Inspection Reports for
Beechwood Court at Lafayette Manor
145 LAFAYETTE MANOR ROAD,, UNIONTOWN, PA, 15401
Back to Facility Profile38 Reports
Inspection Report — Aug 3, 2026
Complaint Investigation
Date: Aug 3, 2026
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.
Report Facts
Residents Served: 48
Secured Dementia Care Unit Residents Served: 15
Hospice Current Residents: 12
Resident Support Staff Daily Total: 63
Waking Staff Daily Total: 47
Inspection Report — Feb 9, 2026
Renewal
Date: Feb 9, 2026
Visit Reason
The inspection was conducted as a renewal and complaint investigation to assess compliance with licensing regulations and to verify correction of previous deficiencies.
Findings
The inspection identified multiple deficiencies including failure to post required documents, confidentiality breaches, incomplete staff training, unsafe conditions such as snow accumulation, improper food storage, use of prohibited portable space heaters, medication storage violations, and incomplete resident medical evaluations and support plans. Plans of correction were accepted and implemented by April 6, 2026.
Citations (13)
2600.3.c The personal care home did not post the current license inspection summaries and 55 Pa. Code Chapter 2600 regulations in a conspicuous and public place.
2600.17 Resident records were not kept confidential; a privacy coding document with resident names was left unlocked and unattended in the lobby.
2600.65.d A direct care staff person hired after April 24, 2006, provided unsupervised ADL services without completing required training and competency testing.
2600.100.b Snow and obstructions were not removed; approximately 3 inches of snow accumulated on the secured dementia care unit courtyard patio and walkway.
2600.103.g Food was not stored properly; 33 uncovered individual servings of apple sauce were found in the refrigerator.
2600.127.a Portable space heaters were used and found in the facility despite prohibition.
2600.141.b.1 Resident medical evaluations lacked required information; a resident's height was missing from the evaluation.
2600.162.c Weekly menus were not posted in a conspicuous and public place as required.
2600.183.a Prescription and OTC medications were not kept in original labeled containers; an unlocked plastic container labeled 'rash cream for butt' was accessible in a resident's bedroom.
2600.183.b Medications and syringes were not kept locked; unlocked medications were accessible in resident shared bathroom and bedroom.
2600.221.c A current weekly activity calendar was not posted in a conspicuous and public place in the home.
2600.231.b Medical evaluations were not completed timely for residents admitted to the secured dementia care unit.
2600.234.a Support plans were not developed and documented within 72 hours of admission to the secured dementia care unit.
Report Facts
Residents Served: 49
Secured Dementia Care Unit Residents Served: 13
Current Hospice Residents: 16
Staff Count: 65
Waking Staff: 49
Uncovered Apple Sauce Servings: 33
Inspection Report — Nov 17, 2025
Follow-Up
Date: Nov 17, 2025
Visit Reason
The inspection was a partial, unannounced follow-up visit triggered by an incident to verify the implementation of the submitted plan of correction.
Findings
The facility was found to have implemented the plan of correction related to multiple deficiencies including resident abuse reporting, incident documentation, staff orientation, and medical evaluations. Continued compliance and ongoing audits were planned to ensure sustained adherence to regulations.
Citations (6)
2600.15a The home failed to immediately report an incident of verbal abuse including a spitting incident to the Area Agency on Aging as required.
2600.16c The home failed to include the spitting incident in the written incident report submitted to the Department within 24 hours.
2600.42b A resident was verbally abused with threatening statements and derogatory names by ancillary staff, and an altercation involving spitting occurred; staff member was terminated.
2600.65a Ancillary staff person A did not receive orientation on required fire safety and emergency preparedness topics on their first day of work.
2600.65b Ancillary staff person A did not receive orientation within 40 scheduled working hours on resident rights, emergency medical plan, and mandatory abuse reporting.
2600.141a A resident's medical evaluation form was incomplete and did not indicate if the resident's needs could be safely met at the personal care home.
Report Facts
Residents Served: 50
Secured Dementia Care Unit Residents Served: 12
Hospice Current Residents: 15
Inspection Report — Nov 4, 2025
Complaint Investigation
Date: Nov 4, 2025
Visit Reason
The inspection was conducted as a complaint investigation during an unannounced partial inspection on 11/04/2025.
Complaint Details
The inspection was complaint-driven as explicitly stated under Inspection Information with Reason: Complaint.
Findings
Multiple violations were found including uncovered trash in the secured dementia care unit courtyard, unsecured cabinet door, electrical cord hazards, stained ceiling tiles, inoperable water fountain and bathtub/shower, and improper items in the designated smoking area. Plans of correction were directed and subsequently implemented.
Citations (4)
85e Trash outside the home was found in an uncovered planter in the secured dementia care unit courtyard.
88a Floors, walls, ceilings, windows, doors and other surfaces had issues including an unsecured cabinet door, electrical cord tripping hazard near a sink, and stained ceiling tiles in the stairwell.
95 Furniture and equipment included an inoperable and corroded water fountain with exposed sharp metal edges and an inoperable bathtub/shower in the 2nd floor common bathroom.
144c1 Smoking area guidelines were violated by the presence of cloth folding chairs and a seat cushion on a metal chair in the designated smoking area.
Report Facts
Residents Served: 49
Secured Dementia Care Unit Residents Served: 13
Hospice Current Residents: 10
Residents Age 60 or Older: 49
Residents with Mental Illness: 1
Residents with Mobility Need: 21
Inspection Report — Jun 4, 2025
Complaint Investigation
Date: Jun 4, 2025
Visit Reason
The inspection was conducted as a complaint and incident investigation at Beechwood Court at Lafayette Manor.
Complaint Details
The inspection was complaint-related, but no deficiencies or citations were found, indicating no substantiated violations.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Residents Served: 51
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 — May 19, 2025
Complaint Investigation
Date: May 19, 2025
Visit Reason
The inspection was conducted as a complaint and incident investigation at Beechwood Court at Lafayette Manor.
Complaint Details
The inspection was triggered by a complaint and incident; no deficiencies or citations were found.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Residents Served: 50
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 — Apr 23, 2025
Complaint Investigation
Date: Apr 23, 2025
Visit Reason
The inspection was conducted as a complaint-related incident investigation at Beechwood Court at Lafayette Manor.
Complaint Details
The inspection was triggered by an incident complaint; no deficiencies or citations were found, indicating no substantiated violations.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Residents Served: 49
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 — Mar 11, 2025
Renewal
Date: 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.
Citations (13)
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
Residents Served: 51
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
Notice — Oct 24, 2024
Date: Oct 24, 2024
Visit Reason
This document serves as a waiver approval for an assisted living facility administrator to temporarily serve without completing the full required training and orientation, under specified conditions.
Findings
The waiver allows the administrator to serve while enrolled in a 15-hour Assisted Living Administrator course and requires passing a competency test by January 30, 2025. The facility must comply with all regulations by January 31, 2025, and the administrator must have regular supervision until training requirements are met.
Report Facts
Training course duration: 15
Competency test deadline: Jan 30, 2025
Compliance deadline: Jan 31, 2025
Notice — Oct 17, 2024
Date: Oct 17, 2024
Visit Reason
This document serves as a waiver approval for an administrator at Beechwood Court at Lafayette Manor to serve while enrolled in and completing the required 100-hour personal care home administrator competency test.
Findings
The waiver permits the administrator to serve temporarily while completing required training and testing, with the expectation that full compliance will be met by November 6, 2024.
Report Facts
Scheduled competency test date: Nov 5, 2024
Inspection Report — Aug 29, 2024
Complaint Investigation
Date: 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.
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.
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.
Citations (16)
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
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 — Sep 22, 2023
Plan of Correction
Date: 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.
Citations (2)
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
Residents Served: 45
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 — Apr 7, 2023
Complaint Investigation
Date: Apr 7, 2023
Visit Reason
The inspection was conducted as a complaint investigation following a complaint received by the Pennsylvania Department of Human Services.
Complaint Details
The inspection was triggered by a complaint. The report does not explicitly state substantiation status.
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.
Citations (4)
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
Residents Served: 48
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 — Jun 29, 2022
Renewal
Date: 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.
Citations (7)
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
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 — Apr 14, 2022
Follow-Up
Date: 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.
Complaint Details
The inspection was complaint-related and included a fine. The follow-up visit verified correction of cited deficiencies.
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.
Citations (6)
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
Residents Served: 48
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 — Nov 29, 2021
Monitoring
Date: 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.
Citations (11)
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
Residents Served: 50
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 — Sep 1, 2021
Date: 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
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary | Signed the renewal notification letter |
Inspection Report — Aug 31, 2021
Complaint Investigation
Date: 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.
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.
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.
Citations (6)
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
Residents Served: 50
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 — Jul 14, 2021
Renewal
Date: 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.
Citations (26)
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
Residents Served: 46
Residents Served in SDCU: 11
Current Hospice Residents: 6
Total Daily Staff: 57
Waking Staff: 43
Inspection Report — Jun 30, 2021
Routine
Date: 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 — Feb 24, 2021
Complaint Investigation
Date: 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.
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.
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.
Citations (1)
Failure to report incidents of resident falls to the Department within 24 hours as required.
Report Facts
Residents Served: 50
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 — Feb 22, 2021
Routine
Date: 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 — Jan 6, 2021
Complaint Investigation
Date: 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.
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.
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.
Citations (4)
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
Residents Served: 41
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
Notice — Sep 17, 2018
Date: Sep 17, 2018
Visit Reason
The document serves as a renewal certificate and notification for the operation of Beechwood Court at Lafayette Manor as a Personal Care Home, including a reminder of the requirement for an annual onsite inspection within the next twelve months.
Findings
No inspection findings are reported in this document. It confirms issuance of a regular license following the renewal application.
Report Facts
Inspection Report — Apr 19, 2018
Complaint Investigation
Date: Apr 19, 2018
Visit Reason
The inspection was conducted as a complaint investigation triggered by an incident involving resident mistreatment.
Complaint Details
The complaint was substantiated based on findings of verbal abuse and neglect of resident #1 by staff person C on 4/8/2018. Staff person C was terminated and training was implemented.
Findings
The investigation found violations related to failure to report an incident timely, resident neglect and verbal abuse, lack of staff training on infection control, and incomplete cognitive screening documentation. Corrective actions including staff termination, training, and use of standardized forms were initiated.
Citations (4)
55 Pa.Code 2600.16(c) - The home failed to report an incident involving a resident screaming and staff response within 24 hours as required by regulation.
55 Pa.Code 2600.42(b) - A resident was verbally abused and neglected by staff who screamed at the resident and failed to provide proper assistance during a meal.
55 Pa.Code 2600.65(g) - Direct care staff did not receive required annual training on infection control and general principles of cleanliness during the 2017 training year.
55 Pa.Code 2600.251(c) - The cognitive prescreening for a resident was not completed on the department's standard form as required.
Report Facts
Number of Residents Served: 48
Number of Residents Served in Secured Dementia Care Unit: 14
Number of Current Hospice Residents: 2
Number of Hospice Residents in past year: 7
Inspection Report — Jan 30, 2018
Annual Inspection
Date: Jan 30, 2018
Visit Reason
The inspection was conducted as part of the Department of Human Services' annual licensing inspection and included renewal and complaint reasons.
Findings
Multiple violations of 55 Pa. Code Chapter 2600 were found, including unsafe water temperatures, lack of thermometers in refrigerators and freezers, blocked egress routes, incomplete medication administration records, and incomplete resident assessments. Plans of correction were submitted and partially implemented with adequate progress noted.
Citations (8)
55 Pa.Code §2600.89(b) - Hot water temperature in areas accessible to residents exceeded 120°F, measuring up to 125.6°F in multiple locations.
55 Pa.Code §2600.103(f) - Refrigerators and freezers lacked required thermometers, preventing verification of safe food storage temperatures.
55 Pa.Code §2600.121(4) - Exit door to resident bedroom #225 was blocked by furniture, limiting door opening to approximately 12 inches.
55 Pa.Code §2600.187(a) - Resident #2's medication administration record contained a prescription for Miralax powder that was discontinued but still administered.
55 Pa.Code §2600.187(b) - Resident #1's January 2018 MAR was not initialed by staff who administered medications at specified times.
55 Pa.Code §2600.225(c) - Resident assessments for residents #4, #5, and #8 were not updated to include required diet modifications and needs.
55 Pa.Code §2600.231(c) - Resident #3 was admitted to the secure dementia unit without a completed cognitive preadmission screening until 1/8/18.
55 Pa.Code §2600.233(c) - Key pad lock system for secure dementia unit did not have exit codes posted near doors, limiting emergency egress directions.
Report Facts
Number of Residents Served: 47
Number of Current Hospice Residents: 6
Number of Hospice Residents in past year: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Diana L. McGregor | Administrator | Signed plans of correction and named in report |
Inspection Report — Dec 14, 2017
Complaint Investigation
Date: Dec 14, 2017
Visit Reason
The inspection was conducted as a complaint investigation at Beechwood Court at Lafayette Manor to assess compliance with 55 Pa. Code Chapter 2600 relating to Personal Care Homes.
Complaint Details
The inspection was triggered by a complaint. Specific substantiation status is not stated in the report.
Findings
Multiple violations were found related to support plan signatures, incomplete medical evaluations, documentation of resident and designated person objections, timely completion of support plans, annual revision of support plans, and inclusion of death certificates in resident records.
Citations (6)
Regulation 2600.227(g): Resident #2 participated in the support plan but did not sign it, with no notation of refusal or inability to sign.
Regulation 2600.231(b): Resident #1's medical evaluation dated 2/9/17 lacks allergies and ability to self-administer medications sections.
Regulation 2600.231(e): Resident #1 was admitted to the secured dementia care unit without documentation that the designated person did not object.
Regulation 2600.234(a): Resident #1's support plan was not completed until 2/17/17, after admission on 2/10/17.
Regulation 2600.234(d): Resident #1's assessment dated 2/17/17 does not reflect condition changes after hospital transfer and hospice services.
Regulation 2600.252: Resident #1 and #2 ceased to breathe in the home, but their records lack official death certificates.
Report Facts
Number of Residents Served: 50
Number of Residents Served in Secured Dementia Care Unit: 16
Number of Current Hospice Residents: 6
Number of Hospice Residents in Past Year: 10
Number of Residents Age 60 or Older: 49
Number of Residents with Mobility Need: 16
Number of Residents with Physical Disability: 1
Notice — Sep 19, 2017
Date: Sep 19, 2017
Visit Reason
This document serves as a renewal approval for the Personal Care Home license for Beechwood Court at Lafayette Manor and informs the facility of the requirement for an annual onsite inspection within the next twelve months.
Findings
No inspection findings are reported in this document. It confirms issuance of a regular license following the renewal application.
Report Facts
Inspection Report — Jan 10, 2017
Renewal
Date: Jan 10, 2017
Visit Reason
The inspection was conducted as an annual licensing renewal inspection of Beechwood Court at Lafayette Manor.
Findings
The inspection identified violations related to direct care staff training, uncovered trash receptacles, and improper refrigeration temperatures in the secured dementia care unit. Plans of correction were submitted and partially implemented to address these issues.
Citations (3)
55 Pa.Code §2600.65(d) - A direct care staff person provided unsupervised ADL services without completing the required Department-approved training and competency test.
55 Pa.Code §2600.85(d) - An uncovered trash can full of paper towels was found in the second floor common bathroom.
55 Pa.Code §2600.103(f) - The refrigerator in the secured dementia care unit measured 49°F, exceeding the required maximum of 40°F.
Report Facts
Number of Residents Served: 50
Number of Current Hospice Residents: 4
Number of Hospice Residents in Past Year: 10
Number of Residents Served in Secured Dementia Care Unit: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer K. Rhodes | Administrator | Named in relation to the plan of correction and signature on violation reports. |
| Donald Knee | Inspector conducting the violation report. |
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