Inspection Reports for Arden Courts A ProMedica Memory Care Community in Susquehanna
PA, 17110
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Inspection Report
Complaint Investigation
Census: 63
Capacity: 64
Deficiencies: 11
Apr 1, 2025
Visit Reason
The inspection was a partial, unannounced complaint investigation conducted on 04/01/2025 and 04/02/2025 to review compliance with submitted plans of correction and address complaints.
Findings
Multiple deficiencies were found including unlocked poisonous materials accessible to residents, unsanitary conditions such as a black substance in a toilet bowl, missing drain covers in showers, loose cabinet brackets, improperly stored food and medications, medication administration errors, incomplete resident assessments, missing support plan signatures, lack of preadmission cognitive screening, and missing conspicuous posting of key-locking device instructions.
Complaint Details
The inspection was conducted as a complaint investigation with unannounced notice. The report documents multiple violations found during the complaint-related inspection.
Deficiencies (11)
| Description |
|---|
| Unlocked, unattended and accessible poisonous materials in kitchen and resident bathrooms despite residents being incapable of recognizing and using poisons safely. |
| Black substance observed inside resident toilet bowl. |
| No drain cover observed in bathroom shower exposing a large drain hole presenting a hazard. |
| Loose cabinet brackets causing cabinet doors to hang below the bottom of the cabinet in kitchen areas. |
| Food items (chocolate pudding and yogurt) labeled with date opened found in medication cart. |
| Loose tablet and small white round pill found inside medication cart. |
| Resident administered incorrect insulin doses and medication administration documentation issues. |
| Resident partial denture observed but not included in resident assessment; incomplete assessments for telephone use, agitation, aggression, and hallucinations. |
| Resident support plan lacked required signatures including resident, POA, and assessor. |
| Resident admitted to secured dementia care unit without completed written cognitive preadmission screening. |
| Directions for operating key-locking devices not conspicuously posted near exits to secured dementia care unit. |
Report Facts
Residents Served: 63
License Capacity: 64
Staffing Hours - Total Daily Staff: 126
Staffing Hours - Waking Staff: 95
Current Hospice Residents: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Resident Services Coordinator | Resident Services Coordinator | Named in multiple findings including locking poisonous materials, medication storage and administration, and training. |
| Regional Maintenance Specialist | Interim Maintenance Director | Named in findings related to repair of loose cabinet brackets and replacement of missing drain covers. |
| Executive Director | Executive Director | Named in multiple corrective actions and ongoing compliance monitoring. |
| Building Services Coordinator | Building Services Coordinator | Named in corrective actions related to locking poisonous materials, cleaning checklists, and keypad audits. |
| Nursing Supervisor | Nursing Supervisor | Named in corrective action related to discarding contaminated food items. |
| Resident Services Coordinator (DON) | Director of Nursing | Named in medication storage and administration violations and related training. |
| Administrative Services Assistant | Administrative Services Assistant | Named in corrective action related to posting keypad codes. |
Inspection Report
Follow-Up
Census: 62
Capacity: 64
Deficiencies: 1
Oct 10, 2024
Visit Reason
The inspection was conducted as a follow-up review of the submitted plan of correction related to an incident involving resident abuse.
Findings
The submitted plan of correction was determined to be fully implemented. The report details an incident where a staff member struck a resident with a cane, resulting in a laceration, and subsequent corrective actions including staff termination, notifications, and staff training.
Deficiencies (1)
| Description |
|---|
| A resident was physically abused by a staff member who struck the resident on the head with a cane, causing a laceration. |
Report Facts
License Capacity: 64
Residents Served: 62
Current Residents in Hospice: 11
Residents Age 60 or Older: 62
Residents with Mobility Need: 62
Staff Total Daily: 124
Waking Staff: 93
Directed Completion Date: Dec 15, 2024
Inspection Report
Complaint Investigation
Census: 58
Capacity: 64
Deficiencies: 0
Jun 13, 2024
Visit Reason
The inspection was conducted as a complaint investigation at Arden Courts (Susquehanna) on 06/13/2024.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Complaint Details
The inspection was complaint-related, but no deficiencies or citations were found, indicating no substantiated issues.
Report Facts
License Capacity: 64
Residents Served: 58
Current Residents in Hospice: 7
Total Daily Staff: 116
Waking Staff: 87
Inspection Report
Renewal
Census: 49
Capacity: 64
Deficiencies: 6
Jan 30, 2024
Visit Reason
The inspection was an unannounced full renewal inspection conducted by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing, to review compliance and verify the submitted plan of correction for Arden Courts Susquehanna of Harrisburg.
Findings
The inspection identified multiple deficiencies including trash receptacle management, outdated food storage, medication storage and administration issues, incomplete admission support plans, and unsecured resident records. Plans of correction were accepted with proposed completion dates and ongoing compliance measures implemented.
Deficiencies (6)
| Description |
|---|
| Trash dumpsters were overflowing and lids remained open, violating requirements for covered receptacles to prevent insect and rodent penetration. |
| Kitchen refrigerator contained wrapped, unlabeled, and undated lunch meat, violating food storage regulations. |
| Medication prescribed to Resident #2 was not found in the home, indicating failure to implement safe storage procedures. |
| Resident #1's insulin administration was not properly documented on several dates despite blood glucose levels requiring insulin. |
| Initial support plans for residents admitted to the Secure Dementia Care Unit were not completed within 72 hours of admission. |
| Resident records were stored in unlocked, accessible locations, exposing confidential information. |
Report Facts
License Capacity: 64
Residents Served: 49
Current Hospice Residents: 8
Residents Age 60 or Older: 48
Residents with Mobility Need: 49
Total Daily Staff: 98
Waking Staff: 74
Inspection Report
Renewal
Census: 49
Capacity: 64
Deficiencies: 19
Nov 7, 2023
Visit Reason
The inspection was conducted as a renewal review of the facility on 11/07/2023 and 11/08/2023 to determine compliance with licensing requirements and verify the submitted plan of correction was fully implemented.
Findings
The facility was found to have multiple deficiencies including failure to post inspection summaries, incomplete direct care staff training documentation, unsecured poisonous materials, lack of protective guards on heat sources, improper refrigerator temperatures, fire drill deficiencies, incomplete medical evaluations and assessments, medication storage and administration issues, and incomplete staff training hours. Plans of correction were accepted and many issues were corrected onsite or scheduled for completion by December 2023.
Deficiencies (19)
| Description |
|---|
| The home's partial inspections dated 03/30/2023 and 07/12/2023 were not posted in a conspicuous and public place. |
| Direct care staff person providing unsupervised ADL services without documentation of completed and passed Department-approved direct care training and competency test. |
| Poisonous materials were unlocked, unattended, and accessible in the Health Center room. |
| No protective guards in place to prevent residents from coming in contact with the electric fireplace which becomes very hot within 30 seconds of being turned on. |
| Piece of siding missing from the exterior wall outside the door to the cottage in the courtyard. |
| Refrigerator section temperature was 50°F and freezer section temperature was 10-15°F, exceeding required temperatures. |
| Fire drills routinely held at the end of the month without varying days and times. |
| During multiple fire drills, only a portion of residents evacuated to designated meeting places or fire-safe areas. |
| Fire alarm was not sounded during a fire drill; a 'Silent Drill' was used instead. |
| Resident medical evaluations were not completed annually as required. |
| Medication found outside original labeled container and not being dispensed for administration. |
| Resident routine medication baskets, PRN medications, and OTC medications were unlocked, unattended, and accessible in the Health Care Center. |
| PRN medications prescribed to residents were unavailable in the home. |
| Resident did not receive prescribed additional insulin doses when blood sugar was greater than 300, though medication was given but not recorded. |
| Resident assessments were not completed annually or when condition significantly changed. |
| Resident support plans did not document how special diet needs would be met despite diet orders. |
| Written cognitive preadmission screenings were not completed within 72 hours prior to admission to the secured dementia care unit. |
| Direct care staff working in the secured dementia care unit had less than the required 6 hours of annual dementia care training during the 2022 training year. |
| Resident records were unlocked, unattended, and accessible in the Health Center Room. |
Report Facts
License Capacity: 64
Residents Served: 49
Current Residents in Hospice: 8
Total Daily Staff: 98
Waking Staff: 74
Inspection Report
Complaint Investigation
Census: 52
Capacity: 64
Deficiencies: 2
Jul 12, 2023
Visit Reason
The inspection was conducted as a complaint investigation due to an incident involving alleged abuse at the facility.
Findings
The investigation found that on 7/1/23, Staff Person A placed a pillow over Resident #1's face for approximately 15 seconds while attempting to restrain the resident, which constituted abuse and use of a prohibited manual restraint. Staff Person A was terminated, and corrective actions including staff training and policy development were directed.
Complaint Details
The complaint investigation was substantiated based on the incident on 7/1/23 involving Staff Person A's inappropriate physical restraint and abuse of Resident #1. Staff Person A was placed on administrative leave, then terminated following investigation. The Executive Director and Director of Nursing reported the claim to local authorities and relevant agencies.
Deficiencies (2)
| Description |
|---|
| Resident #1 was physically abused when Staff Person A placed a pillow over the resident's face for approximately 15 seconds while restraining the resident's arms. |
| Use of a manual restraint, defined as a hands-on physical means that restricts or immobilizes a resident, was prohibited but occurred when Staff Person A held down Resident #1's arms and face. |
Report Facts
License Capacity: 64
Residents Served: 52
Total Daily Staff: 104
Waking Staff: 78
Current Residents in Hospice: 10
Inspection Report
Complaint Investigation
Census: 44
Capacity: 64
Deficiencies: 2
Mar 30, 2023
Visit Reason
The inspection was conducted as a complaint investigation following an incident involving resident-to-resident physical aggression.
Findings
The investigation found that Resident #1 physically pushed Resident #2, resulting in injury requiring surgical intervention. Resident #1 exhibited ongoing physical aggression and wandering behaviors, and the support plan had not been revised to address these behaviors until after the incident.
Complaint Details
The visit was complaint-related due to an incident where Resident #1 physically abused Resident #2. The complaint was substantiated as the incident was confirmed and resulted in injury.
Deficiencies (2)
| Description |
|---|
| Resident #1 entered Resident #2's bedroom and pushed Resident #2, causing an injury requiring surgical intervention. |
| Resident #1's support plan was not revised to address the resident's supervision needs or aggression towards others. |
Report Facts
License Capacity: 64
Residents Served: 44
Current Residents in Hospice: 10
Residents 60 Years or Older: 44
Residents Diagnosed with Mental Illness: 16
Residents with Mobility Need: 44
Residents with Physical Disability: 1
Inspection Report
Renewal
Census: 42
Capacity: 64
Deficiencies: 16
Feb 7, 2023
Visit Reason
The inspection was conducted as a renewal inspection of the facility's license, including a full unannounced review on 02/07/2023 and 02/08/2023.
Findings
The inspection identified multiple deficiencies including failure to post current violation reports, missing resident contract signatures, lack of resident education on medication refusal rights, incomplete fire drill records, and issues with medication storage and training. Plans of correction were directed and many were implemented by April 2023.
Deficiencies (16)
| Description |
|---|
| The home's current violation report dated 2/9/2022 was not posted in a conspicuous and public place. |
| Resident-home contracts for Residents #1 and #2 were not signed by the residents. |
| Resident #1 and Resident #2's records did not contain signed statements acknowledging receipt of resident rights and complaint procedures. |
| Residents were not informed upon admission that certain areas are subject to video recording and signs were not posted indicating video recording. |
| Direct Care Staff Member A provided unsupervised ADL services without completing required training and competency test as of 2/7/2023. |
| Direct Care Staff Member B did not receive required training in medication self-administration, resident needs, personal care service needs, and safe management techniques during 2022. |
| Direct Care Staff Member B did not receive training in the Older Adult Protective Services Act, resident rights, and falls and accident prevention during 2022. |
| Outside dumpster was not covered and not actively in use at the time of observation. |
| Emergency telephone numbers were not posted on or by the telephone in Resident #3's bedroom. |
| Unannounced fire drills were not held during May and June 2022. |
| Fire drill records lacked required details including time, evacuation duration, exit route, resident and staff counts, problems encountered, and alarm operability for multiple drills. |
| Signs specifying smoking policy were not posted at the home's entrance. |
| Resident #4's glucometer was not calibrated to the correct time and blood glucose readings did not match MAR. |
| Residents #1 and #2 were not educated on their right to refuse medication if they believed there was a medication error. |
| Resident #4 did not sign the support plan and no notation was made regarding inability or refusal to sign. |
| No documentation that Residents #4 and #5 and their designated persons have not objected to admission to the secured dementia care unit. |
Report Facts
License Capacity: 64
Residents Served: 42
Current Hospice Residents: 10
Total Daily Staff: 84
Waking Staff: 63
Inspection Report
Plan of Correction
Deficiencies: 0
Feb 9, 2022
Visit Reason
The document confirms that the submitted plan of correction for the facility was reviewed and determined to be fully implemented following visits on 02/09/2022 and 02/10/2022.
Findings
The plan of correction submitted by the facility was found to be fully implemented, and continued compliance must be maintained.
Report Facts
Inspection visit dates: Visits occurred on 02/09/2022 and 02/10/2022
Inspection Report
Follow-Up
Census: 38
Capacity: 64
Deficiencies: 1
Jan 11, 2022
Visit Reason
The 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 submitted plan of correction was determined to be fully implemented, and continued compliance must be maintained.
Complaint Details
The inspection was complaint-related and incident-related, with the reason for the visit stated as Complaint, Incident. The plan of correction was accepted and fully implemented.
Deficiencies (1)
| Description |
|---|
| Resident 1's preadmission screening form did not include a determination that the needs of the resident can be met by the services provided by the home. |
Report Facts
Residents Served: 38
License Capacity: 64
Current Hospice Residents: 14
Residents Age 60 or Older: 36
Residents with Mobility Need: 38
Inspection Report
Renewal
Capacity: 64
Deficiencies: 0
Jun 24, 2021
Visit Reason
The document is a renewal application and license issuance for Arden Courts of Susquehanna, a Personal Care Home, pursuant to Title 55, PA Code, Chapter 2600. The Department will conduct an onsite inspection within the next twelve months as required by regulation.
Findings
The Department has issued a regular license in response to the renewal application. No findings of noncompliance are stated in this document. The Department advises that if noncompliance is found during future inspections, enforcement actions will be taken.
Report Facts
Maximum capacity: 64
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary | Signed letter regarding renewal license issuance |
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