Inspection Reports for Arden Courts A ProMedica Memory Care Community in Yardley
PA, 19067
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Inspection Report
Follow-Up
Census: 38
Capacity: 66
Deficiencies: 1
Mar 6, 2025
Visit Reason
The inspection was an unannounced partial review conducted due to a complaint and incident, with a focus on verifying the submitted plan of correction.
Findings
The submitted plan of correction was determined to be fully implemented, specifically regarding the completion of annual medical evaluations for residents. Continued compliance is required.
Complaint Details
The visit was complaint-related as indicated by the reason 'Complaint, Incident'. Substantiation status is not explicitly stated.
Deficiencies (1)
| Description |
|---|
| Resident most recent medical evaluation was not initially documented as completed on time. |
Report Facts
License Capacity: 66
Residents Served: 38
Current Residents in Hospice: 8
Residents Age 60 or Older: 38
Residents with Mobility Need: 38
Total Daily Staff: 76
Waking Staff: 57
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Executive Director | Educated Resident Services Coordinator on annual medical evaluation requirements and responsible for auditing medical evaluations weekly |
Inspection Report
Monitoring
Census: 37
Capacity: 66
Deficiencies: 12
Feb 19, 2025
Visit Reason
The Pennsylvania Department of Human Services, Bureau of Human Service Licensing conducted a monitoring review of the facility on 02/19/2025 to verify continued compliance and implementation of the submitted plan of correction.
Findings
The inspection identified multiple deficiencies related to resident record confidentiality, locking poisonous materials, sanitary conditions, trash receptacles, toilet paper availability, food storage, unobstructed egress, medication storage and administration, prohibitions on certain procedures, and posting of key-locking device instructions. All deficiencies had corrective plans accepted and were implemented by 04/04/2025 with ongoing audits and education planned.
Deficiencies (12)
| Description |
|---|
| Resident information including nursing communication binder, antipsychotic monitoring, and resident lab book were unlocked, unattended, and accessible in an open health center office. |
| Head and shoulders shampoo with a warning label was unlocked, unattended, and accessible to residents who were not assessed capable of safely using poisonous materials. |
| No method to dry hands in the bathroom of a resident room. |
| Half full, unattended trash can in the Harvest Glen kitchen had an inoperable lid that did not allow closure. |
| No toilet paper was provided for the toilet in a resident bathroom. |
| Sugar container in the Harvest Glen kitchen was opened, unsealed, and jammed under a shelf next to a glue trap. |
| Back gate exit behind Dockside neighborhood was unable to be opened due to gate not properly on hinges and settling into dirt and grass. |
| Prescription and OTC medications stored in refrigerator were unlocked and accessible in the unlocked health center refrigerator. |
| Medication stored uncapped in medication cart contrary to manufacturer’s instructions. |
| Medication administration record did not include initials of staff who administered medications at the time of administration. |
| Medication was administered early and PRN medication was given without proper documentation, violating prohibitions on chemical restraint and medication administration. |
| Directions for operating key-locking devices were not conspicuously posted near many doors in the Secure Dementia Care Unit. |
Report Facts
License Capacity: 66
Residents Served: 37
Current Residents in Hospice: 8
Residents 60 Years or Older: 37
Residents with Mobility Need: 37
Total Daily Staff: 74
Waking Staff: 56
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff person A | Named in medication administration violations and termination for failing to follow prescriber's orders and proper documentation | |
| Resident Services Coordinator | Completed education and audits related to medication administration, confidentiality, and other regulatory requirements | |
| Assistant Executive Director | Conducted audits, education, and environmental rounds to ensure compliance with regulations | |
| Building Services Coordinator | Replaced trash can lids, locked medication refrigerators, corrected egress routes, and conducted audits |
Inspection Report
Renewal
Census: 38
Capacity: 66
Deficiencies: 16
Dec 10, 2024
Visit Reason
The inspection was a renewal visit conducted on December 10, 2024, to assess compliance with licensing requirements for Arden Courts (Yardley).
Findings
The inspection identified multiple deficiencies related to staff qualifications, training, medication storage and administration, emergency procedures, fire drills, poisonous materials handling, and resident documentation. Plans of correction were submitted but not fully implemented as of March 2025.
Deficiencies (16)
| Description |
|---|
| Failure to post waiver requests and Department’s written decisions in a conspicuous and public place within the home. |
| Direct care staff person did not have a high school diploma, GED, or active registry status on the Pennsylvania nurse aide registry. |
| Direct care staff persons C and D received 0 hours of annual training in training year 2023. |
| Direct care staff persons C and D did not receive required training topics including medication self-administration, dementia care, infection control, and safe management techniques during training year 2023. |
| Staff persons C, D, and E did not receive required annual training in fire safety, emergency preparedness, resident rights, and other mandated topics during training year 2023. |
| Unlabeled spray bottle with yellow liquid found under sink in activity room. |
| Poisonous materials including disinfectant cleaner and toothpaste were unlocked and accessible to residents assessed as incapable of safely using poisons. |
| First aid kits in two neighborhoods lacked eye protection, mouth shield, and thermometer. |
| Lack of documentation for emergency procedure submission for year 2023 to local emergency management agency. |
| Fire drills routinely held during last two weeks of each month and not on weekends. |
| Medication storage issues including taped or punctured bubble packs with pills still in place. |
| Medication administration records did not document administration times for controlled substance on specified dates. |
| Resident admitted to secured dementia care unit without timely completed cognitive preadmission screening. |
| Resident admitted to secured dementia care unit without documentation of no objection from resident or designated person. |
| Resident not assessed annually for continuing need for secured dementia care unit in 2024. |
| Direct care staff persons C and D had 0 hours of required dementia care training during 2023 training year. |
Report Facts
License Capacity: 66
Residents Served: 38
Total Daily Staff: 76
Waking Staff: 57
Current Residents in Hospice: 6
Deficiency Repeat Violation Date: Sep 10, 2024
Inspection Report
Complaint Investigation
Census: 41
Capacity: 66
Deficiencies: 6
Sep 10, 2024
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 including unsigned resident contracts, missing signed statements acknowledging receipt of resident rights, unqualified direct care staff, lack of resident education on medication refusal rights, and untimely preadmission screening and support plans for residents in the secured dementia care unit. Plans of correction were submitted and implemented.
Complaint Details
The inspection was triggered by a complaint and incident, as stated under the inspection information section.
Deficiencies (6)
| Description |
|---|
| Resident-home contract was not signed by the resident. |
| Resident record did not contain a signed statement acknowledging receipt of resident rights and complaint procedures. |
| Direct care staff person did not have a high school diploma, GED, or active registry status on the Pennsylvania nurse aide registry. |
| Resident was not educated on the right to refuse medication if a medication error is suspected. |
| Resident's written cognitive preadmission screening was not completed within 72 hours prior to admission to the secured dementia care unit. |
| Resident's initial support plan was not completed within 72 hours of admission to the secured dementia care unit. |
Report Facts
Total Daily Staff: 82
Waking Staff: 62
Residents Served: 41
License Capacity: 66
Current Hospice Residents: 6
Residents 60 Years or Older: 41
Residents with Mobility Need: 41
Inspection Report
Census: 45
Capacity: 66
Deficiencies: 0
Jun 29, 2023
Visit Reason
The inspection was conducted as a licensing inspection by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing, due to an incident.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Total Daily Staff: 89
Waking Staff: 67
Residents Served: 45
License Capacity: 66
Residents Age 60 or Older: 43
Residents with Mobility Need: 44
Residents with Physical Disability: 7
Inspection Report
Routine
Deficiencies: 0
Oct 31, 2022
Visit Reason
The inspection was conducted as a licensing inspection by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing.
Findings
No regulatory citations were identified as a result of this inspection.
Inspection Report
Renewal
Census: 40
Capacity: 66
Deficiencies: 6
Aug 11, 2022
Visit Reason
The inspection was an unannounced full renewal inspection conducted to review compliance with licensing regulations.
Findings
The facility was found to have multiple deficiencies related to staff hiring procedures, resident access to bedrooms, medication record keeping, medication administration, following prescriber's orders, and preadmission screening. Plans of correction were submitted and accepted, with implementation dates ranging from 2022-09-30 to 2023-02-28.
Deficiencies (6)
| Description |
|---|
| Staff A had not held permanent residency in Pennsylvania for two consecutive years prior to employment and the facility did not run an FBI check. |
| Resident #1 had a banner across the bedroom door restricting access, violating the requirement that residents have access to their bedrooms at all times. |
| Resident #1's medication administration record did not indicate diagnosis or purpose for the medication, including PRN. |
| Resident #1's medication administration record did not include initials of staff who administered medication on multiple dates. |
| Resident #2 was administered medication not ordered by the prescriber for UTI treatment from 07/03/22 through 07/10/22. |
| Resident #3's written cognitive preadmission screening was not completed within 72 hours prior to admission to the secured dementia care unit. |
Report Facts
License Capacity: 66
Residents Served: 40
Current Residents in Hospice: 2
Residents Age 60 or Older: 38
Residents with Mobility Need: 40
Residents with Physical Disability: 11
Total Daily Staff: 80
Waking Staff: 60
Inspection Report
Complaint Investigation
Census: 40
Capacity: 66
Deficiencies: 6
Jun 7, 2022
Visit Reason
The inspection was conducted as a complaint investigation following an allegation of mistreatment of resident #1 reported by the resident's spouse.
Findings
The investigation found multiple violations including failure to develop and implement a plan of supervision or suspend the staff involved in the alleged abuse, failure to submit required reports to the Department, failure to provide assistance with activities of daily living as per the resident's support plan, leaving the resident unattended for a concerning amount of time, and unsanitary conditions with strong urine odors in the units.
Complaint Details
The complaint involved an allegation of mistreatment of resident #1 by staff, reported by the resident's spouse, including video evidence. The complaint was substantiated with findings of neglect and failure to follow required procedures.
Deficiencies (6)
| Description |
|---|
| Failure to develop and implement a plan of supervision or suspend staff involved in alleged abuse. |
| Failure to submit a plan of supervision or notice of suspension to the Department's regional office. |
| Failure to report the incident of mistreatment to the Department within required timeframe. |
| Failure to provide assistance with activities of daily living as indicated in the resident's assessment and support plan. |
| Resident left unattended in bedroom with door closed for a concerning amount of time. |
| Sanitary conditions not maintained; strong urine smell throughout units. |
Report Facts
License Capacity: 66
Residents Served: 40
Staffing Hours - Total Daily Staff: 80
Staffing Hours - Waking Staff: 60
Residents Age 60 or Older: 39
Residents with Mobility Need: 40
Residents with Physical Disability: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director | Executive Director | Named in relation to re-education, plan of correction implementation, and investigation of the abuse incident. |
| Resident Services Coordinator | Resident Services Coordinator | Involved in investigation of the abuse incident and implementation of corrective actions. |
Inspection Report
Follow-Up
Census: 36
Capacity: 66
Deficiencies: 5
Nov 19, 2021
Visit Reason
The inspection was a follow-up review of the facility's submitted plan of correction related to medication administration and staffing issues.
Findings
The facility had deficiencies related to missed medication administration due to staffing shortages, incomplete medication administration records, failure to follow prescriber's orders, lack of documentation of medication errors and prescriber responses, and missing incident reports in resident records. The submitted plan of correction was determined to be fully implemented.
Deficiencies (5)
| Description |
|---|
| Residents #1, #2, #3, #4 did not receive Levothyroxin Tabs as prescribed on 11/14/21 due to no Med Techs staffed from 12:00am to 7:00am. |
| Medication administration records for residents #5 through #15 did not include initials of staff who administered 8PM medications on 11/17/2021. |
| Resident #1 through #4 were not administered prescribed Levothyroxin medication on 11/14/21; Resident #5 had missed and partial doses of prescribed medications. |
| No documentation of medication errors and prescriber's response in resident records for residents #1 through #4 regarding missed Levothyroxin doses on 11/14/21. |
| Resident records for residents #1 through #4 did not include incident reports dated 11/14/21. |
Report Facts
License Capacity: 66
Residents Served: 36
Total Daily Staff: 72
Waking Staff: 54
Residents with Mobility Need: 36
Residents 60 Years or Older: 30
Residents with Hospice Care: 4
Residents with Supplemental Security Income: 0
Inspection Report
Renewal
Census: 38
Capacity: 66
Deficiencies: 8
Jul 7, 2021
Visit Reason
The inspection was an unannounced full renewal inspection conducted on 07/07/2021 to assess compliance with licensing requirements.
Findings
The inspection identified multiple deficiencies including failure to timely report incidents, missing required posters, unlocked poisonous materials accessible to residents, exterior hazards, improper refrigerator/freezer temperatures, and missing medications on the medication cart. Plans of correction were accepted and implemented with follow-up actions scheduled.
Deficiencies (8)
| Description |
|---|
| Failure to report incidents involving residents within 24 hours to the Department. |
| Influenza Awareness poster not posted in a conspicuous or public location in the home. |
| Resident Rights poster not posted in a conspicuous and public place in the home. |
| Required telephone numbers not posted in a conspicuous and public place in the home. |
| Poisonous materials (creams and antiperspirant) unlocked and accessible to residents in resident #3's room. |
| Electrical junction box for courtyard magnetic lock gate open with exposed wires and wasp nest present. |
| Refrigerator temperature in Berry Ridge Unit was 46°F and freezer was 12°F, exceeding required limits. |
| Medications for residents #5 and #6 were not present on the medication cart as ordered. |
Report Facts
License Capacity: 66
Residents Served: 38
Current Hospice Residents: 3
Wasp Count: 8
Refrigerator Temperature: 46
Freezer Temperature: 12
Notice
Capacity: 66
Deficiencies: 0
Apr 16, 2021
Visit Reason
The document serves as a renewal notification and license issuance for Arden Courts of Yardley Personal Care Home, confirming receipt of the renewal application and advising of the requirement for an annual onsite inspection within the next twelve months.
Findings
No inspection findings are reported in this document; it is an administrative license renewal notice confirming the issuance of a regular license.
Report Facts
Maximum licensed capacity: 66
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary, Office of Long-term Living | Signed the renewal notification letter. |
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