Inspection Reports for Arcadia at Limerick Pointe
51 West Arcadia Drive, Limerick, PA 19468, PA, 19468
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Inspection Report
Census: 83
Capacity: 122
Deficiencies: 0
Jun 9, 2025
Visit Reason
The inspection was conducted as a licensing inspection 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: 83
License Capacity: 122
Secured Dementia Care Unit Capacity: 48
Secured Dementia Care Unit Residents Served: 35
Current Residents in Hospice: 2
Residents Age 60 or Older: 83
Residents with Mobility Need: 35
Inspection Report
Complaint Investigation
Census: 85
Capacity: 122
Deficiencies: 3
Dec 5, 2024
Visit Reason
The inspection was conducted as a complaint investigation to review compliance related to reported incidents and facility conditions.
Findings
The facility had a malfunctioning HVAC compressor affecting heating on the third and fourth floors, resulting in the use of prohibited portable space heaters. The facility failed to report the heating incident to the Department within 24 hours as required. Repairs were completed on 12/05/2024, and corrective actions including retraining and new procedures were implemented.
Complaint Details
The visit was complaint-related as indicated by the inspection information section stating 'Reason: Complaint'.
Deficiencies (3)
| Description |
|---|
| Failure to report the heating system incident to the Department within 24 hours. |
| HVAC compressor providing heat to personal care bedrooms on the 3rd and 4th floors was not functioning properly. |
| Use of prohibited portable space heaters in resident bedrooms due to malfunctioning heating system. |
Report Facts
Residents served: 85
License capacity: 122
Space heaters provided: 22
Space heaters observed: 10
Space heaters observed: 10
Space heaters observed: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Denise Siniari | Licensing Inspector | Reviewed portable space heater prohibition with Executive Director during inspection |
Inspection Report
Renewal
Census: 83
Capacity: 122
Deficiencies: 5
Nov 18, 2024
Visit Reason
The inspection was conducted as a renewal visit to assess compliance with licensing requirements and verify the implementation of the submitted plan of correction.
Findings
The facility was found to have fully implemented the submitted plan of correction. Several deficiencies were identified related to posting of influenza awareness posters, privacy signage for video monitoring, staff training deficiencies, and medication storage, all of which were addressed with corrective actions and ongoing monitoring plans.
Deficiencies (5)
| Description |
|---|
| Department of Health's influenza awareness poster was not displayed in a public place as required by the Influenza Awareness Act of 2016. |
| No signs were posted to indicate that cameras were video recording the front entrance of the home. |
| Direct care staff person A did not receive required annual training in medication self-administration, resident needs, dementia care, and personal care service needs during training year 2023. |
| Staff person B did not receive training in falls and accident prevention during training year 2023. |
| Resident self-administers medications stored in an unlocked container on their bedroom nightstand, not in a locked safe and secure location. |
Report Facts
License Capacity: 122
Residents Served: 83
Secured Dementia Care Unit Capacity: 48
Secured Dementia Care Unit Residents Served: 33
Current Hospice Residents: 6
Residents with Mobility Need: 33
Residents Age 60 or Older: 83
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff member A | Named in training deficiency for missing required annual training | |
| Staff member B | Named in training deficiency for missing falls and accident prevention training | |
| Director of Nursing | Director of Nursing | Conducted training and re-education related to deficiencies and medication storage |
| Human Resources Director | Human Resources Director | Responsible for scheduling, tracking, auditing, and reporting training compliance |
| Business Office Manager | Business Office Manager | Responsible for auditing and reporting compliance related to influenza poster and video monitoring signage |
| Executive Director | Executive Director | Oversight role in auditing and reporting compliance |
Inspection Report
Follow-Up
Census: 86
Capacity: 122
Deficiencies: 4
Aug 13, 2024
Visit Reason
The inspection was a partial, unannounced follow-up visit triggered by a complaint and incident to verify the implementation of a previously submitted plan of correction.
Findings
The facility was found to have fully implemented the submitted plan of correction related to staff training deficiencies and support plan documentation. Ongoing compliance monitoring and quarterly audits are planned to maintain standards.
Complaint Details
The inspection was complaint-related and incident-related as stated in the inspection information section.
Deficiencies (4)
| Description |
|---|
| Direct care staff person A did not receive required training in medication self-administration, resident needs, personal care service needs, and safe management techniques during 2023. |
| Staff person A did not receive training in fire safety completed by a fire safety expert or trained staff during 2023. |
| Resident participated in the development of the support plan but did not sign the support plan. |
| Resident's initial support plan for Secure Dementia Care Unit was completed after 72 hours of admission. |
Report Facts
License Capacity: 122
Residents Served: 86
Secured Dementia Care Unit Capacity: 48
Residents Served in Secured Dementia Care Unit: 36
Current Hospice Residents: 5
Residents Age 60 or Older: 86
Residents with Mobility Need: 35
Total Daily Staff: 121
Waking Staff: 91
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff member A | Named in deficiencies related to lack of required training in medication administration and fire safety. | |
| Director of Nursing | Director of Nursing | Responsible for conducting training, auditing resident support plans, and monitoring ongoing compliance. |
| Human Resources Director | Human Resources Director | Responsible for coordinating and overseeing training sessions and auditing employee training compliance. |
| Director of Maintenance | Director of Maintenance | Conducted fire safety training after being trained by a fire safety expert. |
| Executive Director | Executive Director | Reviewed regulations with Director of Nursing and receives compliance audit reports. |
Inspection Report
Complaint Investigation
Census: 87
Capacity: 122
Deficiencies: 0
Aug 2, 2024
Visit Reason
The inspection was conducted as a complaint and incident investigation during an unannounced partial licensing inspection.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Complaint Details
The inspection was triggered by a complaint and incident, but no deficiencies or citations were found.
Report Facts
License Capacity: 122
Residents Served: 87
Secured Dementia Care Unit Capacity: 48
Secured Dementia Care Unit Residents Served: 37
Hospice Current Residents: 5
Resident Have Mobility Need: 36
Residents Are 60 Years of Age or Older: 87
Residents Have Physical Disability: 1
Resident Support Staff: 0
Total Daily Staff: 123
Waking Staff: 92
Inspection Report
Follow-Up
Census: 83
Capacity: 110
Deficiencies: 1
Jun 6, 2024
Visit Reason
The inspection was a follow-up visit to verify the implementation of a previously submitted plan of correction related to a keypad lock on a door between the personal care and independent living sides of the facility.
Findings
The plan of correction was determined to be fully implemented, with the Director of Maintenance having fastened the access code to the door threshold and established a weekly audit process to ensure continued compliance.
Deficiencies (1)
| Description |
|---|
| The door separating the personal care side from the independent living side was equipped with a keypad lock without a posted code, obstructing unobstructed egress. |
Report Facts
License Capacity: 110
Residents Served: 83
Secured Dementia Care Unit Capacity: 48
Residents Served in Dementia Unit: 37
Total Daily Staff: 120
Waking Staff: 90
Audit Duration Weeks: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Maintenance | Director of Maintenance | Named in relation to implementing the plan of correction and conducting audits on the keypad lock door |
Inspection Report
Plan of Correction
Census: 85
Capacity: 110
Deficiencies: 1
Oct 17, 2023
Visit Reason
The inspection was conducted as a partial, unannounced incident review related to allegations of abuse and theft involving residents' personal property.
Findings
The investigation found that two residents had checks removed from their apartments and forged signatures on those checks. The checks were deposited by unknown persons not identified as staff. The perpetrator remains unidentified and the incidents are under criminal investigation. A plan of correction was submitted and fully implemented.
Complaint Details
The visit was complaint-related due to incidents of abuse involving theft of residents' checks. The perpetrator has not been identified and the cases remain under criminal investigation by the police department.
Deficiencies (1)
| Description |
|---|
| Resident checks were removed from unlocked desks and apartments, forged signatures were used, and checks were deposited by unknown persons not staff members. |
Report Facts
License Capacity: 110
Residents Served: 85
Secured Dementia Care Unit Capacity: 48
Secured Dementia Care Unit Residents Served: 37
Total Daily Staff: 122
Waking Staff: 92
Inspection Report
Renewal
Census: 81
Capacity: 110
Deficiencies: 2
Sep 6, 2023
Visit Reason
The inspection was conducted as a renewal review of the facility license to ensure compliance with regulatory requirements.
Findings
The facility was found to have deficiencies related to medication record accuracy and following prescriber's orders, which were addressed through a submitted and fully implemented plan of correction.
Deficiencies (2)
| Description |
|---|
| Resident #1's medication list was inaccurate with medications present in the home not listed and vice versa. |
| Resident #2 did not receive the correct insulin dose according to prescribed sliding scale orders. |
Report Facts
License Capacity: 110
Residents Served: 81
Secured Dementia Care Unit Capacity: 48
Secured Dementia Care Unit Residents Served: 35
Current Hospice Residents: 3
Residents with Mobility Need: 35
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ruth Delancey | LPN, Director of Nursing | Named in medication record and prescriber order deficiencies and responsible for training and audits |
Inspection Report
Census: 76
Capacity: 110
Deficiencies: 0
May 11, 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: 110
Residents Served: 76
Secured Dementia Care Unit Capacity: 48
Secured Dementia Care Unit Residents Served: 32
Current Hospice Residents: 5
Residents with Mobility Need: 32
Residents Age 60 or Older: 76
Inspection Report
Complaint Investigation
Census: 53
Capacity: 110
Deficiencies: 0
Sep 28, 2022
Visit Reason
The inspection was conducted as a complaint investigation with multiple off-site inspection dates from 09/28/2022 to 10/11/2022.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Complaint Details
The inspection was complaint-related and the follow-up type was noted as not required. No deficiencies were found, indicating the complaint was not substantiated.
Report Facts
License Capacity: 110
Residents Served: 53
Secured Dementia Care Unit Capacity: 48
Secured Dementia Care Unit Residents Served: 19
Hospice Current Residents: 3
Total Daily Staff: 72
Waking Staff: 54
Resident Support Staff: 0
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Evelyn Perez | Lead Inspector | Named as lead inspector for the complaint investigation |
Inspection Report
Renewal
Census: 61
Capacity: 110
Deficiencies: 3
Aug 29, 2022
Visit Reason
The inspection was conducted as a renewal review of the facility's compliance with licensing requirements.
Findings
The facility was found to have deficiencies related to timely incident reporting, medication storage, and documentation accuracy. The submitted plan of correction was accepted and fully implemented by December 20, 2022.
Deficiencies (3)
| Description |
|---|
| Failure to report a resident fall incident to the Department within 24 hours as required. |
| Blister packs for medications were stored with holes exposing medications, compromising proper storage conditions. |
| Resident's glucometer readings did not match medication administration records, indicating documentation inaccuracies. |
Report Facts
License Capacity: 110
Residents Served: 61
Current Hospice Residents: 3
Residents 60 Years or Older: 61
Residents with Mobility Need: 22
Total Daily Staff: 83
Waking Staff: 62
Inspection Report
Complaint Investigation
Census: 52
Capacity: 110
Deficiencies: 1
Apr 19, 2022
Visit Reason
The inspection was conducted as a complaint investigation to review compliance following a complaint.
Findings
The facility was found to have a deficiency related to failure to follow prescriber's orders when a resident was not administered a prescribed medication. The submitted plan of correction was determined to be fully implemented.
Complaint Details
The visit was complaint-related and the plan of correction submitted by the facility was fully implemented as of 04/19/2022.
Deficiencies (1)
| Description |
|---|
| Resident 1 was prescribed Lorazepam 0.5MG tablet to be taken three times a day, but was not administered the medication at lunch on 4/14/22. |
Report Facts
License Capacity: 110
Residents Served: 52
Secured Dementia Care Unit Capacity: 48
Secured Dementia Care Unit Residents Served: 18
Hospice Residents: 2
Resident Mobility Need: 18
Resident Age 60 or Older: 52
Resident Supplemental Security Income: 0
Resident Diagnosed with Mental Illness: 0
Resident Diagnosed with Intellectual Disability: 0
Resident with Physical Disability: 0
Total Daily Staff: 70
Waking Staff: 53
Inspection Report
Follow-Up
Census: 50
Capacity: 110
Deficiencies: 2
Apr 8, 2022
Visit Reason
The inspection visit on 04/08/2022 was a partial, unannounced follow-up to verify the implementation of a previously submitted plan of correction related to an incident.
Findings
The submitted plan of correction was determined to be fully implemented as of the inspection date. Deficiencies involved staff orientation on fire safety and emergency preparedness, as well as training on resident rights, emergency medical plans, and mandatory reporting of abuse and neglect.
Deficiencies (2)
| Description |
|---|
| Staff person A did not receive orientation on evacuation procedures, staff duties during fire drills and emergencies, designated meeting places, smoking safety procedures, use of fire extinguishers, smoke detectors, fire alarms, and telephone use for emergency services on their first day. |
| Staff person A did not complete training within 40 scheduled work hours on resident rights, emergency medical plan, mandatory reporting of abuse and neglect under the Older Adult Protective Services Act, and reporting of reportable incidents and conditions. |
Report Facts
License Capacity: 110
Residents Served: 50
Secured Dementia Care Unit Capacity: 48
Residents Served in Secured Dementia Care Unit: 18
Hospice Residents: 2
Total Daily Staff: 68
Waking Staff: 51
Residents 60 Years or Older: 50
Residents with Mobility Need: 18
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Shawn Parker | Signed the letter confirming plan of correction implementation |
Inspection Report
Monitoring
Census: 21
Capacity: 110
Deficiencies: 1
Aug 10, 2021
Visit Reason
The inspection was a monitoring visit conducted on 08/10/2021 to review the facility's compliance with regulations and the implementation of the plan of correction.
Findings
The facility was found to have unlocked and unattended resident records accessible in the secured dementia care unit nursing office. The plan of correction was accepted and fully implemented, including staff in-service, signage placement, and routine compliance checks.
Deficiencies (1)
| Description |
|---|
| Resident records were unlocked, unattended, and accessible in the first floor secured dementia care unit nursing office. |
Report Facts
License Capacity: 110
Residents Served: 21
Secured Dementia Care Unit Capacity: 48
Secured Dementia Care Unit Residents Served: 7
Total Daily Staff: 28
Waking Staff: 21
Residents Age 60 or Older: 21
Residents with Mobility Need: 7
Inspection Report
Original Licensing
Capacity: 110
Deficiencies: 0
May 12, 2021
Visit Reason
The inspection was conducted as a licensing inspection for a newly licensed personal care home facility that is not yet serving four or more residents.
Findings
The facility was found to be in substantial compliance with applicable regulations, but the licensing inspector was unable to complete a full inspection due to the home being new and not yet serving four or more residents. A re-inspection will be conducted within three months of the license effective date.
Report Facts
Maximum capacity: 110
Secure Dementia Care Unit capacity: 48
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jamie Buchenauer | Deputy Secretary | Signed letter and certificate as issuing officer |
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