Inspection Report
Follow-Up
Census: 111
Capacity: 165
Deficiencies: 1
Sep 4, 2025
Visit Reason
The inspection visit on 09/04/2025 was a partial, unannounced follow-up inspection triggered by an incident and monitoring related to a plan of correction submission.
Findings
The facility was found to have fully implemented the submitted plan of correction related to an abuse violation involving theft of residents' property by a direct care staff member. The staff member was suspended and subsequently terminated for failure to comply with the investigation. The facility conducted internal investigations, filed a police report, provided staff training, reimbursed the residents, and implemented ongoing monitoring of corrective actions.
Deficiencies (1)
| Description |
|---|
| Violation of abuse regulation 42b involving theft of residents' property by a direct care staff person in the secure dementia care unit. |
Report Facts
License Capacity: 165
Residents Served: 111
Secured Dementia Care Unit Capacity: 25
Secured Dementia Care Unit Residents Served: 21
Hospice Current Residents: 5
Residents Age 60 or Older: 111
Residents with Mental Illness: 3
Residents with Intellectual Disability: 1
Residents with Mobility Need: 45
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director | Conducted internal investigation, filed police report, suspended staff person A, provided in-service training, reimbursed residents, and led corrective actions | |
| Community Business Director | Participated in suspension of staff person A during investigation | |
| Life Guidance Director | Provided in-service training to Life Guidance Resident Services Assistants | |
| Direct Care Staff Person A | Alleged to have stolen residents' iPads, denied theft, failed to provide written statement, suspended and terminated |
Inspection Report
Renewal
Census: 126
Capacity: 165
Deficiencies: 18
Jan 30, 2025
Visit Reason
The inspection was conducted as part of a renewal, provisional, incident, and monitoring review of the facility to ensure compliance with 55 Pa. Code Chapter 2600 relating to Personal Care Homes.
Findings
The facility was found to be in compliance overall, but several deficiencies were cited including missing carbon monoxide detectors, incomplete resident contracts, elopement risk due to alarm failures, privacy violations due to missing signage, incorrect posted telephone numbers, lack of criminal background checks for hospice workers, incomplete fire safety training, missing bedside tables and operable lamps for some residents, refrigerator temperature violations, medication storage and administration issues, incomplete resident assessments and support plans, and incomplete preadmission screening and consent documentation for secured dementia care residents.
Deficiencies (18)
| Description |
|---|
| No Carbon Monoxide detector in kitchen using gas equipment. |
| Resident-home contracts not signed timely or missing signatures. |
| Resident eloped from secured dementia care unit due to alarm system failure. |
| Missing signage indicating video recording in elevator vestibule. |
| Incorrect telephone number posted for local ombudsman. |
| No criminal background checks for hospice workers providing services. |
| Staff did not receive required fire safety training by a fire safety expert. |
| No bedside table or shelf beside beds of residents #4 and #6. |
| Residents #4 and #6 did not have operable lamps or lighting at bedside. |
| Kitchen refrigerator temperature exceeded 40°F. |
| Tears in medication blister packs making medication unsanitary. |
| Medication (Motrin 800 MG) not available for resident #7. |
| Missed medication administrations due to prior authorization delay for resident #6. |
| Resident #5 initial assessment not completed within 15 days of admission. |
| Resident support plans missing required medical, dental, behavioral care documentation. |
| Residents #1 and #8 did not sign their support plans. |
| Resident #3 preadmission cognitive screening incomplete for secured dementia care unit. |
| Resident #9 consent form for secured dementia care unit signed late by resident and designated person. |
Report Facts
License Capacity: 165
Residents Served: 126
Secure Dementia Care Unit Capacity: 25
Secure Dementia Care Unit Residents Served: 19
Hospice Residents: 4
Residents Age 60 or Older: 122
Residents with Intellectual Disability: 1
Residents with Mobility Need: 44
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Juliet Marsala | Deputy Secretary | Signed licensing letter and certificate. |
| Executive Director | Named in multiple plans of correction related to compliance and training. | |
| Maintenance Director | Named in plan of correction for carbon monoxide detector installation. | |
| Community Business Director | Named in plan of correction for resident contract audits. | |
| Resident Services Director | Named in medication and assessment related findings and plans of correction. | |
| Resident Service Supervisor | Named in medication audit and training plans. | |
| Assistant Director Culinary Services | Named in refrigerator temperature violation plan of correction. | |
| Regional Care Director | Named in training and education plans of correction. | |
| Life Guidance Director | Named in elopement protocol training and consent documentation plans. | |
| Resident Medication Assistants | Named in medication storage and administration training. | |
| Wellness Nurse | Named in elopement incident and medication training. |
Inspection Report
Census: 110
Capacity: 165
Deficiencies: 0
Nov 25, 2024
Visit Reason
The inspection was a licensing inspection conducted by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing on 11/25/2024.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Residents Served: 110
License Capacity: 165
Secured Dementia Care Unit Capacity: 25
Secured Dementia Care Unit Residents Served: 20
Hospice Current Residents: 4
Residents Age 60 or Older: 110
Residents Diagnosed with Intellectual Disability: 1
Residents Diagnosed with Mental Illness: 0
Residents with Mobility Need: 36
Residents with Physical Disability: 8
Resident Support Staff: 0
Total Daily Staff: 146
Waking Staff: 110
Inspection Report
Follow-Up
Census: 114
Capacity: 165
Deficiencies: 3
Aug 15, 2024
Visit Reason
The inspection visit on 08/15/2024 was conducted as a follow-up to verify that the submitted plan of correction was fully implemented following previous deficiencies.
Findings
The submitted plan of correction was determined to be fully implemented as of the inspection date. Deficiencies related to annual medical evaluations and medication storage and administration were addressed with corrective actions and training.
Deficiencies (3)
| Description |
|---|
| Resident medical evaluations were not completed annually as required. |
| Medications stored in resident bedrooms were found unlocked and unattended, including alprazolam 1mg tablets. |
| Resident self-administering medications was unable to remember medication details and was not safely self-administering medications. |
Report Facts
Residents Served: 114
License Capacity: 165
Secured Dementia Care Unit Capacity: 20
Secured Dementia Care Unit Residents Served: 11
Hospice Current Residents: 4
Residents Age 60 or Older: 114
Residents with Mobility Need: 32
Total Daily Staff: 146
Waking Staff: 110
Inspection Report
Complaint Investigation
Census: 128
Capacity: 165
Deficiencies: 8
Jun 17, 2024
Visit Reason
The inspection was conducted as a complaint investigation following allegations related to compliance with 55 Pa. Code Chapter 2600 for Personal Care Homes.
Findings
Multiple violations were found including issues with annual medical evaluations, medication management, preadmission screening, support plan documentation, and medication storage. A provisional license was issued due to these violations with required plans of correction.
Complaint Details
The inspection was triggered by a complaint, as indicated by the inspection reason and the unannounced partial inspection conducted on 06/17/2024.
Deficiencies (8)
| Description |
|---|
| Resident #1’s most recent medical evaluation was not current. |
| Discontinued medications were found in the medication cart for resident #2. |
| Pharmacy label for resident #2's Melatonin did not match prescribed dosage. |
| Resident #2's medication administration record did not list diagnosis or purpose for Memantine. |
| Resident #3 was administered medications at incorrect times and received half the prescribed dose of Enalapril Maleate. |
| Resident #4’s preadmission screening form was not completed timely. |
| Assessment and support plan for resident #1 were not signed by participants. |
| Support plan for resident #2 did not address agitation despite medication for agitation. |
Report Facts
License Capacity: 165
Residents Served: 128
Secure Dementia Care Unit Capacity: 25
Secure Dementia Care Unit Residents Served: 13
Fine Per Resident Per Day: 5
Calculated Fine Per Day: 645
Census at Inspection: 129
Staffing Hours: 151
Waking Staff Hours: 113
Inspection Report
Complaint Investigation
Census: 128
Capacity: 165
Deficiencies: 13
Jun 17, 2024
Visit Reason
The inspection was conducted as a complaint investigation following allegations at the facility, Atria Center City, on June 17, 2024.
Findings
Multiple violations were found related to medication management, resident assessments, support plans, and preadmission screening. Several deficiencies were repeated from prior inspections, and a provisional license was issued due to non-compliance.
Complaint Details
The inspection was complaint-driven, triggered by allegations at the facility. The report documents multiple repeated violations and deficiencies related to medication management, resident assessments, and documentation.
Deficiencies (13)
| Description |
|---|
| Resident #1’s most recent medical evaluation was not current. |
| Discontinued medications were found in the medication cart for resident #2. |
| Pharmacy label for resident #2's Melatonin did not match prescribed dosage. |
| Resident #2's medication administration record did not list diagnosis or purpose for Memantine. |
| Resident #3 was administered medications at incorrect times and received half the prescribed dose of Enalapril. |
| Resident #4’s preadmission screening form was not completed timely prior to admission. |
| Assessment and support plan for resident #1 were not signed by participants. |
| Support plan for resident #2 did not address agitation despite medication for agitation. |
| On 8/5/2024, medication was found in the home without a current order for resident #3. |
| Resident #4's medication packaging was torn in multiple spots. |
| Resident #3’s prescribed medication Tramadol was not available in the home. |
| Resident #1’s initial support plan was not completed within 30 days of admission. |
| Resident #4 and #5’s written cognitive preadmission screening was not completed within 72 hours prior to admission to the secured dementia care unit. |
Report Facts
License Capacity: 165
Residents Served: 128
Secured Dementia Care Unit Capacity: 25
Residents Served in Secure Dementia Care Unit: 13
Fine Per Resident Per Day: 5
Calculated Fine Per Day: 645
Staffing Hours - Resident Support Staff: 151
Staffing Hours - Waking Staff: 113
Inspection Report
Complaint Investigation
Census: 128
Capacity: 165
Deficiencies: 11
Jun 17, 2024
Visit Reason
The inspection was conducted as a complaint investigation to assess violations found at Atria Center City related to Personal Care Homes regulations.
Findings
Multiple violations were found related to medical evaluations, medication management, support plans, preadmission screening, and documentation. The facility was issued a first provisional license with a requirement to correct all violations by specified dates.
Complaint Details
The visit was complaint-related, triggered by allegations leading to the identification of multiple violations as detailed in the Licensing Inspection Summary.
Deficiencies (11)
| Description |
|---|
| Resident #1's most recent medical evaluation was not completed timely. |
| Discontinued medications for resident #2 were still in the home's medication cart. |
| Resident #2's medication label did not include correct dosage and administration instructions. |
| Resident #2's medication administration record did not list diagnosis or purpose for medication. |
| Resident #3's medication administration did not follow prescriber's orders. |
| Resident #4's preadmission screening form was not completed within required timeframe. |
| Assessment and support plan for resident #1 were not signed by participants. |
| Support plan for resident #2 did not address agitation and related behaviors. |
| Resident #3's prescribed medication was not available in the home. |
| Resident #1's initial support plan was not completed within 30 days of admission. |
| Resident #4 and #5's written cognitive preadmission screening was not completed within 72 hours prior to admission to secured dementia care unit. |
Report Facts
License Capacity: 165
Residents Served: 128
Secure Dementia Care Unit Capacity: 25
Secure Dementia Care Unit Residents Served: 13
Fine Per Day: 5
Calculated Fine: 645
Census at Inspection: 129
Total Daily Staff: 151
Waking Staff: 113
Inspection Report
Monitoring
Census: 137
Capacity: 165
Deficiencies: 0
Feb 1, 2024
Visit Reason
The inspection was a monitoring visit conducted by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing on 02/01/2024.
Findings
No regulatory citations or deficiencies were identified during this inspection.
Report Facts
Resident Support Staff: 175
Waking Staff: 131
License Capacity: 165
Residents Served: 137
Secured Dementia Care Unit Capacity: 25
Secured Dementia Care Unit Residents Served: 20
Residents Age 60 or Older: 137
Residents Diagnosed with Mental Illness: 1
Residents with Mobility Need: 38
Residents with Physical Disability: 1
Inspection Report
Renewal
Census: 126
Capacity: 165
Deficiencies: 18
Nov 27, 2023
Visit Reason
The inspection was conducted as a renewal visit for the facility license, including a full unannounced inspection on 11/27/2023 and 11/28/2023.
Findings
The inspection identified multiple deficiencies related to resident record confidentiality, contract signatures, privacy violations, inadequate staff training, unsafe bedside mobility devices, emergency preparedness, prohibited portable space heaters, incomplete medical evaluations, medication storage and labeling issues, improper medication administration documentation, resident rights education, preadmission screening delays, incomplete support plans, and incomplete resident record content.
Deficiencies (18)
| Description |
|---|
| A book with residents' toileting schedule/checks was unsecured in the memory care closet, which was unlocked. |
| Resident-home contract for resident #1 was not signed by the resident. |
| Resident #1's record did not contain a signed statement acknowledging receipt of resident rights and complaint procedures. |
| Medication technician was observed administering meds to a resident in the home's Bistro, violating privacy. |
| Direct care staff person B received only 2.5 hours of annual training in 2022, lacking required training topics. |
| Bedside mobility device for resident #2 was not compliant with FDA guidelines and not documented in support plan. |
| Bedside mobility device used by resident #3 slid under mattress and was not secured to bed frame, creating entrapment hazard. |
| Staff person E did not have a copy of the emergency preparedness plan for the local municipality. |
| Portable space heater was in use in resident room #320. |
| Medical evaluations for residents #4 and #5 were incomplete, missing medication list and body positioning information. |
| Medical evaluations for residents #1, #4, #6, #7, #8, and #9 were not completed within the required annual timeframe. |
| Medications for residents #4, #10, and #11 were improperly stored or labeled, including undated insulin pens and expired nasal spray. |
| Glucometers for residents #4, #10, and #12 were not calibrated correctly or documentation was incomplete. |
| Resident #1 was not educated on the right to refuse medication if a medication error is suspected. |
| Resident #14's preadmission screening form was completed after admission date. |
| Support plans for residents #2 and #3 did not document or address the use of bedside mobility devices (enablers). |
| Written cognitive preadmission screening for residents #5 and #15 were incomplete or not timely. |
| Resident records for #8, #16, and #17 were missing required demographic information, photographs, or preadmission screening. |
Report Facts
Residents Served: 126
License Capacity: 165
Total Daily Staff: 164
Waking Staff: 123
Secured Dementia Care Unit Capacity: 25
Secured Dementia Care Unit Residents Served: 18
Residents Diagnosed with Mental Illness: 2
Residents with Mobility Need: 38
Residents Aged 60 or Older: 126
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Medication Technician | Observed administering medication inappropriately outside resident apartment |
| Staff Person B | Received insufficient annual training and training on required topics | |
| Staff Person C | Did not receive required annual training on multiple topics | |
| Staff Person D | Did not receive required annual training on resident rights and protective services | |
| Staff Person E | Did not have copy of emergency preparedness plan |
Inspection Report
Follow-Up
Census: 135
Capacity: 165
Deficiencies: 1
May 16, 2023
Visit Reason
The inspection visit on 05/16/2023 was conducted as a follow-up to verify the implementation of a previously submitted plan of correction related to support plan signatures.
Findings
The facility was found to have fully implemented the plan of correction regarding support plan signatures, ensuring that residents participate in and sign their support plans as required by state regulation.
Deficiencies (1)
| Description |
|---|
| Resident #1 did not have a signature on the support plan or any indication that the resident was unable or declined to sign or participate in the support plan. |
Report Facts
License Capacity: 165
Residents Served: 135
Secured Dementia Care Unit Capacity: 25
Secured Dementia Care Unit Residents Served: 20
Current Hospice Residents: 4
Residents Age 60 or Older: 135
Residents with Mobility Need: 43
Total Daily Staff: 178
Waking Staff: 134
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Resident Services Director | Named in plan of correction and responsible for ensuring compliance with support plan signature regulation | |
| Regional Care Director | Provided additional training to Executive Director and Resident Services Director on support plan signature requirements | |
| Executive Director | Received training and met weekly with Resident Services Director to review support plans for compliance |
Inspection Report
Plan of Correction
Census: 134
Capacity: 165
Deficiencies: 1
Apr 10, 2023
Visit Reason
The inspection was conducted as a complaint and incident investigation with an unannounced partial inspection on 04/10/2023.
Findings
The facility failed to submit a final incident report to the Department following a resident's hospitalization due to seizure-like activity. The plan of correction was accepted and fully implemented by 06/12/2023.
Complaint Details
The visit was complaint-related and involved an incident where Resident #1 was hospitalized with seizure-like activity. The home submitted an initial incident report but did not submit the required final report to the Department.
Deficiencies (1)
| Description |
|---|
| Failure to submit a final incident report to the Department following a resident's hospitalization. |
Report Facts
License Capacity: 165
Residents Served: 134
Secured Dementia Care Unit Capacity: 26
Secured Dementia Care Unit Residents Served: 22
Residents Age 60 or Older: 134
Residents with Intellectual Disability: 2
Residents with Physical Disability: 2
Residents with Mobility Need: 42
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Resident Services Director | Named in plan of correction for submitting initial and final incident reports | |
| ED | Named in plan of correction for retraining and auditing incident reports | |
| RSD | Named in plan of correction for retraining on reporting requirements | |
| RVP | Responsible for retraining ED and RSD on reporting requirements |
Inspection Report
Complaint Investigation
Census: 130
Capacity: 165
Deficiencies: 5
Mar 2, 2023
Visit Reason
The inspection was conducted as a complaint investigation following a complaint received by the Pennsylvania Department of Human Services.
Findings
The inspection found multiple deficiencies including failure to report an unwitnessed fall incident to the department, inadequate assistance with activities of daily living such as Foley bag management, neglect in checking on a resident leading to a fall in the shower, and failure to ensure direct care staff met qualification requirements. Plans of correction were accepted and implemented.
Complaint Details
The visit was complaint-related, triggered by a complaint regarding neglect and failure to provide required care to resident 1, including failure to report an incident and inadequate assistance with Foley bag management. The complaint was substantiated by the findings.
Deficiencies (5)
| Description |
|---|
| Failure to report an unwitnessed fall incident to the department within 24 hours. |
| Failure to provide assistance with activities of daily living as indicated in the resident’s assessment and support plan, specifically Foley bag management. |
| Neglect of resident leading to a fall in the shower with the water running and flooding the bathroom. |
| Direct care staff person did not have a high school diploma, GED, or active registry status on the Pennsylvania nurse aide registry. |
| Resident support plan did not document dates, times, or staff names for assistance provided, and resident did not sign the support plan as required. |
Report Facts
License Capacity: 165
Residents Served: 130
Secured Dementia Care Unit Capacity: 22
Secured Dementia Care Unit Residents Served: 19
Current Hospice Residents: 4
Total Daily Staff: 169
Waking Staff: 127
Resident with Mobility Need: 39
Resident Age 60 or Older: 130
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Resident Services Director | Named in multiple findings related to monitoring communication logs, training, and auditing incident reports and support plans. | |
| Executive Director | Named in multiple findings related to training, auditing, and ensuring compliance with incident reporting and support plans. | |
| Regional Care Director | Named in findings related to providing training and education to staff on incident reporting and support plans. | |
| Manager on Duty | Named in monitoring communication logs and incident reporting. | |
| Staff member A | Reported failure to check on resident leading to fall incident. |
Inspection Report
Census: 136
Capacity: 165
Deficiencies: 0
Oct 18, 2022
Visit Reason
The inspection was conducted as a partial, unannounced visit related to an incident.
Findings
No regulatory citations or deficiencies were identified during the inspection.
Report Facts
License Capacity: 165
Residents Served: 136
Secured Dementia Care Unit Capacity: 25
Secured Dementia Care Unit Residents Served: 18
Residents 60 Years or Older: 136
Residents with Mobility Need: 41
Total Daily Staff: 177
Waking Staff: 133
Inspection Report
Follow-Up
Census: 136
Capacity: 165
Deficiencies: 3
Aug 17, 2022
Visit Reason
The visit was conducted as a follow-up to review the submitted plan of correction after an incident at the facility.
Findings
The facility was found to have deficiencies related to insufficient direct care staffing hours for residents with mobility needs and incomplete orientation and training of a staff person on fire safety, resident rights, and abuse reporting. The submitted plan of correction was determined to be fully implemented.
Deficiencies (3)
| Description |
|---|
| Direct care staff hours were insufficient to provide at least 2 hours per day of personal care services to residents with mobility needs; 154.5 hours provided versus 160 hours required. |
| A staff person did not receive required orientation on fire safety and emergency preparedness topics on their first day of work. |
| A staff person did not complete training within 40 scheduled working hours on resident rights, emergency medical plan, mandatory reporting of abuse and neglect, and reporting of reportable incidents and conditions. |
Report Facts
Residents served: 136
License capacity: 165
Residents with mobility needs: 41
Direct care staffing hours provided: 154.5
Direct care staffing hours required: 160
Staffing audit period: 90
Training completion timeframe: 10
Inspection Report
Renewal
Census: 120
Capacity: 165
Deficiencies: 12
Jul 19, 2022
Visit Reason
The inspection was conducted as a renewal review of the facility's compliance with regulatory requirements.
Findings
Multiple deficiencies were identified including failure to timely report incidents, missing resident contract signatures, incomplete criminal background checks, unqualified direct care staff, unsanitary conditions, improper lighting in resident rooms, improper food storage, failure to submit emergency procedures annually, improper medication storage, inaccurate glucometer calibration, and late preadmission screening for secured dementia care unit residents. Corrective actions and training plans were submitted and accepted.
Deficiencies (12)
| Description |
|---|
| Failure to report incidents to the department within 24 hours as required. |
| Resident-home contract not signed by resident due to cognitive impairment. |
| Staff person A lacked FBI criminal background check prior to hire. |
| Direct care staff person B lacked required high school diploma, GED, or registry status. |
| Direct care staff persons B and C lacked documentation of completion and passing of Department-approved direct care training. |
| Strong fecal odor and fecal matter found in secured dementia care unit; unsanitary use of resident glucometer. |
| Residents #9 and #10 lacked operable lamp or source of lighting at bedside. |
| Food stored in opened and unsealed containers in dry food pantry. |
| Written emergency procedures not submitted annually to local Emergency Management Agency. |
| Loose pills observed in nursing/diabetic treatment cart. |
| Resident #7's glucometer not calibrated to correct time; multiple inaccurate glucose log readings for residents #7 and #8. |
| Resident #9 admitted to secured dementia care unit without timely preadmission cognitive screening. |
Report Facts
Residents served: 120
License capacity: 165
Residents served in secured dementia care unit: 19
Capacity of secured dementia care unit: 25
Current hospice residents: 7
Residents age 60 or older: 120
Residents with mobility need: 43
Residents with physical disability: 4
Inspection Report
Follow-Up
Census: 128
Capacity: 165
Deficiencies: 7
May 6, 2022
Visit Reason
The inspection was a partial, unannounced follow-up review conducted due to an incident involving medication errors and related compliance issues at the facility.
Findings
The facility failed to fully implement its plan of correction related to medication administration errors, incident reporting delays, and communication failures. Multiple deficiencies were identified including failure to report incidents timely, improper medication order clarifications, missed medication doses, and failure to notify prescribers of medication refusals.
Deficiencies (7)
| Description |
|---|
| Failure to provide immediate access to the home, residents, and records to Department agents upon request. |
| Failure to report a medication error incident to the Department within 24 hours as required. |
| Failure to follow medication procedures including triple check physician verification and clarification of unclear orders. |
| Changes in medication orders were not properly documented or communicated, including discontinuation without written or verbal order. |
| Medication administration records lacked diagnoses or purpose for prescribed medications. |
| Failure to document and report resident refusals of medication to prescribers within 24 hours. |
| Failure to follow prescriber's orders resulting in missed administration of prescribed medication on specified dates. |
Report Facts
License Capacity: 165
Residents Served: 128
Secured Dementia Care Unit Capacity: 25
Residents Served in Dementia Unit: 16
Residents with Mobility Need: 41
Medication Refusal Dates: 11
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Claire Mendez | Human Services Licensing Supervisor | Signed the letter regarding plan of correction implementation. |
| Resident Services Director | Named in multiple findings related to medication errors, incident reporting, and staff training. | |
| Executive Director | Named in findings related to communication failures and training on incident reporting and medication procedures. | |
| Regional Care Director | Provided training to Executive Director and Resident Services Director on policies and procedures. |
Notice
Capacity: 165
Deficiencies: 0
Sep 13, 2021
Visit Reason
The document serves as a renewal notification and license issuance for the Personal Care Home 'Atria Center City' following receipt of the renewal application dated August 17, 2021.
Findings
The Department advises that an onsite annual inspection will be conducted within the next twelve months to ensure compliance with applicable regulations; no inspection findings are reported in this document.
Report Facts
Maximum capacity: 165
Secure Dementia Care Unit capacity: 25
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary | Signed the renewal notification letter. |
Inspection Report
Renewal
Census: 80
Capacity: 165
Deficiencies: 23
Apr 5, 2021
Visit Reason
The inspection was conducted as a renewal review of the Atria Center City personal care home to verify compliance with state regulations and licensing requirements.
Findings
The inspection identified multiple deficiencies including missing posted documents, incomplete resident contract signatures, lack of staff training documentation, improper storage and labeling of medications, and issues with emergency procedures and facility maintenance. Plans of correction were accepted and documented for all deficiencies.
Deficiencies (23)
| Description |
|---|
| The home did not have a copy of the current license inspection summary or Personal Care Homes regulation book posted in a conspicuous and public place. |
| The home did not post required influenza information year-round as required by the Influenza Awareness Act. |
| Residents #1, #2, and #3 did not sign the Atria Senior Living contract and there was no documentation of refusal or inability to sign. |
| Residents #1, #2, and #3's records did not contain a signed statement acknowledging receipt of resident rights and complaint procedures. |
| Direct care staff persons A, B, C, and D lacked documentation of required qualifications including high school diploma, GED, or active registry status. |
| Staff persons B and D did not have documentation of required fire safety and emergency preparedness orientation on their first day. |
| Staff persons B and D did not have documentation of training within 40 scheduled working hours on resident rights, emergency medical plan, mandatory reporting of abuse and neglect, and reporting of reportable incidents. |
| Direct care staff persons B and D did not complete and pass the Department-approved direct care training course. |
| Three large trash cans and two rectangular trash cans were uncovered and without lids in the kitchen. |
| The first aid kit in the administrative area lacked a thermometer, tweezers, and scissors. |
| Apartments # and # did not have a source of light that can be turned on/off at the bedside. |
| There was no toilet paper in bathroom 236. |
| Two thermometers in the SDCU kitchenette refrigerator measured above required temperatures (46°F and 50°F). |
| Two tubs of ice cream in the kitchen freezer were uncovered. |
| The home’s written emergency procedures had not been submitted to the local emergency management agency since 11/4/2019. |
| The home’s emergency procedures were not posted in a conspicuous and public place. |
| The home's menu for the week of 4/5/21 was not posted on the SDCU. |
| Resident #6's medication label for MAPAP was inconsistent with the prescribed dosage instructions. |
| Resident #3's prescribed Acetaminophen medication was not available in the home on 4/6/21. |
| Resident #1's prescribed Vitamin D3 was not administered on 4/5/21 or 4/6/21 due to medication unavailability. |
| The home did not provide documentation that residents #1, #2, and #3 were educated on their right to refuse medication. |
| An initial assessment was not completed within 15 days of admission for resident #5. |
| A support plan was not completed within 30 days of admission for resident #5. |
Report Facts
License Capacity: 165
Residents Served: 80
Secured Dementia Care Unit Capacity: 25
Secured Dementia Care Unit Residents Served: 15
Hospice Current Residents: 4
Residents Age 60 or Older: 79
Residents with Mobility Need: 61
Residents with Physical Disability: 7
Staff Total Daily: 141
Staff Waking: 106
Uncovered Trash Cans: 5
Thermometers in Refrigerator: 2
Inspection Report
Complaint Investigation
Census: 115
Capacity: 165
Deficiencies: 0
Feb 12, 2021
Visit Reason
The inspection was conducted as a complaint 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, but no deficiencies or citations were found.
Report Facts
Residents Served: 115
License Capacity: 165
Secured Dementia Care Unit Capacity: 25
Secured Dementia Care Unit Residents Served: 20
Residents Age 60 or Older: 115
Residents Diagnosed with Mental Illness: 1
Residents with Mobility Need: 28
Resident Support Staff: 0
Total Daily Staff: 143
Waking Staff: 107
Inspection Report
Follow-Up
Census: 97
Capacity: 165
Deficiencies: 3
Jan 26, 2021
Visit Reason
The inspection was a partial, unannounced follow-up review conducted due to an incident at the facility on January 26 and 27, 2021.
Findings
The submitted plan of correction related to resident abuse allegations was determined to be fully implemented. The facility was found to have complied with the required corrective actions, including staff training and supervision plans.
Deficiencies (3)
| Description |
|---|
| Staff person A escorted resident #1 roughly by holding the resident's arm and pushed the resident in the back, constituting abuse. |
| The home did not develop and implement a plan of supervision or suspend the staff person involved in the alleged abuse incident in a timely manner. |
| The home failed to report the abuse incident to the Department's personal care home regional office within the required timeframe. |
Report Facts
Residents Served: 97
License Capacity: 165
Capacity: 25
Current Residents in Hospice: 2
Residents with Mobility Need: 25
Residents Age 60 or Older: 97
Residents Served in Dementia Unit: 7
Report
May 28, 2025
File
20250528_13657.pdf
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