Inspection Report
Complaint Investigation
Census: 111
Capacity: 170
Deficiencies: 4
Jun 10, 2025
Visit Reason
The inspection was conducted as a complaint and incident investigation at Atria Lafayette Hill on 06/10/2025.
Findings
The inspection found violations related to resident dignity and respect, lack of required staff training in medication self-administration and fire safety, and incomplete training records. Staff member A was suspended and terminated due to inappropriate behavior and failure to meet training requirements. Plans of correction were accepted with completion dates mostly by 07/31/2025 and implemented by 08/04/2025.
Complaint Details
The visit was complaint-related, triggered by allegations reported on 05/07/2025 regarding staff mistreatment of a resident and training deficiencies. Staff member A was suspended immediately and later terminated.
Deficiencies (4)
| Description |
|---|
| Resident was treated without dignity and respect; staff member A was rude and threatening while assisting a resident. |
| Direct care staff person A did not receive training in medication self-administration during training year 2024. |
| Staff person A did not receive training in fire safety completed by a fire safety expert during training year 2024. |
| The home's record of direct care staff training does not include length of each course. |
Report Facts
License Capacity: 170
Residents Served: 111
Secured Dementia Care Unit Capacity: 33
Secured Dementia Care Unit Residents Served: 28
Residents Diagnosed with Mental Illness: 3
Residents with Mobility Need: 43
Residents Age 60 or Older: 111
Inspection Report
Monitoring
Census: 102
Capacity: 170
Deficiencies: 7
Apr 10, 2025
Visit Reason
The visit occurred as a monitoring inspection to review the facility's compliance with regulations and the implementation of a previously submitted plan of correction.
Findings
The inspection identified multiple deficiencies including failure to post the current license inspection summary conspicuously, unsecured resident records, missing emergency telephone numbers in resident rooms, medication storage and administration errors, incomplete medication records, and delayed admission support plans. Plans of correction were accepted and implemented by June 5, 2025.
Deficiencies (7)
| Description |
|---|
| The home's copy of 55 Pa. Code Chapter 2600 and current violation report was not posted in a conspicuous and public place in the home. |
| A white binder labeled 'Resident Schedule and Needs List' was unlocked, unattended, and accessible on the dining room counter in memory care. |
| No emergency telephone numbers including nearest hospital and fire department were posted on or by the telephone in a resident room. |
| Discrepancies in resident narcotic pill counts were found, with more pills remaining than indicated on the narcotic count sheets. |
| Medication administration records did not indicate diagnosis or purpose for the medication, including pro re nata (PRN). |
| Medication administration times were inaccurately recorded; a staff person incorrectly initialed medication as administered when it was not. |
| The home failed to complete a resident's initial support plan within 72 hours of admission to the secured dementia care unit. |
Report Facts
Residents Served: 102
License Capacity: 170
Secured Dementia Care Unit Capacity: 33
Secured Dementia Care Unit Residents Served: 27
Hospice Current Residents: 2
Residents Age 60 or Older: 102
Residents with Mental Illness: 3
Residents with Mobility Need: 39
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Resident Services Director | Named in medication error findings and responsible for retraining and audits | |
| Executive Director | Named in multiple findings related to posting license, securing resident records, and medication administration training and audits | |
| Regional Care Director | Provided education and training related to medication policies and service plan compliance | |
| Resident Service Supervisor | Responsible for reviewing order verification forms and controlled substance counts | |
| Medication Technician | Involved in medication error and retrained | |
| Life Guidance Director | Placed emergency phone numbers in resident room | |
| Maintenance Director | Responsible for weekly room audits of emergency phone numbers |
Inspection Report
Complaint Investigation
Census: 102
Capacity: 170
Deficiencies: 0
Nov 14, 2024
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 triggered by a complaint and incident; no deficiencies or citations were found.
Report Facts
License Capacity: 170
Residents Served: 102
Secured Dementia Care Unit Capacity: 33
Secured Dementia Care Unit Residents Served: 27
Hospice Current Residents: 1
Residents Diagnosed with Mental Illness: 3
Residents Diagnosed with Intellectual Disability: 1
Residents with Mobility Need: 36
Residents Age 60 or Older: 102
Inspection Report
Monitoring
Census: 103
Capacity: 170
Deficiencies: 2
Nov 1, 2024
Visit Reason
The visit was a monitoring inspection conducted on 11/01/2024 to review the facility's compliance and plan of correction implementation.
Findings
The facility was found to have fully implemented the submitted plan of correction. Two deficiencies were noted: failure to immediately report suspected resident abuse to the local area agency on aging, and failure to include a record of an incident report in a resident's file.
Deficiencies (2)
| Description |
|---|
| Failure to immediately report suspected abuse of a resident to the local area agency on aging. |
| Resident record did not include a record of the incident report dated 10/29/2024 for the individual resident. |
Report Facts
License Capacity: 170
Residents Served: 103
Secured Dementia Care Unit Capacity: 33
Secured Dementia Care Unit Residents Served: 28
Hospice Current Residents: 2
Residents Diagnosed with Mental Illness: 3
Residents Diagnosed with Intellectual Disability: 1
Residents with Mobility Need: 37
Residents Age 60 or Older: 103
Inspection Report
Complaint Investigation
Census: 103
Capacity: 170
Deficiencies: 0
Oct 16, 2024
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 triggered by a complaint and incident, but no deficiencies or citations were found.
Report Facts
Residents Served: 103
License Capacity: 170
Secured Dementia Care Unit Capacity: 34
Secured Dementia Care Unit Residents Served: 25
Hospice Current Residents: 2
Residents Diagnosed with Mental Illness: 3
Residents Diagnosed with Intellectual Disability: 1
Residents with Mobility Need: 41
Residents Aged 60 or Older: 103
Inspection Report
Complaint Investigation
Census: 100
Capacity: 170
Deficiencies: 2
Sep 5, 2024
Visit Reason
The inspection was conducted as a complaint and incident investigation at Atria Lafayette Hill on 09/05/2024.
Findings
The investigation found an abuse incident involving a resident left unable to call for help due to staff negligence, resulting in the suspension and termination of a staff member. Additionally, a staff list deficiency was identified where an agency-employed medication assistant was not listed.
Complaint Details
The complaint involved an allegation of abuse reported on 08/05/2024 to the Montgomery County Area of Aging and the Department of Human Services. The allegation was substantiated leading to immediate suspension and subsequent termination of the involved staff member.
Deficiencies (2)
| Description |
|---|
| Resident was neglected when a staff member left the call bell pendant out of reach, causing the resident to be found crying and partially hanging off their bed. |
| Staff member C, an agency-employed Resident Medication Assistant, was not included on the staff list provided. |
Report Facts
License Capacity: 170
Residents Served: 100
Secured Dementia Care Unit Capacity: 33
Secured Dementia Care Unit Residents Served: 26
Residents with Mental Illness: 3
Residents 60 Years or Older: 100
Residents with Intellectual Disability: 1
Residents with Mobility Need: 40
Residents with Physical Disability: 0
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff member A | Named in abuse incident involving neglect of resident | |
| Staff member B | Found resident crying and partially hanging off bed during abuse incident | |
| Staff member C | Resident Medication Assistant | Agency-employed staff not listed on staff list |
Inspection Report
Monitoring
Census: 89
Capacity: 170
Deficiencies: 3
May 16, 2024
Visit Reason
The visit was an unannounced partial inspection conducted as a monitoring review of the facility on 05/16/2024.
Findings
The inspection identified deficiencies related to unsecured poisonous materials accessible to residents, incomplete medication records lacking diagnoses or purposes, and missing cognitive preadmission screening documentation for a resident in the secured dementia care unit. Plans of correction were accepted and implemented by 06/25/2024.
Deficiencies (3)
| Description |
|---|
| A Colgate toothpaste with a warning label was unlocked and accessible in resident room #6, violating the requirement that poisonous materials be locked and inaccessible unless residents can safely use or avoid them. |
| Medication administration records for Resident #1 and Resident #2 did not indicate the diagnoses or purposes for prescribed medications. |
| Resident #3's written cognitive preadmission screening was missing the determination that the resident requires secured dementia care. |
Report Facts
License Capacity: 170
Residents Served: 89
Secured Dementia Care Unit Capacity: 34
Secured Dementia Care Unit Residents Served: 27
Residents with Mobility Need: 36
Residents Age 60 or Older: 89
Total Daily Staff: 125
Waking Staff: 94
Inspection Report
Renewal
Census: 92
Capacity: 170
Deficiencies: 18
Mar 25, 2024
Visit Reason
The inspection was conducted as part of a licensing renewal, complaint, and incident review for Atria Lafayette Hill.
Findings
The facility was found to be in compliance overall, with several deficiencies identified related to posting of telephone numbers, criminal background checks, sanitary conditions, food storage, medical evaluations, medication administration, and support plan signatures. All deficiencies had plans of correction submitted and were implemented by the dates specified.
Deficiencies (18)
| Description |
|---|
| Telephone numbers of the Department’s personal care home regional office and other agencies were not posted in a conspicuous place. |
| The home did not run FBI check for staff A, who does not reside in Pennsylvania. |
| Unlabeled urinal (commode) in the shower shared by two residents. |
| Use of common towels without identifying labels in shared bathrooms. |
| Food not stored in closed or sealed containers; opened brown sugar and uncovered ice cream tubs. |
| Unlabeled, undated container of gravy in walk-in freezer. |
| Fire drills routinely held on Saturdays, not varying days and times as required. |
| Resident medical evaluation missing medical diagnoses and body positioning/movement information. |
| Resident annual medical evaluation not completed within required timeframe. |
| Discontinued medication (Oxycodone) found in medication cart. |
| Medication labeling discrepancy: two blister cards with different dosage instructions without direction change sticker. |
| Medication record missing diagnoses or purposes for prescribed medications. |
| Medication administration record documented medication given when it was not administered. |
| Failure to follow prescriber's orders for medication administration. |
| Support plans not signed by assessor and resident. |
| Poisonous materials (toothpaste) unlocked and accessible to residents not assessed as safe to use poisons. |
| Medication records missing diagnoses for medications for residents #1 and #2. |
| Resident admitted to secured dementia care unit without completed cognitive preadmission screening indicating need for secured care. |
Report Facts
License Capacity: 170
Residents Served: 92
Secured Dementia Care Unit Capacity: 34
Residents Served in Secured Dementia Care Unit: 18
Total Daily Staff: 129
Waking Staff: 97
Residents Age 60 or Older: 91
Residents with Mobility Need: 37
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Juliet Marsala | Deputy Secretary | Signed licensing letters and certificates. |
Inspection Report
Follow-Up
Census: 82
Capacity: 170
Deficiencies: 2
Feb 12, 2024
Visit Reason
The inspection was a partial, unannounced follow-up visit triggered by complaint, provisional, and monitoring reasons to verify the implementation of a previously submitted plan of correction.
Findings
The submitted plan of correction related to bedside mobility devices and physical site accommodations was found to be fully implemented as of the follow-up inspection date. The facility addressed issues with potentially dangerous gaps in bedside mobility devices and unsecured devices that could create entrapment hazards.
Complaint Details
The inspection was complaint-related, provisional, and monitoring in nature. The plan of correction was accepted and fully implemented.
Deficiencies (2)
| Description |
|---|
| Bedside mobility device attached to hospital bed had potentially dangerous, uncovered gaps exceeding FDA guidelines. |
| Bedside mobility devices in multiple rooms were not securely attached to beds, creating entrapment hazards. |
Report Facts
License Capacity: 170
Residents Served: 82
Secured Dementia Care Unit Capacity: 34
Secured Dementia Care Unit Residents Served: 17
Hospice Residents: 3
Residents Age 60 or Older: 85
Residents Diagnosed with Mental Illness: 3
Residents Diagnosed with Intellectual Disability: 1
Residents with Mobility Need: 38
Residents with Physical Disability: 1
Total Daily Staff: 120
Waking Staff: 90
Inspection Report
Plan of Correction
Census: 90
Capacity: 170
Deficiencies: 1
Dec 19, 2023
Visit Reason
The inspection was a partial, unannounced visit conducted on 12/19/2023 due to a fine related to medication administration procedures. The visit included a follow-up on the submitted plan of correction.
Findings
A medication administration violation was found where a resident's morning medications from the previous day were found unsigned and not properly administered, despite being recorded as given on the medication administration record (MAR). The staff failed to observe the resident ingest the medication and complete documentation properly.
Deficiencies (1)
| Description |
|---|
| Failure to follow proper medication administration procedures including observing resident ingest medication and completing documentation on the MAR. |
Report Facts
License Capacity: 170
Residents Served: 90
Secured Dementia Care Unit Capacity: 34
Secured Dementia Care Unit Residents Served: 21
Resident Mobility Need: 41
Residents 60 Years or Older: 90
Residents Diagnosed with Mental Illness: 2
Residents Diagnosed with Intellectual Disability: 1
Inspection Report
Monitoring
Census: 79
Capacity: 170
Deficiencies: 10
Aug 28, 2023
Visit Reason
The inspection was a monitoring visit to assess ongoing compliance with regulations and to review the facility's corrective actions following previous inspections.
Findings
The facility was found to have multiple deficiencies including medication management issues, staff training deficiencies, resident abuse and safety concerns, incomplete resident documentation, and sanitary condition problems. Several repeat violations were noted. The facility submitted plans of correction and was undergoing follow-up monitoring.
Deficiencies (10)
| Description |
|---|
| Medication carts contained discontinued medications and lacked proper storage and availability of prescribed medications. |
| Staff failed to administer medications as prescribed and did not report medication refusals to prescribers. |
| Resident abuse incidents involving aggressive behaviors were not properly managed or reported. |
| Staff did not complete required training including CPR, abuse reporting, and orientation topics within required timeframes. |
| First aid kits were missing required items such as eye coverings and breathing shields. |
| Resident support plans and medical evaluations were incomplete or missing required elements. |
| Sanitary conditions were poor, including malodorous urine smell and uncovered trash receptacles. |
| The facility failed to follow admission and discharge criteria for residents requiring higher levels of care. |
| Residents lacked adequate program activities promoting involvement with family and community. |
| Resident bedrooms lacked required furniture and operable bedside lighting. |
Report Facts
License Capacity: 170
Residents Served: 79
Secured Dementia Care Unit Capacity: 34
Residents Served in Secure Dementia Care Unit: 24
Total Daily Staff: 105
Waking Staff: 79
Number of Deficiencies Cited: 17
Inspection Report
Monitoring
Census: 79
Capacity: 170
Deficiencies: 13
Aug 28, 2023
Visit Reason
The inspection was a monitoring visit to assess ongoing compliance with regulations and review corrective actions following previous inspections.
Findings
The facility had multiple deficiencies related to medication management, staff training, resident care plans, abuse reporting, and safety measures. Several repeat violations were noted, and plans of correction were submitted with some not yet implemented at the time of the report.
Deficiencies (13)
| Description |
|---|
| Discontinued medications were found in the medication cart. |
| Medications were not available in the home as prescribed, leading to missed doses. |
| Medication administration records lacked diagnosis or purpose for medications. |
| Refusals of medications were not reported to the prescriber as required. |
| Resident #4 displayed aggressive behaviors that were not adequately managed, jeopardizing safety. |
| Staff failed to complete required training including CPR, abuse reporting, and emergency preparedness. |
| First aid kits were missing required items such as eye coverings and breathing shields. |
| Resident assessments and support plans were incomplete or missing required elements. |
| The facility failed to follow admission and discharge criteria for residents requiring higher levels of care. |
| Medications were not stored properly according to manufacturer instructions. |
| Resident rooms lacked required furniture and operable lighting at bedside. |
| Sanitary conditions were not maintained, including malodorous smells in resident areas. |
| The facility lacked a program of activities promoting resident involvement with family and community. |
Report Facts
License Capacity: 170
Residents Served: 79
Residents Served in Secure Dementia Care Unit: 24
Total Daily Staff: 105
Waking Staff: 79
Fine Amount: 395
Fine Amount: 237
Fine Amount: 395
Fine Amount: 395
Fine Amount: 395
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff person A | Mentioned in relation to resident abuse report and failure to complete required training. | |
| Staff person B | Mentioned in relation to resident abuse report and failure to complete required training. | |
| Resident Service Director | Named in multiple findings related to medication management, training, audits, and corrective actions. | |
| Executive Director | Named in multiple findings related to oversight, training, audits, and corrective actions. | |
| Regional Care Director | Named in relation to training and oversight of corrective actions. | |
| Maintenance Director | Named in relation to corrective actions for first aid kits, lighting, and sanitary conditions. | |
| Regional Vice President | Named in relation to training and oversight of compliance. |
Inspection Report
Monitoring
Census: 79
Capacity: 170
Deficiencies: 15
Aug 28, 2023
Visit Reason
The visit was a monitoring inspection to review compliance with previously cited deficiencies and ongoing regulatory requirements.
Findings
The facility was found to have multiple deficiencies including medication management issues, staff training gaps, inadequate documentation, resident abuse incidents, and environmental concerns. Several repeat violations were noted. Plans of correction were accepted but many were not yet implemented at the time of the report.
Deficiencies (15)
| Description |
|---|
| Medications were found discontinued but still present in medication carts. |
| Medications were not available in the home as prescribed, leading to missed doses. |
| Medications were not administered as prescribed on multiple occasions. |
| Medication administration records lacked diagnosis or purpose for medications. |
| Refusals of medication were not reported to the prescriber as required. |
| Resident abuse incidents were not reported timely to the appropriate authorities. |
| Resident #4 displayed aggressive behaviors that were not adequately managed or addressed. |
| Staff failed to complete required training including CPR, abuse reporting, and resident rights within required timeframes. |
| First aid kits were missing required items such as eye coverings, breathing shields, and thermometers. |
| Resident rooms lacked required furniture and operable bedside lighting. |
| Medications were improperly stored, including eye drops kept beyond manufacturer recommended time. |
| Resident medical evaluations and support plans were incomplete or missing required elements. |
| The facility failed to follow admission and discharge criteria for residents requiring higher levels of care. |
| Sanitary conditions were inadequate, including malodorous urine smell in resident rooms. |
| The facility lacked a program of activities promoting resident involvement with family and community. |
Report Facts
License Capacity: 170
Residents Served: 79
Secured Dementia Care Unit Capacity: 34
Residents Served in Secure Dementia Care Unit: 24
Total Daily Staff: 105
Waking Staff: 79
Inspection Report
Monitoring
Census: 79
Capacity: 170
Deficiencies: 9
Aug 28, 2023
Visit Reason
The visit was a monitoring inspection to assess ongoing compliance with regulations and review corrective actions following previous inspections.
Findings
The inspection identified multiple deficiencies including medication management issues, staff training gaps, resident abuse and safety concerns, incomplete resident assessments and support plans, and sanitary condition problems. Several repeat violations were noted. Plans of correction were accepted but many were not yet implemented at the time of the report.
Deficiencies (9)
| Description |
|---|
| Medication carts contained discontinued medications and lacked proper storage and availability of prescribed medications. |
| Staff failed to follow prescriber's orders resulting in missed or incorrect medication administration. |
| Resident abuse incidents were not properly reported and managed, including aggressive behaviors by a resident. |
| Staff training deficiencies including lack of CPR certification, incomplete orientation and annual training. |
| Support plans and medical evaluations were incomplete or missing required elements. |
| Sanitary conditions were poor in some areas, including uncovered trash receptacles and malodorous smells. |
| First aid kits were missing required items such as eye coverings and breathing shields. |
| Residents lacked required bedroom furnishings such as chairs and operable lamps. |
| The home failed to follow admission and discharge criteria for residents requiring higher levels of care. |
Report Facts
License Capacity: 170
Residents Served: 79
Secured Dementia Care Unit Capacity: 34
Residents Served in Dementia Unit: 24
Total Daily Staff: 105
Waking Staff: 79
Number of Deficiencies Cited: 17
Inspection Report
Monitoring
Census: 85
Capacity: 170
Deficiencies: 4
Mar 27, 2023
Visit Reason
The visit was an unannounced partial inspection conducted as a monitoring review of the facility to verify compliance with regulations and the submitted plan of correction.
Findings
The inspection identified multiple deficiencies including failure to report suspected resident abuse, improper labeling and storage of leftover food, incomplete medical evaluations for secured dementia care unit residents, and delayed development of admission support plans. The facility submitted and implemented plans of correction for all deficiencies.
Deficiencies (4)
| Description |
|---|
| Failure to immediately report suspected resident abuse to the local area agency on aging. |
| Unlabeled and undated leftover food items found in kitchen refrigerator and freezer. |
| Medical evaluation for a resident admitted to the secured dementia care unit did not specify the need for secured care. |
| Admission support plan for a resident admitted to the secured dementia care unit was not completed within 72 hours prior to admission. |
Report Facts
Residents served: 85
License capacity: 170
Capacity of secured dementia care unit: 23
Residents served in secured dementia care unit: 12
Current hospice residents: 2
Residents aged 60 or older: 85
Residents diagnosed with mental illness: 3
Residents with mobility need: 43
Residents with physical disability: 2
Residents diagnosed with intellectual disability: 1
Inspection Report
Census: 80
Capacity: 170
Deficiencies: 14
Mar 14, 2023
Visit Reason
Partial inspection conducted on 2023-03-14 due to a fine related to violations of 55 Pa. Code Chapter 2600 for Personal Care Homes.
Findings
Multiple medication management deficiencies were identified including discontinued medications remaining in carts, missing medications, failure to follow prescriber's orders, and improper medication storage. Several plans of correction were proposed with deadlines mostly in April 2023. Additional findings included staff training deficiencies and failure to maintain sanitary conditions.
Deficiencies (14)
| Description |
|---|
| Discontinued medications were found in the home's medication cart for residents 1 and 2. |
| Medications prescribed for resident 3 were not available in the home on multiple dates. |
| Failure to follow prescriber's orders for multiple residents with missed or improperly administered medications. |
| Staff training deficiencies including failure to complete required medication and direct care training. |
| Sanitary conditions not maintained with malodorous smell in resident rooms. |
| First aid kits missing required items such as breathing shields, eye coverings, and thermometer. |
| Failure to report medication refusals to prescriber in a timely manner. |
| Failure to maintain proper storage of medications including expired eye drops and unprotected nasal spray. |
| Failure to maintain proper documentation on medication records including diagnosis or purpose for medication. |
| Failure to complete required medical evaluations and support plans for residents. |
| Failure to report and address resident abuse and aggressive behaviors adequately. |
| Failure to maintain adequate staffing with required certifications such as CPR and first aid. |
| Failure to maintain proper fire safety orientation for new staff. |
| Failure to maintain proper lighting and furniture in resident rooms. |
Report Facts
Fine Per Resident Per Day: 5
Fine Per Resident Per Day: 3
Fine Per Resident Per Day: 5
Fine Per Resident Per Day: 5
Fine Per Resident Per Day: 5
License Capacity: 170
Residents Served: 80
Residents Served: 23
Total Daily Staff: 122
Waking Staff: 92
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Juliet Marsala | Deputy Secretary | Signed the letter issuing the second provisional license. |
Inspection Report
Plan of Correction
Census: 86
Capacity: 170
Deficiencies: 5
Feb 8, 2023
Visit Reason
The inspection was a partial, unannounced review conducted on 02/08/2023 to assess compliance and follow up on a submitted plan of correction.
Findings
The report details multiple medication-related deficiencies including discontinued medications remaining on carts, incorrect medication labeling, inaccurate controlled substance counts, and failure to administer prescribed medications due to unavailability. The submitted plan of correction was accepted and fully implemented by 03/15/2023.
Deficiencies (5)
| Description |
|---|
| Discontinued medication was found in the medication cart for Resident 1. |
| Medication labels did not match physician orders for Residents 1 and 2. |
| OTC medications for Residents 3 and 4 were not labeled with the resident's name. |
| Controlled substance log showed negative 145 pills remaining despite 23 pills in blister pack for Resident 5. |
| Multiple prescribed medications for Residents 1, 2, 5, 6, 7, 8, and 9 were not administered due to unavailability in the home. |
Report Facts
License Capacity: 170
Residents Served: 86
Secured Dementia Care Unit Capacity: 34
Secured Dementia Care Unit Residents Served: 24
Current Hospice Residents: 3
Resident Support Staff Total Daily Staff: 128
Waking Staff: 96
Inspection Report
Follow-Up
Census: 89
Capacity: 170
Deficiencies: 5
Jan 31, 2023
Visit Reason
The inspection visit was a partial, unannounced review triggered by an incident to verify the implementation of a submitted plan of correction.
Findings
The facility was found to have multiple deficiencies including lack of fire safety orientation for new staff, incomplete documentation of staff training, unsanitary conditions in a memory care unit apartment, failure to implement positive interventions to prevent resident elopement, and incomplete resident support plans. The submitted plan of correction was determined to be fully implemented by the follow-up review.
Deficiencies (5)
| Description |
|---|
| Staff person A did not receive orientation on evacuation procedures, staff duties during fire drills and emergencies, designated meeting place, smoking safety, fire extinguisher use, smoke detectors, and emergency telephone use. |
| The home does not maintain documentation of completion of courses in the staff training plan including fire safety and emergency preparedness for agency staff. |
| Strong urine smell detected in a room of the Life Guidance unit indicating unsanitary conditions. |
| Resident #1 eloped by leaving from a window; the home failed to implement positive interventions to modify or eliminate the behavior. |
| Resident #1's support plan did not address the tendency to enjoy walking routinely and the need for more engagement activities. |
Report Facts
License Capacity: 170
Residents Served: 89
Secured Dementia Care Unit Capacity: 34
Secured Dementia Care Unit Residents Served: 24
Current Hospice Residents: 4
Residents Age 60 or Older: 89
Residents with Mental Illness: 4
Residents with Mobility Need: 43
Residents with Physical Disability: 1
Inspection Report
Follow-Up
Census: 65
Capacity: 170
Deficiencies: 1
Jan 12, 2023
Visit Reason
The inspection was a partial, unannounced follow-up visit triggered by an incident to verify the implementation of a previously submitted plan of correction.
Findings
The submitted plan of correction regarding the medical evaluation deficiency was determined to be fully implemented. Continued compliance must be maintained.
Deficiencies (1)
| Description |
|---|
| The medical evaluation for resident 1 did not include the medication regimen, contraindicated medications, or medication side effects; the required attachment was missing initially. |
Report Facts
License Capacity: 170
Residents Served: 65
Memory Care Capacity: 25
Memory Care Residents Served: 22
Total Daily Staff: 108
Waking Staff: 81
Residents 60 Years or Older: 87
Residents with Mobility Need: 43
Residents with Physical Disability: 1
Inspection Report
Plan of Correction
Census: 63
Capacity: 170
Deficiencies: 2
Dec 13, 2022
Visit Reason
The inspection was a partial, unannounced review conducted due to an incident at the facility.
Findings
The inspection identified deficiencies related to abuse and medication record keeping, including a missing $559 from a resident's purse and incomplete medication administration records lacking diagnosis or purpose for use.
Deficiencies (2)
| Description |
|---|
| Resident's purse was misplaced by staff, resulting in missing money, constituting neglect and abuse. |
| Medication administration record for Resident 1 did not indicate the diagnosis or purpose for the medication. |
Report Facts
License Capacity: 170
Residents Served: 63
Secured Dementia Care Unit Capacity: 25
Residents Served in Dementia Care Unit: 23
Missing Money: 559
Inspection Report
Enforcement
Census: 90
Capacity: 170
Deficiencies: 6
Oct 3, 2022
Visit Reason
The inspection was conducted due to an incident, as indicated by the partial and unannounced inspection on 10/03/2022. The report includes findings from multiple inspection dates and follow-up submissions related to violations and enforcement actions.
Findings
Multiple violations were found including abuse, treatment of residents, furniture and equipment maintenance, medication labeling, follow prescriber's orders, and prohibited procedures. The facility was issued a first provisional license due to these violations, with a fine pending if corrections are not made by the mandated date.
Deficiencies (6)
| Description |
|---|
| Abuse: Staff attempted to provide care to a resident who refused, resulting in the resident becoming combative and distressed, leading to staff restraining the resident. |
| Treatment of Residents: Resident reported being humiliated by staff when requesting assistance and mistreatment related to mobility and assistance refusal. |
| Furniture and Equipment: Faucet in the kitchen area of the Life Guidance unit was not bolted and loose; dishwasher area had a leak. |
| Resident’s Medications Labeled: Pharmacy label for a resident's medication did not have the correct flavor. |
| Follow Prescriber's Orders: Medication prescribed was administered late and was not available in the medication cart at the time of administration. |
| Prohibitions: Staff attempted to provide care against resident refusal, leading to combative behavior and physical restraint. |
Report Facts
Census at Inspection: 90
Total Licensed Capacity: 170
Fine Per Resident Per Day: 5
Calculated Fine Per Day: 450
Mandated Correction Date: 5
Inspection Report
Enforcement
Census: 87
Capacity: 170
Deficiencies: 10
Sep 7, 2022
Visit Reason
The inspection was conducted as a partial, unannounced visit for incident and monitoring reasons, including follow-up on previous issues and enforcement actions.
Findings
Multiple violations were found including failure to report resident abuse, incomplete resident contracts, medication labeling and administration errors, incomplete support plans, and missing documentation in resident records. A provisional license was issued with a fine threatened if violations were not corrected by the mandated date.
Deficiencies (10)
| Description |
|---|
| Failure to immediately report suspected resident abuse involving a resident hitting another with a metal rod causing injury. |
| Resident-home contract was not signed by the resident. |
| Resident abuse incident not properly addressed in support plans, leading to further incidents. |
| Prescription medications were not properly labeled with updated directions on blister packs. |
| Medication administration records did not indicate diagnosis/purpose for prescribed medications. |
| Medication administration records lacked initials of staff administering medications at specified times. |
| Resident support plan was not signed by the assessor or resident. |
| Written cognitive preadmission screening was not completed for a resident admitted to the secured dementia care unit. |
| Support plan was not revised to address resident's aggressive behaviors after incidents. |
| Resident record did not include the initial intake assessment. |
Report Facts
Census at Inspection: 90
Fine Per Resident Per Day: 5
Calculated Fine Per Day: 450
License Capacity: 170
Residents Served: 87
Secured Dementia Care Unit Capacity: 34
Secured Dementia Care Unit Residents Served: 21
Residents 60 Years or Older: 87
Residents with Mobility Need: 29
Residents with Physical Disability: 2
Staff Total Daily: 116
Staff Waking: 87
Inspection Report
Complaint Investigation
Census: 87
Capacity: 170
Deficiencies: 0
Aug 31, 2022
Visit Reason
The inspection was conducted as an unannounced incident investigation on 08/31/2022 by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Complaint Details
The visit was incident-related and no deficiencies were found, indicating no substantiated complaint issues.
Report Facts
Total Daily Staff: 120
Waking Staff: 90
License Capacity: 170
Residents Served: 87
Secured Dementia Care Unit Capacity: 34
Secured Dementia Care Unit Residents Served: 22
Current Hospice Residents: 4
Residents Diagnosed with Mental Illness: 2
Residents Diagnosed with Intellectual Disability: 0
Residents with Mobility Need: 33
Residents 60 Years of Age or Older: 87
Residents with Physical Disability: 1
Residents Receiving Supplemental Security Income: 0
Inspection Report
Complaint Investigation
Census: 94
Capacity: 170
Deficiencies: 17
Jun 30, 2022
Visit Reason
The inspection was conducted as a complaint and incident investigation, including unannounced visits on multiple dates in 2022.
Findings
Multiple violations were found including failure to report suspected abuse timely, inadequate personal hygiene assistance, unlocked poisonous materials accessible to residents, unsanitary conditions, improper medication administration, and deficiencies in resident support plans. A provisional license was issued due to these violations.
Complaint Details
The visit was complaint-related and included investigation of alleged abuse and neglect of resident #1, including delayed reporting and staff aggression. The complaint was filed on 06/27/2022 and the home failed to provide a written decision within 7 days as required.
Deficiencies (17)
| Description |
|---|
| Failure to immediately report suspected abuse of a resident by a staff member. |
| Failure to report an incident involving a resident taken to emergency room due to alleged abuse by direct care staff within required timeframe. |
| Inadequate assistance with activities of daily living including grooming, dressing, and bathing for resident #1. |
| Failure to provide assistance with personal hygiene as required for resident #1. |
| Resident-home contract for resident #1 was not signed by the resident. |
| Resident #1 was noticed with a small scratch and later diagnosed with a radial head fracture; staff aggression was reported. |
| Poisonous materials were unlocked, unattended, and accessible to residents. |
| Sanitary conditions not maintained; soiled chair and towels found in resident rooms and bathrooms. |
| Trash can in bathroom shared by two residents was not covered. |
| Resident #2's bed enabler was not covered and was wider than allowed. |
| Resident in Secure Dementia Care Unit was locked out of bedroom without key. |
| Soap dispensers in bathrooms were missing or unlabeled bar soaps. |
| Resident #1's medical evaluation was incomplete, missing special health or dietary needs. |
| Resident #1's medication Hydroxyzine Pamoate was pending delivery and not available for administration. |
| Resident #1's medication Donepezil was not administered on multiple dates due to unavailability. |
| Resident #2's support plan did not address need for enabler and safe use of device. |
| Resident #1's support plan did not identify bowel and bladder continence correctly and was not updated to reflect ongoing behavior issues. |
Report Facts
Census at Inspection: 94
License Capacity: 170
Fine Per Resident Per Day: 5
Calculated Fine Per Day: 450
Mandated Correction Date: 5
Residents Served in Secured Dementia Care Unit: 26
Capacity of Secured Dementia Care Unit: 32
Residents Aged 60 or Older: 94
Residents with Mobility Need: 38
Total Daily Staff: 132
Waking Staff: 99
Inspection Report
Complaint Investigation
Census: 91
Capacity: 170
Deficiencies: 5
Jun 14, 2022
Visit Reason
The inspection was conducted as a complaint investigation following allegations related to resident care and facility conditions.
Findings
The inspection found multiple deficiencies including inadequate staffing levels, lack of housekeeping services especially on the secure dementia care unit (SDCU), unsafe access to poisonous materials, unsanitary conditions in resident rooms and common areas, and residents being denied access to their bedrooms due to locked doors.
Complaint Details
The visit was complaint-related as indicated by the inspection information section stating the reason as 'Complaint'.
Deficiencies (5)
| Description |
|---|
| Inadequate direct care staffing on the 7:00am - 3:30pm shift with only two direct care workers responsible for the entire building including Personal Care and Memory Care. |
| No housekeeping services or housekeeping staff present on Sundays or Mondays, and no housekeeping provided on the SDCU from 6/1/22 through 6/11/22, resulting in unsanitary conditions and staff burnout. |
| Poisonous materials such as bars of soap were accessible to residents on the SDCU who had not been assessed as safe around such materials. |
| Unsanitary conditions observed on the SDCU including urine smells, soiled furniture, dirty toilets, overflowing trash cans, and lack of thorough cleaning. |
| Resident bedroom doors were locked during inspection, and residents did not have keys or access to their bedrooms. |
Report Facts
Residents present: 91
Residents on secure dementia unit: 19
Residents with mobility needs: 64
License capacity: 170
Staff on 7am-3:30pm shift after correction: 8
Housekeepers scheduled per day: 3
Inspection Report
Renewal
Census: 79
Capacity: 170
Deficiencies: 12
Apr 26, 2022
Visit Reason
The inspection was a full, unannounced renewal inspection conducted on 04/26/2022 to review compliance with licensing requirements.
Findings
The inspection identified multiple deficiencies including unlocked resident records, incorrect posting of ombudsman phone numbers, incomplete direct care staff training, unsecured poisonous materials accessible to residents, unsanitary conditions, tripping hazards from carpet, incomplete first aid kits, expired elevator certificates, lint accumulation in dryers, incomplete fire drills, presence of discontinued medications, and failure to follow prescriber's medication orders. Plans of correction were accepted and implemented with follow-up dates scheduled.
Deficiencies (12)
| Description |
|---|
| Resident records were unlocked, unattended, and accessible in the wellness office. |
| Incorrect phone number for the local ombudsman was posted in a conspicuous and public place. |
| Direct care staff person provided unsupervised ADL services before completing required training and competency test. |
| Unlocked, accessible poisonous materials were found in multiple locations accessible to residents. |
| Strong odor of urine present in room 18 side B and sink/vanity vestibule of room 18. |
| Ripped or rippled carpeting creating a tripping hazard outside room 213 on the second floor. |
| First aid kits in wellness center and front desk did not include eye coverings. |
| Elevators did not have valid certificate of operation; certificates expired on 2/28/22. |
| Accumulation of lint in lint traps of dryers in Life Guidance laundry room. |
| Fire drills conducted on multiple dates did not include evacuation to designated meeting places. |
| Discontinued medications were still present on medication cart. |
| Medications prescribed for residents were not available in the home on inspection date. |
Report Facts
License Capacity: 170
Residents Served: 79
Secured Dementia Care Unit Capacity: 34
Residents Served in Secured Dementia Care Unit: 22
Current Hospice Residents: 1
Residents with Mobility Need: 43
Residents with Physical Disability: 1
Total Daily Staff: 122
Waking Staff: 92
Deficiency Completion Dates: 12
Inspection Report
Follow-Up
Census: 78
Capacity: 170
Deficiencies: 6
Apr 8, 2022
Visit Reason
The visit was a partial inspection conducted to review the facility's compliance and follow up on the submitted plan of correction.
Findings
The inspection found multiple deficiencies related to staff supervision, heat source safety, lighting in resident bedrooms, medical evaluation documentation, and preadmission screening forms. The facility submitted plans of correction which were accepted and implemented.
Deficiencies (6)
| Description |
|---|
| Failure to submit a plan of supervision for a staff person reinstated without Department approval. |
| No protective guards on heat sources accessible to residents in the Life Guidance kitchen area. |
| Resident #1 did not have access to an operable lamp or source of light at bedside. |
| Resident #1's medical evaluation did not include a pulse rate and self-administration ability for medications. |
| Resident #1's preadmission screening form was completed late, after admission to the home. |
| Resident #1's written cognitive preadmission screening for the secured dementia care unit was completed late, after admission. |
Report Facts
Residents Served: 78
License Capacity: 170
Capacity: 34
Residents Served: 20
Inspection Report
Complaint Investigation
Census: 78
Capacity: 170
Deficiencies: 0
Mar 18, 2022
Visit Reason
The inspection was conducted as a complaint investigation during an unannounced partial licensing inspection on 03/18/2022.
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, and follow-up was not required.
Report Facts
License Capacity: 170
Residents Served: 78
Secured Dementia Care Unit Capacity: 25
Secured Dementia Care Unit Residents Served: 20
Hospice Residents: 1
Residents with Mobility Need: 37
Residents with Physical Disability: 1
Residents 60 Years or Older: 78
Notice
Capacity: 170
Deficiencies: 0
Apr 30, 2021
Visit Reason
The document serves as a renewal application acknowledgment and license issuance for the Personal Care Home 'Atria Lafayette Hill' pursuant to Title 55, PA Code, Chapter 2600, with notification of an upcoming annual inspection within twelve months.
Findings
No inspection findings are reported; the document confirms issuance of a regular license and advises that enforcement action will be taken if noncompliance is found during future inspections.
Report Facts
Maximum capacity: 170
Secure Dementia Care Unit capacity: 34
Inspection Report
Renewal
Census: 36
Capacity: 170
Deficiencies: 11
Apr 29, 2021
Visit Reason
The inspection was conducted as a renewal inspection of the facility's license by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing on 04/29/2021.
Findings
The inspection identified multiple deficiencies including failure to post required regulations and influenza information, privacy concerns due to unmarked recording cameras, lack of documentation for direct care staff qualifications, incomplete first aid kits, restricted resident access to bedrooms, lack of operable bedside lighting, missing emergency procedure postings, presence of discontinued medications, missing prescribed medications, and inadequate posting of key-locking device instructions. Plans of correction were accepted and implemented with completion dates set for 05/31/2021.
Deficiencies (11)
| Description |
|---|
| The home did not have a copy of the 2600 regulations posted in a conspicuous and public place. |
| The home did not have an influenza poster anywhere as required by the Influenza Awareness Act. |
| Cameras that record images were observed without signs indicating recording. |
| Direct care staff person A lacked documentation or verification of a high school diploma, GED, or active registry status. |
| The first aid kit in the nursing office did not include eye coverings or a thermometer. |
| Bedrooms on the Secure Dementia Care Unit were locked denying residents access to their bedrooms. |
| Bedroom did not have access to a source of light that can be turned on/off at bedside. |
| The home’s emergency procedures were not posted in a conspicuous and public place. |
| Discontinued medications for residents #1 and #2 were still on the medication cart. |
| Medication prescribed to resident #1 was not available in the home. |
| Directions for operating the home's locking mechanism were not conspicuously posted near the exit door near the linen storage room on the Secure Dementia Care Unit. |
Report Facts
Residents Served: 36
License Capacity: 170
Secured Dementia Care Unit Capacity: 34
Residents Served in Secured Dementia Care Unit: 8
Total Daily Staff: 50
Waking Staff: 38
Residents Age 60 or Older: 36
Residents with Mobility Need: 14
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Shawn Parker | Signed the letter confirming plan of correction implementation | |
| Resident Service Director | Responsible for medication cart audits, retraining, and ensuring compliance with medication regulations | |
| Executive Director | Reviewed regulations, ensured compliance, and accepted plans of correction | |
| Maintenance Director | Reviewed camera compliance, inspected security cameras, and ensured signage for key-locking devices | |
| Community Business Director | Conducted audits of staff documentation and ensured compliance with staff qualifications | |
| Care Specialist | Retrained Resident Service Director on first aid kit regulations | |
| Memory Care Director | Assisted with ensuring resident access to bedrooms and compliance with key-locking device signage | |
| Med Tech | Received retraining on medication regulations |
Inspection Report
Complaint Investigation
Census: 37
Capacity: 170
Deficiencies: 0
Feb 4, 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 and the follow-up type was noted as not required. No deficiencies or citations were found.
Report Facts
Residents Served: 37
License Capacity: 170
Secured Dementia Care Unit Capacity: 34
Secured Dementia Care Unit Residents Served: 10
Current Hospice Residents: 0
Residents Age 60 or Older: 37
Residents with Mobility Need: 14
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