Inspection Report
Follow-Up
Census: 120
Capacity: 150
Deficiencies: 30
Oct 15, 2025
Visit Reason
The visit was a follow-up review conducted on October 15-16, 2025, to verify that the submitted plan of correction for previous violations was fully implemented.
Findings
The facility was found to have implemented the plan of correction fully. Several deficiencies were noted in the prior inspection, including issues with resident confidentiality, compliance with health and safety laws, infestation, and sanitary conditions, all of which were addressed with corrective actions and education.
Complaint Details
The inspection was complaint-related, triggered by a complaint and interim exit conference was held on 10/16/2025. The submitted plan of correction was found to be fully implemented.
Deficiencies (30)
| Description |
|---|
| Resident medication lists were unlocked and accessible in a common area. |
| Carbon monoxide detector was missing on the first floor of the secured dementia care unit. |
| Evidence of rodent infestation with a mouse seen in a resident's room. |
| Influenza awareness poster was not posted in a public place. |
| Carbon monoxide alarms were not audible in certain hallways and had outdated batteries. |
| Resident contracts were not signed by residents. |
| Staff member without required high school diploma or registry status. |
| Insufficient number of staff certified in first aid and CPR during night shifts. |
| Direct care staff did not receive required annual training on multiple topics. |
| Poisonous materials were unlocked and accessible in a resident's room without proper assessment. |
| Unsanitary conditions including uncovered urinal and fecal matter in resident areas. |
| Exposed electrical wires and missing door threshold creating hazards. |
| Freezer lid did not close properly due to ice buildup; leaking faucet in resident bathroom. |
| Elevators lacked current certificates of operation. |
| Unlabeled and undated leftover food containers in kitchen. |
| No thermometer in kitchen chest freezer. |
| Food stored improperly, including uncovered snacks and refrigerated items stored at room temperature. |
| Exit door partially blocked by wheelchair and walker. |
| Fire drill during sleeping hours not conducted within required 6-month period. |
| Resident medical evaluation not completed within required timeframe after admission. |
| Cigarettes found in non-designated smoking area in secured dementia care unit courtyard. |
| Resident self-administering medications without required assessment by authorized medical professional. |
| Medications stored unlocked and unattended in resident's room. |
| Resident medication record did not include all medications present in resident's room. |
| Medications and syringes found unlocked and unattended on floors in resident areas. |
| Expired medications and unlabeled insulin pens found in medication storage. |
| Prescription medication lacked current order from authorized prescriber. |
| Medication prescribed was not administered due to unavailability in the home. |
| Staff administered medications without completing required Department-approved medication administration course and competency testing. |
| Directions for operating key-locking devices on secured dementia care unit doors were not conspicuously posted. |
Report Facts
License Capacity: 150
Residents Served: 120
Secured Dementia Care Unit Capacity: 32
Residents Served in Secured Dementia Care Unit: 31
Hospice Residents: 15
Total Daily Staff: 177
Waking Staff: 133
Inspection Report
Complaint Investigation
Census: 120
Capacity: 150
Deficiencies: 3
Oct 15, 2025
Visit Reason
The inspection was conducted as a complaint and interim review of the facility on 10/15/2025 and 10/16/2025 to determine compliance with regulations and verify the submitted plan of correction.
Findings
The inspection found violations related to resident record confidentiality, compliance with health and safety laws including carbon monoxide detector placement, and evidence of rodent infestation. Plans of correction were accepted and implemented for all deficiencies.
Complaint Details
The inspection was complaint-related and interim in nature. The submitted plan of correction was reviewed and determined to be fully implemented.
Deficiencies (3)
| Description |
|---|
| Resident medication lists were unlocked, unattended, and accessible in the A-hall kitchenette, violating confidentiality requirements. |
| A carbon monoxide detector was not present on the first floor of the secured dementia care unit, and installed alarms could not be heard from this area. |
| Evidence of rodent infestation was found when a mouse ran out from underneath a resident's closet and disappeared beneath the baseboard heater. |
Report Facts
Residents Served: 120
License Capacity: 150
Residents Served in Secured Dementia Care Unit: 31
Current Hospice Residents: 15
Residents with Mobility Need: 57
Residents Age 60 or Older: 120
Residents with Physical Disability: 2
Total Daily Staff: 177
Waking Staff: 133
Inspection Report
Follow-Up
Census: 120
Capacity: 150
Deficiencies: 5
Apr 29, 2025
Visit Reason
The visit was a follow-up review of the facility's submitted plan of correction after previous incidents and violations, including an incident and fine.
Findings
The facility was found to have implemented the submitted plan of correction fully, with education provided to staff and administrators on abuse reporting, medication documentation, and resident care. Several deficiencies related to abuse reporting, medication storage, and following prescriber's orders were identified and addressed with corrective actions.
Deficiencies (5)
| Description |
|---|
| Failure to immediately report suspected financial abuse of a resident and delay in submitting the Act 13 Mandatory Abuse Reporting form. |
| Failure to report an incident or condition to the Department within 24 hours as required. |
| Resident-to-resident abuse resulting in injury, with inadequate timely reporting and monitoring. |
| Discrepancies between blood sugar readings in resident's glucometer and medication administration record (MAR). |
| Failure to follow prescriber's orders for blood sugar testing as prescribed. |
Report Facts
License Capacity: 150
Residents Served: 120
Residents Served in Secured Dementia Care Unit: 29
Current Hospice Residents: 16
Residents Age 60 or Older: 120
Residents with Mobility Need: 55
Residents with Physical Disability: 1
Total Daily Staff: 175
Waking Staff: 131
Inspection Report
Complaint Investigation
Census: 116
Capacity: 150
Deficiencies: 0
Apr 2, 2025
Visit Reason
The inspection was conducted as a complaint investigation during an unannounced partial licensing inspection of 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, indicating no substantiated issues.
Report Facts
Total Daily Staff: 168
Waking Staff: 126
Resident Support Staff: 0
Secured Dementia Care Unit Capacity: 32
Secured Dementia Care Unit Residents Served: 31
Hospice Current Residents: 13
Residents Served: 116
License Capacity: 150
Residents Age 60 or Older: 116
Residents with Mobility Need: 52
Residents with Physical Disability: 2
Inspection Report
Renewal
Census: 119
Capacity: 150
Deficiencies: 23
Mar 19, 2024
Visit Reason
The inspection was conducted as a renewal and incident-related visit to assess compliance with 55 Pa. Code Ch. 2600 for Personal Care Homes.
Findings
Multiple violations were found including resident abuse, inadequate staff CPR certification, incomplete medical evaluations, medication labeling and storage issues, and safety concerns such as fire drill documentation and smoking policy violations. Plans of correction were submitted with proposed completion dates.
Deficiencies (23)
| Description |
|---|
| Failure to immediately report suspected resident abuse and verbal reporting deficiencies. |
| Resident abuse incidents involving physical altercations between residents. |
| Insufficient number of staff with current CPR and first aid certification during multiple shifts. |
| Direct care staff hired without completing required training and competency test. |
| Resident personal equipment (enabler bar) posed entrapment risk due to improper covering. |
| Dead mouse found on floor of hallway tub room indicating unsanitary conditions. |
| Bathroom exhaust fans inoperable and no operable outside window in certain bathrooms. |
| Emergency telephone numbers missing from posted locations. |
| Resident bedside lighting not operable or accessible. |
| Food requiring refrigeration stored above required temperatures and opened food not refrigerated. |
| Fire drill records incomplete and residents did not evacuate properly during drills. |
| Medical evaluations missing required components or not completed timely. |
| Smoking policy violations with cigarette butts found in prohibited areas. |
| Medications not labeled properly with current orders or missing medications. |
| Discrepancies between glucometer readings and medication administration records. |
| Verbal medication orders not properly documented or received by licensed staff. |
| Failure to follow prescriber's orders including medication administration and resident monitoring. |
| Support plans not signed by assessors or residents with no notation of refusal. |
| Resident records contained correction tape and privacy coding documents were left accessible. |
| Unlabeled soap dispenser and bar soap left in common areas. |
| Food stored in unsealed containers and outdated or unlabeled food items found. |
| Prescription medications and syringes not locked in resident rooms. |
| Medication labels did not match current orders or lacked diagnosis/purpose. |
Report Facts
License Capacity: 150
Residents Served: 119
Secured Dementia Care Unit Capacity: 32
Residents Served in Dementia Unit: 30
Current Hospice Residents: 15
Staff CPR Certification Deficiency: 1
Deficiency Counts: 23
Inspection Report
Renewal
Census: 119
Capacity: 150
Deficiencies: 23
Mar 19, 2024
Visit Reason
The inspection was conducted as part of a renewal and incident review of the Personal Care Home facility, Autumn House East, including multiple onsite and offsite visits between March and May 2024.
Findings
The inspection identified multiple violations related to resident abuse reporting, instrumental activities of daily living assistance, contract signatures, abuse incidents, staff training, resident personal equipment safety, sanitary conditions, bathroom ventilation, emergency telephone postings, lighting, food storage temperatures, fire drill documentation, medical evaluations, smoking area guidelines, medication labeling and storage, medication administration, support plan documentation, record keeping, and confidentiality of resident information. Plans of correction were accepted with various completion dates, some not yet implemented as of the report date.
Deficiencies (23)
| Description |
|---|
| Failure to immediately report suspected resident abuse to appropriate agencies. |
| Resident did not receive required supervision leading to elopement. |
| Resident contracts not signed by residents. |
| Resident-to-resident abuse incidents not properly managed or reported. |
| Insufficient staff with current CPR and first aid certification during multiple shifts. |
| Direct care staff hired without completing required training and competency test. |
| Resident personal equipment posed entrapment risk due to improper covering. |
| Dead mouse found in tub room indicating poor sanitary conditions. |
| Inoperable exhaust fan in resident bathroom without window. |
| Emergency telephone numbers missing near telephone in kitchenette area. |
| Resident bedside lamp not operable or accessible. |
| Food stored above safe refrigeration temperatures and improperly labeled. |
| Fire drill records incomplete, missing resident counts and evacuation details. |
| Residents failed to evacuate properly during fire drills. |
| Resident medical evaluations incomplete or not timely. |
| Smoking occurred in prohibited areas with cigarette butts found on porch. |
| Medications not labeled with current orders or instructions. |
| Medications prescribed were not present in the home. |
| Blood sugar readings inconsistently documented and discrepancies between glucometer and MAR. |
| Verbal medication orders not obtained or documented by licensed staff. |
| Prescriber’s orders not consistently followed including medication administration and resident monitoring. |
| Support plans missing required signatures or not signed by residents without notation. |
| Resident records contained correction tape and were not maintained confidentially. |
Report Facts
License Capacity: 150
Residents Served: 119
Residents Served: 121
Secured Dementia Care Unit Capacity: 32
Residents Served in Dementia Unit: 30
Residents Served in Dementia Unit: 32
Current Hospice Residents: 15
Current Hospice Residents: 18
Total Daily Staff: 176
Waking Staff: 132
Total Daily Staff: 178
Waking Staff: 134
Deficiencies Cited: 28
Inspection Report
Complaint Investigation
Census: 115
Capacity: 150
Deficiencies: 14
Jul 19, 2023
Visit Reason
The inspection was conducted as a complaint investigation and due to a change in legal entity at the facility.
Findings
Multiple violations were found including unlabeled carbon monoxide alarms, unsecured poisonous materials accessible to residents, sanitary issues such as mold in the ice machine, inoperable exhaust fans, missing mirrors and operable lamps in resident rooms, improper medication storage, and incomplete resident support plans. Plans of correction were proposed and partially implemented by the follow-up date.
Complaint Details
The inspection was complaint-driven and also involved a change in legal entity. Violations were found as detailed in the inspection summary.
Deficiencies (14)
| Description |
|---|
| Battery operated carbon monoxide alarms in kitchen and basement were not labeled with date of installation. |
| Resident #3 was observed with bowel on body and bedding due to refusal of personal care. |
| Poisonous materials were unlocked and accessible to residents in the secured dementia care unit shower room. |
| Mold observed inside kitchen ice machine. |
| Exhaust fan in resident bathroom E8 was inoperable and bathroom D10 was dusty. |
| Screen door in laundry room had holes and tears. |
| Resident room A3 did not have a mirror. |
| Residents #1 and #2 did not have access to operable bedside lamps. |
| Unlabeled used bar of soap found in shared F-Hall shower room. |
| Home did not maintain a 3-day supply of emergency drinking water. |
| Written emergency procedures not reviewed or submitted to local emergency management agency since 3/21/2022. |
| Medications and syringes were not locked and were accessible in resident rooms without self-administration orders. |
| Resident #3's support plan did not include refusal of personal care. |
| Directions for operating key-locking devices were not conspicuously posted near the secured dementia care unit exit. |
Report Facts
License Capacity: 150
Residents Served: 115
Residents Served in Secured Dementia Care Unit: 28
Total Daily Staff: 172
Waking Staff: 129
Deficiency Counts: 14
Residents Served: 127
Residents Served in Secured Dementia Care Unit: 29
Total Daily Staff: 213
Waking Staff: 160
Residents Served: 125
Gallons of Emergency Drinking Water Required: 375
Gallons of Emergency Drinking Water Available: 348
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Juliet Marsala | Deputy Secretary | Signed the provisional license letter. |
| Administrator | Named in multiple findings related to education, training, and implementation of corrections. | |
| Director of Wellness | Named in findings related to resident care, medication storage, and audits. | |
| Assistant Director of Wellness | Named in findings related to resident support plans and audits. | |
| Maintenance Director | Named in findings related to maintenance issues, repairs, and audits. | |
| Memory Care Coordinator | Named in findings related to secured dementia care unit and audits. | |
| Dementia Care Director | Named in findings related to secured dementia care unit and audits. | |
| Dietary Manager | Named in findings related to food safety and labeling. | |
| Cook | Named in findings related to food safety and labeling. |
Inspection Report
Complaint Investigation
Census: 115
Capacity: 150
Deficiencies: 14
Jul 19, 2023
Visit Reason
The inspection was conducted as a complaint investigation and due to a change in legal entity at the facility.
Findings
Multiple violations were found including unlabeled carbon monoxide alarms, unsecured poisonous materials accessible to residents, inadequate sanitary conditions, inoperable exhaust fans, missing mirrors and operable lamps in resident rooms, unlabeled soap bars, insufficient emergency water supply, and medication storage issues. Several residents were observed with unmet care needs and improper medication storage. The facility was issued a first provisional license based on an acceptable plan of correction.
Complaint Details
The inspection was complaint-driven and included a change in legal entity. Specific complaints involved resident care refusals, medication storage, and safety hazards.
Deficiencies (14)
| Description |
|---|
| Battery operated carbon monoxide alarms not labeled with date of installation and batteries not changed within past year. |
| Resident #3 observed with bowel on body and bedding due to refusal of personal care. |
| Poisonous materials unlocked and accessible to residents in secured dementia care unit shower room. |
| Mold observed inside kitchen ice machine. |
| Exhaust fan in resident bathroom E8 inoperable and bathroom D10 covered in dust preventing ventilation. |
| Screen door in laundry room had holes and tears. |
| Resident room A3 did not have a mirror. |
| Residents #1 and #2 did not have access to operable bedside lamps. |
| Unlabeled used bar of soap found in shared bathrooms and shower rooms. |
| Home did not maintain a 3-day supply of emergency drinking water as required. |
| Written emergency procedures not reviewed, updated, or submitted to local emergency management agency since 3/21/2022. |
| Medications and syringes not locked; medications found in residents' rooms without self-administration orders. |
| Resident #3's support plan did not include refusal of personal care or plan to meet this need. |
| Directions for operating key-locking devices not conspicuously posted near secured dementia care unit exit. |
Report Facts
License Capacity: 150
Residents Served: 115
Residents Served in Secured Dementia Care Unit: 28
Total Daily Staff: 172
Waking Staff: 129
Number of Deficiencies: 14
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Juliet Marsala | Deputy Secretary | Signed the provisional license letter. |
Inspection Report
Renewal
Census: 116
Capacity: 150
Deficiencies: 6
Feb 8, 2022
Visit Reason
The inspection was conducted as a renewal visit to assess compliance and verify the submitted plan of correction was fully implemented.
Findings
The facility was found to have several deficiencies including issues with bathroom ventilation, hot water temperature, medication storage procedures, medication administration documentation, refusal of medication documentation, and annual assessments. The submitted plans of correction were accepted and implemented with completion dates ranging from March to May 2022.
Deficiencies (6)
| Description |
|---|
| Bathroom in Resident 2's bedroom lacks an operable outside window and ventilation fan is inoperable. |
| Hot water temperature in E hall's bath/shower room measured at 126.3 degrees Fahrenheit, exceeding the 120°F limit. |
| Discrepancies found in medication and medical equipment storage and documentation, including missing glucometer readings and mismatched blood sugar readings. |
| Medication administration records (MAR) for multiple residents did not include initials of staff administering medications at specified dates and times. |
| Resident 7 refused to take prescribed medication on multiple dates and times; refusals were not documented in the MAR. |
| Resident 1's annual assessment was not completed timely; POA did not take resident to physician when assessment was due. |
Report Facts
Residents Served: 116
License Capacity: 150
Secured Dementia Care Unit Capacity: 32
Secured Dementia Care Unit Residents Served: 26
Hospice Current Residents: 8
Resident Mobility Need: 43
Blood Sugar Readings: 5
Notice
Capacity: 150
Deficiencies: 0
Aug 31, 2021
Visit Reason
The document serves as a renewal notification and license issuance for the Personal Care Home 'Autumn House East' following receipt of the renewal application dated July 8, 2021. It also informs the facility that an annual onsite inspection will be conducted within the next twelve months as required by regulation.
Findings
No inspection findings are reported in this document. It confirms issuance of a regular license and advises that enforcement action will be taken if noncompliance is found during future inspections.
Report Facts
Maximum licensed capacity: 150
Secure Dementia Care Unit capacity: 32
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary, Office of Long-term Living | Signed the renewal notification letter |
Inspection Report
Renewal
Deficiencies: 0
Feb 26, 2021
Visit Reason
The inspection was conducted as part of licensing inspections on multiple dates in late February and early March 2021 to assess compliance with regulatory requirements for the facility.
Findings
No regulatory citations or deficiencies were identified as a result of these inspections.
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