Inspection Report
Renewal
Census: 14
Capacity: 23
Deficiencies: 6
Aug 13, 2024
Visit Reason
The inspection was a renewal inspection conducted on 08/13/2024 to review the facility's compliance with licensing requirements.
Findings
The inspection found multiple deficiencies including incomplete annual training hours and topics for a staff member, incomplete training records, lack of a three-day emergency supply of drinking water, an exit door requiring excessive force to open, and missing documented blood glucose readings in a resident's medication administration record. Plans of correction were accepted and implemented by 09/30/2024.
Deficiencies (6)
| Description |
|---|
| Staff Member A did not receive 12 hours of annual training in 2023; only 4.75 hours were verified. |
| Staff Member A did not receive 2023 annual trainings on required topics including medication self-administration and safe management techniques. |
| Staff Member A’s annual training records did not include the length of training for certain topics. |
| The home did not have a three-day emergency supply of drinking water onsite or a contract for immediate delivery. |
| An exit door required excessive force to be opened during physical site inspection. |
| Resident #2’s Medication Administration Record did not contain the documented blood glucose reading on 8/8/24 at 8am. |
Report Facts
License Capacity: 23
Residents Served: 14
Total Daily Staff: 14
Waking Staff: 11
Annual Training Hours Verified: 4.75
Gallons of Water Onsite: 45
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff Member A | Named in deficiencies related to annual training hours, training topics, and training record | |
| Director of Nursing | Named in deficiency related to missing blood glucose documentation and plan of correction | |
| Administrator | Named in deficiencies related to exit door correction and emergency water supply |
Inspection Report
Renewal
Census: 13
Capacity: 23
Deficiencies: 5
May 19, 2022
Visit Reason
The inspection was conducted as a renewal inspection of the Birdsboro Lodge facility to assess compliance with licensing requirements.
Findings
The inspection found several deficiencies including failure to review staff training during quality management meetings in 2021, lack of documentation for emergency procedures submission to the local emergency management agency in 2021, failure to conduct a fire drill in April 2022, conducting fire drills only on the last day of the month, and improper labeling of medication storage items. Plans of correction were submitted and accepted for all deficiencies with evidence of implementation.
Deficiencies (5)
| Description |
|---|
| The home did not review staff training during the quality management meeting in 2021. |
| The home did not have documentation that their emergency procedures were reviewed and submitted to the local emergency management agency in 2021. |
| The home did not conduct a fire drill in the month of April 2022. |
| The home's last 4 fire drills were conducted only on the last day of the month, not on varied days and times as required. |
| Medications belonging to resident #1 were not labeled with the date the pens were opened for use, contrary to manufacturer instructions. |
Report Facts
License Capacity: 23
Residents Served: 13
Total Daily Staff: 13
Waking Staff: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Responsible for conducting staff training on medication storage and reviewing manufacturers instructions |
| Administrator | Administrator | Responsible for quality management meetings, emergency procedures submission, fire drill compliance, and monitoring ongoing compliance |
Inspection Report
Renewal
Census: 15
Capacity: 23
Deficiencies: 12
Jun 30, 2021
Visit Reason
The inspection was conducted as a renewal inspection of the Birdsboro Lodge facility to assess compliance with licensing requirements.
Findings
The inspection identified multiple deficiencies including failure to post the current license inspection summary, unsigned resident contracts, outdated quality management meetings, prohibited use of audio monitors, unsafe resident equipment, lack of bedside lighting, failure to test smoke detectors monthly, fire safety hazards in smoking areas, incomplete medication instructions, incomplete narcotic counts, unsigned support plans, and incomplete resident record content. Plans of correction were accepted or implemented for all deficiencies except one medication issue which was initially not accepted but later accepted.
Deficiencies (12)
| Description |
|---|
| Licensing inspection summary dated 6/21/19 was not posted in a public conspicuous area. |
| Resident #1 and Resident #2 contracts were not signed by the residents. |
| Last quality management meeting was completed on 12/6/19, overdue for annual meeting. |
| Use of prohibited audio monitors on 1st and 2nd floors. |
| Grab assist bars attached to beds had uncovered 12 inch slats posing limb entrapment hazard. |
| Room #2 lacked an operable lamp or other source of lighting accessible from bedside. |
| Fire alarms and smoke detectors were not tested monthly as required. |
| Propane gas grill located in designated smoking area posing fire hazard. |
| Resident #3's sample medication Dulera lacked written instructions from prescriber. |
| Narcotic counts were not completed at the end of every shift as required. |
| Resident #2's RASP dated 5/21/21 was not signed by the resident or documented inability to sign. |
| Resident #1 and Resident #2 records lacked hair color, eye color, and identifying marks. |
Report Facts
License Capacity: 23
Residents Served: 15
Total Daily Staff: 16
Waking Staff: 12
Deficiencies cited: 12
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