Inspection Reports for Beechwood Court at Lafayette Manor
145 LAFAYETTE MANOR ROAD,, UNIONTOWN, PA, 15401
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
32.4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
589% worse than Pennsylvania average
Pennsylvania average: 4.7 deficiencies/yearDeficiencies per year
36
27
18
9
0
Census
Latest occupancy rate
80% occupied
Based on a June 2025 inspection.
Census over time
Inspection Report
Complaint Investigation
Census: 51
Capacity: 64
Deficiencies: 0
Jun 4, 2025
Visit Reason
The inspection was conducted as a complaint and incident investigation at Beechwood Court at Lafayette Manor.
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 violations.
Report Facts
License Capacity: 64
Residents Served: 51
Secured Dementia Care Unit Capacity: 23
Secured Dementia Care Unit Residents Served: 15
Hospice Current Residents: 12
Total Daily Staff: 67
Waking Staff: 50
Resident Support Staff: 0
Residents Age 60 or Older: 51
Residents Diagnosed with Mental Illness: 1
Residents with Mobility Need: 16
Inspection Report
Complaint Investigation
Census: 50
Capacity: 64
Deficiencies: 0
May 19, 2025
Visit Reason
The inspection was conducted as a complaint and incident investigation at Beechwood Court at Lafayette Manor.
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: 64
Residents Served: 50
Secured Dementia Care Unit Capacity: 23
Secured Dementia Care Unit Residents Served: 15
Hospice Current Residents: 11
Residents Age 60 or Older: 50
Residents Diagnosed with Mental Illness: 1
Residents with Mobility Need: 18
Inspection Report
Complaint Investigation
Census: 49
Capacity: 64
Deficiencies: 0
Apr 23, 2025
Visit Reason
The inspection was conducted as a complaint-related incident investigation at Beechwood Court at Lafayette Manor.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Complaint Details
The inspection was triggered by an incident complaint; no deficiencies or citations were found, indicating no substantiated violations.
Report Facts
License Capacity: 64
Residents Served: 49
Secured Dementia Care Unit Capacity: 23
Secured Dementia Care Unit Residents Served: 16
Current Hospice Residents: 5
Residents Age 60 or Older: 49
Residents Diagnosed with Mental Illness: 1
Residents with Mobility Need: 21
Inspection Report
Renewal
Census: 51
Capacity: 64
Deficiencies: 13
Mar 11, 2025
Visit Reason
The inspection was conducted as a renewal and complaint investigation to assess compliance with 55 Pa. Code Chapter 2600 relating to Personal Care Homes.
Findings
The facility was found to be in compliance overall but had multiple deficiencies including improper placement of carbon monoxide detectors, outdated criminal background checks, entrapment hazards with bedside mobility devices, uncovered trash receptacles, lack of operable bedside lamps, incomplete medical evaluations, undated menus, unlocked medications, mislabeled medications, improper medication documentation, incomplete training records, and incomplete support plans for residents with mobility devices. Corrective actions were accepted and implemented with ongoing audits planned.
Deficiencies (13)
| Description |
|---|
| Carbon monoxide detector was installed approximately 8 feet from a gas fired dryer, less than the required 15 feet. |
| Criminal history background check for a staff person was outdated, completed in 2019 despite a 2023 hire date. |
| Bedside mobility devices attached to residents' beds had uncovered openings posing entrapment hazards. |
| One of two trash cans in a shared resident bathroom was uncovered and contained discarded paper towels. |
| No operable lamp or other source of lighting that could be turned on and off at the bedside of a resident. |
| Plaster in ceiling of a resident's room was crumbling and falling. |
| Resident's annual medical evaluation did not include the resident's height. |
| Posted menus were not dated. |
| Medications were unlocked, unattended, and accessible in residents' rooms and bathrooms. |
| Pharmacy label on a resident's medication indicated a different dosing frequency than the physician's order. |
| Resident's blood glucose levels were incorrectly recorded on the medication administration record. |
| Medication administration training records for several staff did not indicate the date of the month the training occurred. |
| Support plans for residents with bedside mobility devices did not address the need, use, risks, safety, device identification, or FDA cover requirements. |
Report Facts
License Capacity: 64
Residents Served: 51
Secure Dementia Care Unit Capacity: 23
Secure Dementia Care Unit Residents Served: 15
Hospice Residents: 10
Total Daily Staff: 72
Waking Staff: 54
Residents Age 60 or Older: 51
Residents with Mobility Need: 21
Inspection Dates: 2
Inspection Report
Complaint Investigation
Census: 51
Capacity: 64
Deficiencies: 16
Aug 29, 2024
Visit Reason
The inspection was a complaint and incident investigation conducted on August 29, 2024, following allegations of abuse and other regulatory concerns at Beechwood Court at Lafayette Manor.
Findings
The investigation found multiple violations including failure to immediately report suspected abuse, failure to suspend the alleged abuser promptly, delayed notification to the resident and designated person, and deficiencies in staff training, medical evaluations, medication management, and fire safety procedures.
Complaint Details
The complaint involved allegations of abuse by direct care staff person D towards resident #1, including rough handling and verbal mistreatment. The abuse was witnessed by multiple staff but was not immediately reported to the Department or acted upon with suspension of the alleged abuser. Notification to the resident and designated person was also delayed.
Deficiencies (16)
| Description |
|---|
| Failure to immediately report suspected abuse of resident #1 and delayed reporting to the Department. |
| Failure to immediately suspend staff person D involved in alleged abuse and continued provision of care. |
| Failure to immediately notify resident #1 and designated person of suspected abuse. |
| Failure to report incident to Department’s complaint hotline within 24 hours. |
| Resident #2’s medical evaluation missing assessment of ability to self-administer medications. |
| Discontinued medication still present in medication cart for resident #5. |
| Resident #1’s medication label incorrect dosage instructions; missing pharmacy label on resident #5’s insulin pen. |
| Resident #1’s Hyoscyamine medication not present in home; resident #5’s glucometer not set to current date/time; sharps containers improperly stored in resident #5’s room. |
| Medication administration records missing staff initials for multiple medications administered to resident #3. |
| Resident #2 administered incorrect insulin dose per sliding scale. |
| Resident #5’s preadmission screening undated and incomplete regarding service needs. |
| Resident #3 and #4 medical diagnoses not reflected in assessments; repeat violation. |
| Resident #4’s support plan missing documentation of bedrail use despite presence. |
| Resident #1 and #3 missing no objection statements for admission to secured dementia care unit. |
| Direct care staff persons A and C lacked required dementia care training hours for 2023. |
| Correction fluid used on resident #5’s contract signature page. |
Report Facts
License Capacity: 64
Residents Served: 51
Residents Served in Secured Dementia Care Unit: 15
Staffing Hours: 66
Waking Staff: 50
Number of Deficiencies: 34
Follow-Up Dates: 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Direct Care Staff Person A | Named in findings related to lack of timely orientation, incomplete dementia training, and involvement in abuse reporting. | |
| Direct Care Staff Person B | Witnessed abuse incident and involved in reporting; named in abuse complaint. | |
| Direct Care Staff Person C | Witnessed abuse incident and involved in reporting; named in abuse complaint. | |
| Direct Care Staff Person D | Alleged abuser in resident abuse incident; terminated following investigation. | |
| Direct Care Staff Person E | Overheard statements regarding abuse incident. | |
| Administrator | Administrator | Named in multiple findings related to plan of correction, staff education, and regulatory compliance. |
| Wellness Director | Named in medication management and staff education findings. | |
| Human Resources Director | Named in findings related to staff background checks and orientation audits. |
Inspection Report
Complaint Investigation
Census: 51
Capacity: 64
Deficiencies: 36
Jun 13, 2024
Visit Reason
The inspection was conducted as a renewal and incident investigation visit on June 13-14, 2024, with follow-up and enforcement activities related to violations found during prior inspections.
Findings
Multiple violations were found including failure to post license inspection summary, delayed access to records, record confidentiality breaches, incomplete criminal background checks, lack of staff training and orientation, environmental hazards, medication management issues, fire safety deficiencies, and abuse incidents. Several repeat violations were noted. Plans of correction were directed or accepted with deadlines for compliance.
Complaint Details
The complaint investigation involved an incident on 8/18/24 where direct care staff person D was witnessed handling resident #1 roughly and smacking the resident's hand. The incident was not immediately reported to the Department or the resident's designated person. Staff person D was not immediately suspended and continued to provide care until later suspended. Staff person D was terminated following the investigation. Education and audits were planned to ensure compliance with abuse reporting and prevention.
Deficiencies (36)
| Description |
|---|
| License inspection summary was not posted in a conspicuous and public place. |
| Delayed provision of resident list and resident record to Department agent. |
| Resident medical records were unlocked, unattended and accessible in secured dementia care unit and administrator’s office. |
| No Pennsylvania criminal background check completed for direct care staff person A. |
| No staff present trained in first aid and certified in obstructed airway techniques and CPR during specified night shifts. |
| Direct care staff person B did not receive required fire safety orientation on first day. |
| Direct care staff person B did not receive required orientation on resident rights, emergency medical plan, abuse reporting, and incident reporting within 40 hours. |
| Direct care staff person B provided unsupervised ADL services without completing Department-approved direct care training and competency test. |
| Direct care staff persons A and C did not receive required annual training on medication self-administration, resident needs, dementia care, infection control, personal care, safe management, and care for mental illness or intellectual disability. |
| Numerous ceiling tiles stained and missing doorknob on resident closet door. |
| Sink drain clogged in private resident dining room. |
| No operable lamp or other source of lighting at bedside for residents #6 and #7. |
| Uncovered and unsealed food trays and open unsealed bag of grilled chicken breasts in kitchen refrigerators/freezers. |
| Debris and wooden boards obstructing external emergency exit route. |
| Fire extinguisher in boiler room lacked inspection date. |
| Unannounced fire drills not conducted for multiple months; staff notified in advance of drills. |
| No documentation of annual fire safety inspection and fire drill by fire safety expert within past year. |
| Fire drill records incomplete, missing evacuation time and number of staff participating. |
| No documentation of maximum evacuation time by fire safety expert; evacuation times exceeded limits or were blank. |
| Alternate exit routes not used during fire drills. |
| Resident #2 medical evaluation missing assessment of ability to self-administer medications. |
| Discontinued medication still present in medication cart for resident #5. |
| Resident #1 pharmacy label medication instructions inconsistent with prescribed dosage; missing pharmacy label on resident #5 medication. |
| Resident #1 prescribed medication not present in home; resident #5 glucometer not set to current date/time; sharps containers improperly stored in resident #5 bedroom. |
| Medication administration records missing staff initials for multiple medications administered to resident #3. |
| Resident #2 prescribed medication not present in home but documented as administered. |
| Resident #2 administered incorrect insulin dose per sliding scale. |
| Resident #5 preadmission screening undated and incomplete regarding service needs. |
| Resident #3 and #4 medical diagnoses not reflected in most recent assessments. |
| Resident #4 support plan missing documentation of bedrail use despite presence of bedrail. |
| Resident #1 and #3 records missing no objection statement for admission to secured dementia care unit. |
| Direct care staff persons A and C did not receive required dementia care training hours during 2023. |
| Correction fluid present on signature page of resident #5’s resident-home contract. |
| Direct care staff person B witnessed abusing resident #1; incident not immediately reported to Department; staff person D not immediately suspended; resident and designated person not immediately notified of suspected abuse. |
| Incident of suspected abuse not reported to Department’s complaint hotline within 24 hours. |
| Resident #3 status change medical evaluation missing medical professional’s license number. |
Report Facts
License Capacity: 64
Residents Served: 51
Secured Dementia Care Unit Capacity: 23
Residents Served in Secured Dementia Care Unit: 15
Current Residents on Hospice: 12
Total Daily Staff: 66
Waking Staff: 50
Number of Violations: 34
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Juliet Marsala | Deputy Secretary | Signed enforcement and licensing letters |
Inspection Report
Complaint Investigation
Census: 51
Capacity: 64
Deficiencies: 30
Jun 13, 2024
Visit Reason
The inspection was conducted due to a complaint and incident involving allegations of abuse and other regulatory concerns at Beechwood Court at Lafayette Manor.
Findings
Multiple violations were found including failure to immediately report suspected abuse, failure to suspend staff involved in alleged abuse, deficiencies in staff training, medication management errors, incomplete medical evaluations and assessments, fire safety violations, and issues with facility maintenance and resident care documentation.
Complaint Details
The complaint involved allegations of abuse by a staff person towards a resident, failure to immediately report the abuse to the Department, failure to suspend the staff person involved, and failure to notify the resident and designated person of the suspected abuse in a timely manner.
Deficiencies (30)
| Description |
|---|
| License inspection summary was not posted in a conspicuous place. |
| Delayed provision of resident list and records to Department agents. |
| Resident medical records were unlocked, unattended and accessible. |
| No Pennsylvania criminal background check completed for a direct care staff person. |
| No staff trained in first aid and CPR present during specified times. |
| Direct care staff person did not receive required fire safety orientation on first day. |
| Direct care staff person did not receive required orientation on resident rights, emergency medical plan, abuse reporting, and reportable incidents within 40 hours. |
| Direct care staff person did not complete Department-approved direct care training before providing unsupervised ADL services. |
| Direct care staff persons did not receive required annual training on medication self-administration, dementia care, infection control, and other topics. |
| Numerous ceiling tiles stained and a closet door missing a doorknob. |
| Sink drain clogged in private resident dining room. |
| No operable lamp or lighting at bedside for residents #6 and #7. |
| Uncovered and unsealed food items in kitchen refrigerators and freezer. |
| Debris and obstructions present on emergency exit route. |
| Fire extinguisher tag missing inspection date. |
| Unannounced fire drills not conducted monthly; staff notified in advance. |
| No documentation of annual fire safety inspection and fire drill by fire safety expert. |
| Fire drill records incomplete, missing evacuation times and staff participation. |
| No documentation of maximum evacuation time by fire safety expert; evacuation times exceeded limits or were blank. |
| Alternate exit routes not used during fire drills. |
| Resident medical evaluations missing required assessments or documentation. |
| Discontinued medications still present in medication carts. |
| Medication labels incorrect or missing required information. |
| Medications and medical equipment not stored properly; glucometer date/time incorrect; sharps containers improperly stored. |
| Medication administration records incomplete or inaccurate. |
| Resident assessments missing diagnoses or not completed timely. |
| Resident support plans missing documentation of care needs such as use of bedrails. |
| No objection statements missing for residents admitted to secured dementia care unit. |
| Direct care staff did not receive required dementia care training hours. |
| Resident abuse was witnessed but not immediately reported to the Department; staff involved were not immediately suspended; resident and designated person not immediately notified. |
Report Facts
License Capacity: 64
Residents Served: 51
Residents Served in Secured Dementia Care Unit: 15
Current Residents Hospice: 12
Total Daily Staff: 66
Waking Staff: 50
Number of Violations: 34
Follow-Up Dates: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Direct care staff person A | Named in multiple findings including failure to complete training, orientation, and involvement in abuse incident reporting. | |
| Direct care staff person B | Witnessed abuse incident and involved in reporting failures. | |
| Direct care staff person C | Witnessed abuse incident and involved in reporting failures. | |
| Direct care staff person D | Alleged abuser of resident #1, involved in rough handling and verbal abuse. | |
| Direct care staff person E | Overheard statements regarding abuse incident. | |
| Administrator | Named in multiple findings related to education, plan of correction, and compliance oversight. | |
| Wellness Director | Named in medication management and record confidentiality findings. | |
| Human Resources Director | Named in findings related to criminal background checks and staff training. |
Inspection Report
Plan of Correction
Census: 45
Capacity: 64
Deficiencies: 2
Sep 22, 2023
Visit Reason
The inspection was a partial, unannounced incident investigation conducted on 09/22/2023 to review the facility's compliance with licensing requirements following an incident.
Findings
The submitted plan of correction was found to be fully implemented. Two deficiencies were noted: a failure to immediately report an allegation of resident abuse and an incomplete annual resident assessment regarding behavioral issues. Both deficiencies were corrected by the facility with documented plans of correction.
Deficiencies (2)
| Description |
|---|
| Failure to immediately report an allegation of abuse against a staff person regarding resident #1 to the local Area Agency on Aging. |
| Resident #1's annual assessment was not updated to include irritability, agitation, and aggressive behaviors during assistance with toileting, dressing, and showering. |
Report Facts
License Capacity: 64
Residents Served: 45
Secured Dementia Care Unit Capacity: 23
Secured Dementia Care Unit Residents Served: 12
Current Hospice Residents: 12
Residents Age 60 or Older: 45
Residents with Mobility Need: 13
Residents with Physical Disability: 1
Total Daily Staff: 58
Waking Staff: 44
Inspection Report
Complaint Investigation
Census: 48
Capacity: 64
Deficiencies: 4
Apr 7, 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 unsanitary conditions in a resident's bedroom, improper storage and labeling of medications, and failure to update a resident's support plan to address incontinence and related behaviors.
Complaint Details
The inspection was triggered by a complaint. The report does not explicitly state substantiation status.
Deficiencies (4)
| Description |
|---|
| Unsanitary conditions in private bedroom including strong urine odor, urine-soiled carpet, and unclean bedside commode. |
| Prescription and OTC medications were not stored with proper open dates or labeling as required. |
| OTC medication (lubricating eye drops) not labeled with resident's name, repeat violation. |
| Support plan for resident not revised to address incontinence behavior or monitoring requirements. |
Report Facts
License Capacity: 64
Residents Served: 48
Secured Dementia Care Unit Capacity: 23
Secured Dementia Care Unit Residents Served: 14
Current Hospice Residents: 7
Residents Age 60 or Older: 48
Residents with Mobility Need: 14
Residents with Physical Disability: 1
Total Daily Staff: 62
Waking Staff: 47
Inspection Report
Renewal
Census: 51
Capacity: 64
Deficiencies: 7
Jun 29, 2022
Visit Reason
The inspection was conducted as a renewal, provisional licensing inspection with unannounced full visits on 06/29/2022 and 06/30/2022, followed by corrections and document submissions.
Findings
The facility was found to be in compliance overall, but several deficiencies were cited including unlocked confidential resident records, lack of a recent quality management review, incomplete staff orientation and training, incomplete medical evaluations, unlabeled over-the-counter medications, and incomplete documentation of blood glucose readings.
Deficiencies (7)
| Description |
|---|
| Resident records were unlocked, unattended, and accessible on the nurses' station desk. |
| The home had not conducted a quality management review in the last year. |
| Staff person A did not receive required orientation on fire safety and emergency preparedness prior to or during the first work day. |
| Staff person A did not receive required orientation on resident rights, emergency medical plan, mandatory abuse reporting, and reporting of incidents within 40 scheduled working hours. |
| Medical evaluation for resident #1 did not indicate blood pressure, temperature, or pulse rate. |
| A bottle of Diphenhydramine HCL 25 mg on the medication cart was not labeled with a resident's name. |
| Resident #2's glucometer reading was not documented on the medication administration record. |
Report Facts
License Capacity: 64
Residents Served: 51
Staffing Hours: 64
Waking Staff: 48
Residents in Secured Dementia Unit: 13
Hospice Residents: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff person A | Named in findings related to incomplete orientation and training | |
| RN supervisor | RN Supervisor | Named in findings related to medical evaluation and glucometer documentation |
| Administrator | Named in multiple findings related to corrective actions and training |
Inspection Report
Follow-Up
Census: 48
Capacity: 64
Deficiencies: 6
Apr 14, 2022
Visit Reason
The inspection visit on 04/14/2022 was a follow-up to verify the implementation of a previously submitted plan of correction related to a complaint and fine.
Findings
The facility was found to have fully implemented the submitted plan of correction. Deficiencies related to medication labeling, storage procedures, medical evaluations, assessments, and admission support plans were addressed with corrective actions including staff education, documentation improvements, and ongoing monitoring.
Complaint Details
The inspection was complaint-related and included a fine. The follow-up visit verified correction of cited deficiencies.
Deficiencies (6)
| Description |
|---|
| Resident #1's prescription medication label did not match the prescribed dosage and instructions. |
| Resident #2's prescribed medication was not available in the home for administration. |
| Resident #1's medical evaluation did not include an assessment of the ability to self-administer medications. |
| An initial assessment was not completed for Resident #3 within 15 days of admission. |
| Resident #2's initial medical evaluation was completed late; Residents #4 and #5's initial medical evaluations did not include a current list of medications. |
| Resident #2's initial support plan was not completed timely; Resident #5 did not have an initial support plan completed. |
Report Facts
License Capacity: 64
Residents Served: 48
Secured Dementia Care Unit Capacity: 23
Residents Served in Secured Dementia Care Unit: 12
Current Hospice Residents: 8
Total Daily Staff: 60
Waking Staff: 45
Residents with Mobility Need: 12
Residents 60 Years or Older: 48
Inspection Report
Monitoring
Census: 50
Capacity: 64
Deficiencies: 11
Nov 29, 2021
Visit Reason
The inspection was a monitoring visit conducted on 11/29/2021 to assess compliance with licensing regulations at Beechwood Court at Lafayette Manor.
Findings
The inspection identified multiple deficiencies including incomplete criminal background checks, lack of staff orientation on fire safety and resident rights, inoperable bathroom exhaust fans, bedside lamps not operable at bedside, outdated medical evaluations and assessments, presence of discontinued medication, incomplete medication documentation, and unsigned resident support plans. Plans of correction were accepted with specified completion dates.
Deficiencies (11)
| Description |
|---|
| Criminal background check was not completed timely for a newly hired staff person. |
| Staff person did not receive orientation on fire safety and emergency preparedness topics on first day. |
| Staff person did not receive orientation on resident rights, emergency medical plan, and mandatory abuse reporting within 40 hours. |
| Exhaust fans in shared bathrooms were inoperable and there were no operable windows for ventilation. |
| Resident bedside lamps were not operable at bedside and were located too far from beds. |
| Residents #4 and #5 had outdated annual medical evaluations. |
| Discontinued medication was still present in the home for resident #8. |
| Blood glucose readings for residents #4 and #8 were not properly documented on medication administration records. |
| Resident #4's blood glucose was not checked as prescribed and insulin administration could not be verified. |
| Residents #5, #6, and #7 had outdated additional assessments. |
| Resident #4's support plan was not signed by the resident and did not indicate participation status. |
Report Facts
License Capacity: 64
Residents Served: 50
Secured Dementia Care Unit Capacity: 23
Residents Served in SDCU: 14
Hospice Residents: 11
Total Daily Staff: 64
Waking Staff: 48
Residents 60 Years or Older: 50
Residents with Mobility Need: 14
Notice
Capacity: 64
Deficiencies: 0
Sep 1, 2021
Visit Reason
This document serves as a renewal notification and license issuance for Beechwood Court at Lafayette Manor, a Personal Care Home, confirming the facility's compliance and informing that an annual inspection will be conducted within the next twelve months.
Findings
The Department has issued a regular license in response to the renewal application and advises that an onsite inspection will be conducted within the next twelve months to ensure compliance with applicable regulations.
Report Facts
Maximum capacity: 64
Secure Dementia Care Unit capacity: 23
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary | Signed the renewal notification letter |
Inspection Report
Complaint Investigation
Census: 50
Capacity: 64
Deficiencies: 6
Aug 31, 2021
Visit Reason
The inspection was conducted as a complaint investigation with multiple on-site and off-site review dates to assess compliance and follow-up on a submitted plan of correction.
Findings
The facility was found to have multiple deficiencies related to failure to report medication side effects timely, safeguarding resident property, proper labeling and return of clothing, medication record inaccuracies, and failure to follow prescriber's orders. The submitted plan of correction was determined to be fully implemented.
Complaint Details
The inspection was complaint-driven as indicated by the reason 'Complaint' and the unannounced partial inspection type. The exit conference was held on 09/10/2021.
Deficiencies (6)
| Description |
|---|
| Failure to report side effects from medication Revlimid for resident #1 in a timely manner. |
| Failure to provide a system to safeguard resident #1's money and property, including lack of room key. |
| Loss of resident #1's clothing items during laundering and failure to return clothing within 24 hours. |
| Presence of discontinued medication (Digoxin) in medication cart for resident #1. |
| Medication administration record for resident #1 lacked required details for Revlimid and Hydrocodone-APAP. |
| Resident #1 was administered incorrect dosage of Metoprolol Succinate ER, not following prescriber's orders. |
Report Facts
License Capacity: 64
Residents Served: 50
Memory Care Capacity: 23
Memory Care Residents Served: 15
Hospice Current Residents: 6
Resident with Mobility Need: 15
Staffing Hours - Total Daily Staff: 65
Staffing Hours - Waking Staff: 49
Inspection Report
Renewal
Census: 46
Capacity: 64
Deficiencies: 26
Jul 14, 2021
Visit Reason
The inspection was a full, unannounced renewal inspection conducted on 07/14/2021 and 07/15/2021 to assess compliance with licensing requirements for Beechwood Court at Lafayette Manor.
Findings
The inspection identified multiple deficiencies including failure to conduct annual quality management reviews, improper use of restraints (bedrails), incomplete criminal background checks and staff training, sanitary condition issues, inadequate medical evaluations and support plans, missing emergency telephone numbers, and medication administration documentation errors. Plans of correction were accepted with specified completion dates.
Deficiencies (26)
| Description |
|---|
| The home has not conducted a quality management review within the past year. |
| Bilateral half-length bedrails were present at the top of several residents' beds who were unable to demonstrate the ability to use the device. |
| Pennsylvania criminal background checks were not completed timely for some staff. |
| Staff person A did not receive required training on emergency medical plan, mandatory abuse reporting, and reporting of incidents within 40 hours of hire. |
| Unlabeled loofa found in shared shower of residents #3 and #4. |
| Exhaust fans in bathrooms of residents #5, #6, #7, and #8 were inoperable or clogged, lacking proper ventilation. |
| Emergency telephone numbers were not posted near telephones of residents #2 and #3. |
| Bedside lamps were not within reach or operable at bedside for residents #2, #3, and #7. |
| Unlabeled bar soap found in shared bathroom of residents #3 and #4. |
| Unlabeled towels found in shared bathrooms of residents #3, #4, #7, and #8. |
| Lint trap in dryer of 2nd floor laundry room was completely covered in lint. |
| Resident #10's medical evaluation did not include medication addendum and incorrectly documented use of bedrails. |
| Resident #2, #3, #11 medical evaluations were incomplete or inaccurate regarding body positioning and bedrail use. |
| Menus were not posted in a public and conspicuous place for the required time period. |
| First aid kit in the home’s van was missing required items including thermometer, scissors, eye coverings, breathing shield, and tweezers. |
| Resident #6's blood glucose reading was not documented on the medication administration record (MAR). |
| Resident #6's prescribed medications were not administered as ordered on multiple occasions. |
| Activity calendar posted was outdated and not current. |
| No initial assessment was completed for resident #9 within 15 days of admission. |
| Resident #2, #3, #6, and #11 had incomplete or outdated additional assessments. |
| No support plan was completed for resident #9 within 30 days of admission. |
| Resident #10, #11, #12 support plans did not address the need for bedrails or safety plans related to bedrails. |
| Resident #3, #7, #8, and #13 had incomplete or missing medical evaluations documenting diagnosis and need for secured dementia care unit (SDCU). |
| Resident #3 and #13 had missing or untimely cognitive preadmission screenings for SDCU admission. |
| Resident #7, #8, and #13 had incomplete or missing support plans related to SDCU admission and bedrail use. |
| Correction fluid was used on resident #10's medical evaluation in name and date of birth sections. |
Report Facts
License Capacity: 64
Residents Served: 46
SDCU Capacity: 23
Residents Served in SDCU: 11
Current Hospice Residents: 6
Total Daily Staff: 57
Waking Staff: 43
Inspection Report
Routine
Deficiencies: 0
Jun 30, 2021
Visit Reason
The inspection was conducted as a licensing inspection by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing.
Findings
No regulatory citations were identified as a result of this inspection.
Inspection Report
Complaint Investigation
Census: 50
Capacity: 64
Deficiencies: 1
Feb 24, 2021
Visit Reason
The inspection was conducted as a complaint investigation to review compliance and follow up on a plan of correction submission.
Findings
The facility failed to report two falls of a resident in the secured dementia care unit to the Department within the required 24-hour timeframe. The resident sustained injuries including lacerations and a fractured hip. The facility submitted a plan of correction and conducted training to address incident reporting deficiencies.
Complaint Details
The complaint investigation found that resident #1 fell twice on the same day, sustaining injuries including a large laceration and a fractured hip. The facility did not report these incidents to the Department as required by regulations.
Deficiencies (1)
| Description |
|---|
| Failure to report incidents of resident falls to the Department within 24 hours as required. |
Report Facts
License Capacity: 64
Residents Served: 50
Secured Dementia Care Unit Capacity: 23
Secured Dementia Care Unit Residents Served: 13
Current Hospice Residents: 7
Residents 60 Years or Older: 50
Residents with Mobility Need: 14
Residents Diagnosed with Intellectual Disability: 1
Inspection Report
Routine
Deficiencies: 0
Feb 22, 2021
Visit Reason
The inspection was conducted as a licensing inspection by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing.
Findings
No regulatory citations were identified as a result of this inspection.
Inspection Report
Complaint Investigation
Census: 41
Capacity: 64
Deficiencies: 4
Jan 6, 2021
Visit Reason
The inspection was conducted as a complaint investigation to review compliance with licensing requirements at Beechwood Court at Lafayette Manor.
Findings
The inspection found multiple deficiencies related to resident documentation including unsigned resident contracts, missing medical evaluations, incomplete initial assessments, and absent support plans for residents. Plans of correction were submitted and deemed fully implemented.
Complaint Details
The inspection was triggered by a complaint, and the visit was unannounced. The complaint reason is explicitly stated as 'Complaint' in the inspection summary.
Deficiencies (4)
| Description |
|---|
| Resident #1's resident-home contract, dated 11/17/20, is not signed by the resident. |
| Resident #1 was admitted to the home but a medical evaluation was not completed. |
| Resident #1 and Resident #2 were admitted but initial assessments were not completed. |
| Resident #1 was admitted but an initial support plan was not completed. |
Report Facts
License Capacity: 64
Residents Served: 41
Secured Dementia Care Unit Capacity: 23
Secured Dementia Care Unit Residents Served: 11
Current Hospice Residents: 6
Residents Age 60 or Older: 41
Residents with Mobility Need: 11
Residents with Physical Disability: 1
Total Daily Staff: 52
Waking Staff: 39
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