in the development of a support plan but did not sign it. |
| Resident 2’s medical evaluation did not indicate a need for Secure Dementia Care Unit (SDCU). |
| Resident 2’s written cognitive preadmission screening was completed after admission to the SDCU. |
| Resident 2’s admission support plan was completed after admission to the SDCU. |
| Correction fluid was used on resident 8’s support plan. |
Report Facts
Inspection dates: 2
Resident census: 71
Total licensed capacity: 99
Memory care capacity: 33
Residents with mobility needs: 28
Residents age 60 or older: 71
Residents diagnosed with intellectual disability: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff person A | Named in multiple medication administration training and procedure deficiencies | |
| Staff person B | Named in medication administration training record deficiency | |
| Juliet Marsala | Deputy Secretary, Office of Long-term Living | Signed the licensing letter |
Inspection Report
Renewal
Census: 71
Capacity: 99
Deficiencies: 18
May 10, 2023
Visit Reason
The inspection was conducted for renewal, complaint, and provisional reasons as part of a full, unannounced licensing inspection of Arbor Terrace Exton.
Findings
The inspection identified multiple deficiencies including missing resident contract signatures, maintenance issues, food safety violations, obstructed egress, medication administration training deficiencies, recordkeeping errors, and incomplete resident assessments and support plans. Plans of correction were submitted and fully implemented by July 25, 2023.
Deficiencies (18)
| Description |
|---|
| Resident-home contracts for residents 1, 2, and 3 were not signed by the residents. |
| The stopper in the bathroom sink in room 109 was broken, causing the sink to be unable to drain. |
| An unlabeled, undated plastic container of salad was found in the refrigerator in the tavern on the third floor. |
| Two patio chairs and a patio table blocked egress from the Memory Care sunroom. |
| Staff person A administered medications without completing the required medication administration training. |
| Glucometer for resident 4 was not calibrated to the correct time; glucometer reading for resident 5 was not recorded on the Medication Administration Record. |
| Staff person A administered medications without successfully completing the Department-approved medication administration course. |
| Staff person A administered insulin injections without completing required training and competency testing. |
| Medication administration training record for staff person B lacked date of initial training, source, trainer name, and documentation of successful completion. |
| Resident 6's preadmission screening form did not include a determination that the resident's needs could be met by the home. |
| Resident 2 and Resident 7's preadmission screening forms were completed after their admission dates. |
| Resident 3 and Resident 6's assessments did not include all diagnoses. |
| Resident 7's additional assessment did not include all diagnoses. |
| Resident 2 participated in the development of the support plan but did not sign it. |
| Resident 2's medical evaluation did not indicate a need for the secured dementia care unit. |
| Resident 2's written cognitive preadmission screening was completed after admission. |
| Resident 2's initial support plan was completed after admission. |
| Correction fluid was used on resident 8's support plan. |
Report Facts
Inspection Dates: 2
Resident Census: 71
Total Licensed Capacity: 99
Memory Care Capacity: 33
Memory Care Residents Served: 23
Staffing Hours: 99
Waking Staff Hours: 74
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff person A | Named in multiple medication administration training and competency deficiencies. | |
| Staff person B | Named in medication administration training record deficiency. | |
| Maintenance Director | MD | Named in deficiency related to maintenance of bathroom sink and unobstructed egress. |
| Resident Care Director | RCD | Responsible for education, audits, and training related to medication administration and resident assessments. |
| Executive Director | ED | Involved in education and oversight of corrective actions. |
| Board of Directors | BOD | Involved in education and oversight of corrective actions. |
| Licensed Practical Nurse | LPN | Involved in education on glucometer recording. |
| Medication Technician | MT | Involved in education on glucometer recording. |
| Memory Care Director | MCD | Involved in moving furniture blocking egress and audits of fire exits. |
| Director of Nursing | DD | Involved in education on food labeling and dating. |
Inspection Report
Follow-Up
Census: 72
Capacity: 99
Deficiencies: 3
Apr 11, 2023
Visit Reason
The inspection was conducted as a partial, unannounced visit for complaint and monitoring reasons.
Findings
The report found deficiencies related to failure to provide written investigation findings for a complaint, lack of annual fire extinguisher inspection, and excessive hours between meals for a resident. Plans of correction were submitted and implemented to address these issues.
Complaint Details
A written complaint was filed on 03/24/2023 regarding resident #1's nutrition, weight loss, and medication disbursement. The home failed to provide investigation findings and a plan to resolve the complaint to the complainant as required.
Deficiencies (3)
| Description |
|---|
| Failure to provide investigation findings and plan to resolve a complaint regarding resident #1's nutrition, weight loss, and medication disbursement. |
| Fire extinguishers had not been inspected by a fire safety expert since March 2022. |
| Resident #1 experienced approximately 19 hours between meals, exceeding the allowed maximum of 15 hours between the evening meal and the first meal of the next day. |
Report Facts
License Capacity: 99
Residents Served: 72
Secured Dementia Care Unit Capacity: 32
Secured Dementia Care Unit Residents Served: 21
Current Hospice Residents: 6
Hours Between Meals: 19
Inspection Report
Follow-Up
Census: 73
Capacity: 99
Deficiencies: 2
Apr 4, 2023
Visit Reason
The inspection was a follow-up visit to verify the implementation of a previously submitted plan of correction for cited deficiencies.
Findings
The facility was found to have fully implemented the submitted plan of correction related to locking poisonous materials and proper recording of medication administration times. Continued compliance is required.
Deficiencies (2)
| Description |
|---|
| Poisonous materials were found unlocked and accessible to residents who have not been assessed capable of safely using or avoiding them. |
| Medication administration times were not recorded at the time of administration, with errors noted in the medication administration record (MAR). |
Report Facts
Licensed Capacity: 99
Residents Served: 73
Memory Care Unit Capacity: 32
Memory Care Unit Residents Served: 21
Total Daily Staff: 106
Waking Staff: 80
Inspection Report
Monitoring
Census: 71
Capacity: 99
Deficiencies: 2
Dec 6, 2022
Visit Reason
The inspection was a monitoring visit conducted on December 6, 2022, as part of ongoing regulatory oversight of the Personal Care Home facility Arbor Terrace Exton.
Findings
The inspection identified violations related to lighting in resident bedrooms and medication storage procedures. The facility submitted plans of correction for these deficiencies, but as of January 10, 2023, the corrections were not fully implemented.
Deficiencies (2)
| Description |
|---|
| Room does not have access to a source of light that can be turned on/off at bedside. |
| An oval shaped pill, red in color was observed loose in the Evergreen (SDU) medication cart. |
Report Facts
Census at Inspection: 71
Total Licensed Capacity: 99
Fine Per Resident Per Day: 5
Calculated Fine Per Day: 355
Mandated Correction Date: 5
Inspection Report
Complaint Investigation
Census: 68
Capacity: 99
Deficiencies: 1
Sep 23, 2022
Visit Reason
The inspection was conducted as a complaint investigation to assess violations related to resident abuse and neglect at Arbor Terrace Exton.
Findings
The inspection found a violation of abuse regulations where a resident was injured due to a clogged shower drain that caused flooding and a fall resulting in a fractured hip. The facility submitted a plan of correction which was not implemented by the proposed date.
Complaint Details
The complaint investigation found substantiated abuse involving neglect related to maintenance issues causing resident injury.
Deficiencies (1)
| Description |
|---|
| Resident 2 suffered a serious injury of a fractured hip from a fall caused by a clogged shower drain that was not corrected properly to avoid future flooding. |
Report Facts
Census at Inspection: 68
License Capacity: 99
Secured Dementia Care Unit Capacity: 32
Current Hospice Residents: 2
Fine Per Resident Per Day: 5
Calculated Fine Per Day: 355
Inspection Report
Renewal
Census: 68
Capacity: 99
Deficiencies: 7
Aug 22, 2022
Visit Reason
The inspection was a renewal licensing inspection conducted on August 22 and 23, 2022, as part of the Pennsylvania Department of Human Services Bureau of Human Services Licensing process.
Findings
Multiple violations were found including direct care staff qualifications, lack of operable bedside lighting, medication storage and administration errors, failure to educate residents on their right to refuse medication, and incomplete resident support plan signatures. Plans of correction were submitted but many were not implemented as of December 9, 2022.
Deficiencies (7)
| Description |
|---|
| Direct care staff person A does not have a high school diploma, GED, or active registry status on the Pennsylvania nurse aide registry. |
| Resident 1 does not have access to a source of light that can be turned on/off at bedside. |
| Loose maroon oval pill found in the third drawer of the medication cart and multiple discrepancies in resident 2's glucometer readings versus medication administration record. |
| Resident 2 was administered 2 units of insulin Lispro in error due to incorrect recording of blood sugar levels. |
| Residents 3 through 9 have not been educated on their right to refuse medication if they believe there may be a medication error, and documentation is missing. |
| Resident 9 participated in the development of the support plan but did not sign it; the home did not document refusal or inability to sign. |
| Resident 9 did not sign the support plan and the home failed to document refusal or inability to sign. |
Report Facts
Census at Inspection: 68
Total Licensed Capacity: 99
Fine Per Resident Per Day: 5
Calculated Fine Per Day: 355
Mandated Correction Date: 5
Inspection Report
Complaint Investigation
Census: 65
Capacity: 99
Deficiencies: 0
May 10, 2022
Visit Reason
The inspection was conducted as a complaint and incident investigation at the facility.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Complaint Details
The inspection was complaint-related with no deficiencies found and no follow-up required.
Report Facts
License Capacity: 99
Residents Served: 65
Memory Care Capacity: 31
Memory Care Residents Served: 24
Hospice Residents: 3
Residents Age 60 or Older: 65
Residents Diagnosed with Mental Illness: 2
Residents with Mobility Need: 28
Residents with Physical Disability: 2
Total Daily Staff: 93
Waking Staff: 70
Inspection Report
Complaint Investigation
Census: 46
Capacity: 99
Deficiencies: 10
Feb 11, 2022
Visit Reason
The inspection was conducted as a complaint and incident investigation with multiple on-site visits between 02/11/2022 and 02/23/2022, including an exit conference on 02/23/2022.
Findings
The inspection identified multiple deficiencies including abuse and neglect of residents, privacy violations, incomplete criminal background checks for agency staff, staff sleeping on duty, inadequate fire safety orientation, incomplete rights and abuse training within 40 hours, missing medical evaluations after condition changes, unsigned support plans, incomplete preadmission cognitive screenings, and missing incident reports in resident records. Plans of correction were submitted and accepted with reeducation and auditing measures implemented.
Complaint Details
The inspection was complaint-driven, investigating allegations of abuse, neglect, and other regulatory violations. The complaint was substantiated with multiple deficiencies found and plans of correction accepted.
Deficiencies (10)
| Description |
|---|
| Resident #1 was found on the floor with dried vomit and urine, indicating neglect and abuse; Resident #2 was not properly assisted with transfers and had food caked to their face causing injury. |
| A staff member took and circulated a photo of Resident #1 in a vulnerable state, violating resident privacy. |
| Staff Member B was hired without a completed criminal background check. |
| Staff member A was asleep on duty during a night shift when 43 residents were present. |
| Several agency staff did not receive required fire safety orientation on their first day. |
| Several agency staff did not complete required orientation on resident rights, emergency medical plans, and mandatory reporting within 40 hours. |
| Resident #2 started hospice services without a new medical evaluation being completed. |
| Resident #2's support plan was not signed nor marked for refusal or inability to sign. |
| Resident #1's cognitive preadmission screening was completed three days prior to admission and did not indicate need for secured dementia care. |
| Incident reports for Resident #1 (dated 2/8/22) and Resident #3 (dated 11/5/21) were missing from their medical records. |
Report Facts
License Capacity: 99
Residents Served: 46
Residents in Secured Dementia Care Unit: 16
Hospice Residents: 4
Staff on Duty: 63
Waking Staff: 47
Residents with Mobility Need: 17
Residents 60 Years or Older: 46
Incident Reports Missing: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff Member B | Hired without a criminal background check and failed to complete required orientation and training | |
| Staff Member A | Found asleep during night shift violating awake staff requirement | |
| Staff Member F | Did not enter Resident #2's room during shift and failed to assist properly |
Inspection Report
Monitoring
Census: 22
Capacity: 99
Deficiencies: 7
Jun 28, 2021
Visit Reason
The visit was a monitoring inspection conducted on 06/28/2021 to review the facility's compliance with licensing requirements and the implementation of a previously submitted plan of correction.
Findings
The inspection identified several deficiencies including lack of privacy signage for video surveillance, missing emergency telephone numbers by telephones, improper freezer temperature, unposted menus, presence of discontinued medication, missing resident signatures on support plans, and lack of documentation of no objection for admission to the secured dementia care unit. Plans of correction were accepted and documented as implemented or scheduled.
Deficiencies (7)
| Description |
|---|
| Video cameras recorded without signs posted alerting residents and visitors of surveillance. |
| No emergency telephone numbers including nearest hospital and fire department posted by telephones in resident rooms. |
| Ice cream freezer temperature was 10 degrees Fahrenheit, above required 0°F. |
| Weekly menus were not posted in the home or in the secured dementia care unit. |
| Discontinued medication Ondansetron was still present on the medication cart. |
| Resident #1 did not sign the support plan and no documentation of refusal or inability to sign was present. |
| No documentation that resident #2 and designated person did not object to admission to the secured dementia care unit. |
Report Facts
Residents Served: 22
License Capacity: 99
Freezer Temperature: 10
Inspection Report
Original Licensing
Capacity: 99
Deficiencies: 2
Mar 18, 2021
Visit Reason
The inspection was conducted as a licensing inspection of a newly licensed personal care home facility that was not yet serving four or more residents.
Findings
The facility was found to be in substantial compliance with applicable regulations, but the inspection was partial due to the home being new and not yet serving four or more residents. Citations were found and must be corrected as specified.
Deficiencies (2)
| Description |
|---|
| The home did not post influenza information in a conspicuous place as required by the Influenza Awareness Act. |
| Directions for operating the home's locking mechanism were not conspicuously posted near the door to the enclosed courtyard of the Secure Dementia Care Unit or near the door to the outside from the courtyard. |
Report Facts
License Capacity: 99
Secure Dementia Care Unit Capacity: 32
Residents Served: 0
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Michael Hagarty | Administrator | Named as facility administrator |
| Youn Hie Chung | Lead Inspector | Lead inspector for the licensing inspection |
| Jamie Buchenauer | Deputy Secretary | Signed the licensing letter and certificate |
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