Deficiencies per Year
16
12
8
4
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Follow-Up
Census: 40
Capacity: 67
Deficiencies: 1
Apr 25, 2025
Visit Reason
The inspection was conducted as a partial, unannounced visit due to an incident, with a follow-up on the submitted plan of correction.
Findings
The facility was found to have a deficiency where a resident did not sign their support plan and the home failed to document the resident's inability or refusal to sign. The plan of correction was accepted and fully implemented by the Health and Wellness Coordinator.
Deficiencies (1)
| Description |
|---|
| Resident participated in the development of their initial support plan but did not sign it, and the home did not make a notation regarding the resident's inability to sign. |
Report Facts
License Capacity: 67
Residents Served: 40
Current Residents in Hospice: 4
Residents Age 60 or Older: 40
Residents with Mobility Need: 1
Residents with Physical Disability: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Health and Wellness Coordinator | Responsible for fixing the support plan deficiency and implementing corrective actions | |
| Health and Wellness Director | Conducts monthly audits of support plans to ensure compliance |
Inspection Report
Follow-Up
Census: 41
Capacity: 67
Deficiencies: 3
Jul 17, 2024
Visit Reason
The visit was a partial, unannounced inspection triggered by an incident involving alleged inappropriate touching between residents, requiring review and follow-up on the submitted plan of correction.
Findings
The facility was found to have failed to report an incident of inappropriate touching between residents within the required timeframe and failed to provide a written 30-day discharge notice as stipulated in the resident contract. The submitted plan of correction was accepted and fully implemented by mid-August 2024.
Complaint Details
The visit was complaint-related due to an incident where Resident 2 reported inappropriate touching by Resident 1. The complaint was substantiated as abuse occurred. Resident 1 was subsequently discharged following a verbal 30-day notice.
Deficiencies (3)
| Description |
|---|
| Failure to report an incident of inappropriate touching between residents to the Department within 24 hours as required. |
| Resident was touched inappropriately against their wishes by another resident, constituting abuse. |
| Failure to provide a written 30-day discharge notice to the resident as required by contract; only verbal notice was given. |
Report Facts
Residents served: 41
License capacity: 67
Staffing hours - Total Daily Staff: 41
Staffing hours - Waking Staff: 31
Inspection Report
Plan of Correction
Census: 37
Capacity: 67
Deficiencies: 1
Feb 28, 2024
Visit Reason
The inspection was a partial, unannounced visit conducted on 02/28/2024 due to an incident at the facility. The report documents the review and acceptance of the facility's plan of correction.
Findings
The facility had a deficiency related to the resident's support plan not being updated to reflect renewed physical therapy services following a fall that resulted in serious injury and rehabilitation stay. The submitted plan of correction was fully implemented and compliance was maintained.
Deficiencies (1)
| Description |
|---|
| Resident's support plan was not updated to reflect the reason for renewed physical therapy services after a fall and rehabilitation stay. |
Report Facts
License Capacity: 67
Residents Served: 37
Total Daily Staff: 37
Waking Staff: 28
Current Hospice Residents: 1
Residents 60 Years or Older: 37
Residents Diagnosed with Mental Illness: 1
Residents with Physical Disability: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Health and Wellness Director (HWD) | Retrained on community policy and conducted audits related to support plan documentation | |
| Health and Wellness Coordinator (HWC) | Retrained on community policy and responsible for conducting audits of resident therapy documentation | |
| Executive Director (ED) | Provided retraining to HWD and HWC on support plan policy |
Inspection Report
Follow-Up
Census: 43
Capacity: 67
Deficiencies: 1
Nov 21, 2023
Visit Reason
The inspection was conducted as a follow-up review of the submitted plan of correction for the facility.
Findings
The facility was found to have corrected the previously identified deficiency regarding uncovered trash receptacles in the women's bathroom. Compliance was verified through audits and staff retraining, with ongoing monitoring planned.
Deficiencies (1)
| Description |
|---|
| Trash can in the common women's bathroom/shower room was uncovered and had a broken lid. |
Report Facts
License Capacity: 67
Residents Served: 43
Current Hospice Residents: 3
Staffing Hours - Resident Support Staff: 0
Staffing Hours - Total Daily Staff: 44
Staffing Hours - Waking Staff: 33
Audit Frequency: 4
Inspection Report
Renewal
Census: 40
Capacity: 67
Deficiencies: 13
Sep 6, 2023
Visit Reason
The inspection was conducted as a renewal review of the facility's license and compliance with regulatory requirements.
Findings
The inspection identified multiple deficiencies related to resident record confidentiality, hospice care informed consent and fire drill procedures, resident personal equipment safety, surface hazards, soap dispenser labeling, evacuation procedures, fire drill timing and designated meeting places, smoking area safety, and record log completeness. Plans of correction were accepted and implemented for all deficiencies.
Deficiencies (13)
| Description |
|---|
| Electronic resident records were left unlocked and accessible on a medication cart computer. |
| No written informed consent from Resident #1 regarding non-evacuation during fire drills. |
| Staff did not inform Resident #1 or responsible staff that the fire drill alarm was a drill, not an actual fire. |
| Staff responsible for evacuating Resident #1 did not use a safe mode of transportation during fire drill simulation. |
| Staff did not reasonably simulate the level of effort required to move Resident #1 during fire drill evacuation. |
| Required hospice documentation was not kept with the fire drill record for Resident #1. |
| Grab assist bar on Resident #2's bed was not securely attached, posing entrapment hazard. |
| A green rug outside shower in Room #2 lacked slip resistant backing, posing fall hazard. |
| Unlabeled bar of soap found in shared bathroom of Room #18. |
| Evacuation times recorded only included residents in fire affected zone, not entire building. |
| Residents did not evacuate to designated meeting places during fire drills; some only evacuated to doorways. |
| Smoking area contained combustible materials including propane tanks and nylon chairs without fire-resistant tags. |
| Destroyed records log did not include residents' dates of birth. |
Report Facts
Residents served: 40
License capacity: 67
Current hospice residents: 5
Residents age 60 or older: 40
Residents with intellectual disability: 1
Residents with mobility need: 3
Inspection Report
Complaint Investigation
Census: 38
Capacity: 67
Deficiencies: 0
Mar 15, 2023
Visit Reason
The inspection was conducted as a complaint investigation at the facility on 03/15/2023.
Findings
No regulatory citations or deficiencies were identified as a result of this complaint inspection.
Complaint Details
The inspection was complaint-driven and no deficiencies or citations were found, indicating the complaint was not substantiated.
Report Facts
Total Daily Staff: 41
Waking Staff: 31
Residents Served: 38
License Capacity: 67
Current Hospice Residents: 2
Residents Age 60 or Older: 38
Residents with Mobility Need: 3
Inspection Report
Renewal
Census: 45
Capacity: 67
Deficiencies: 5
Jun 7, 2022
Visit Reason
The inspection was an unannounced full renewal inspection conducted on 06/07/2022 and 06/08/2022 to review compliance with licensing requirements.
Findings
The inspection identified several deficiencies including lack of exterior lighting at a door, presence of a dented can of food, incomplete menu posting, medication storage and documentation issues, and medication administration concerns. All deficiencies had plans of correction implemented and verified by the Department Representative.
Deficiencies (5)
| Description |
|---|
| No exterior lighting at the door exiting from the home to the garden area. |
| A dented can of spaghetti sauce was stored in the home’s pantry. |
| Menus were only posted up until 6/11/2022, not a full week in advance. |
| Resident 3’s glucometer reading was documented incorrectly in the MAR; Resident 4’s PRN medication was not available on the medication cart at time of inspection. |
| Medications were sometimes left for residents on their nightstand or in their room, contrary to policy; repeat violation from 6/29/2021. |
Report Facts
License Capacity: 67
Residents Served: 45
Total Daily Staff: 50
Waking Staff: 38
Current Hospice Residents: 1
Residents 60 Years or Older: 44
Residents with Mobility Need: 5
Residents with Physical Disability: 1
Notice
Capacity: 67
Deficiencies: 0
Jun 30, 2021
Visit Reason
The document serves as a license renewal approval for the Brookdale Bloomsburg Personal Care Home and notifies that an annual inspection will be conducted within the next twelve months as required by regulation.
Findings
The Department issued a regular license in response to the renewal application and advised that an onsite inspection will be conducted within the next twelve months to ensure compliance with applicable regulations.
Report Facts
Total licensed capacity: 67
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary, Office of Long-term Living | Signed the renewal approval letter |
Inspection Report
Renewal
Census: 35
Capacity: 67
Deficiencies: 3
Jun 29, 2021
Visit Reason
The inspection was conducted as a renewal inspection of the facility license.
Findings
The facility was found to have deficiencies related to emergency telephone numbers not posted near a resident's phone and a missed medication administration. The submitted plan of correction was determined to be fully implemented.
Deficiencies (3)
| Description |
|---|
| Resident room #21 did not have the required emergency numbers posted near or by the phone as required. |
| Resident #1 was administered a 8:00 AM dose of treatment by staff person 'A' on 6/30/21 but the 8 AM dose was unused and not ensured to be completed as prescribed. |
| Resident #1 did not receive their 8:00 AM dose of treatment as prescribed by the prescriber. |
Report Facts
License Capacity: 67
Residents Served: 35
Total Daily Staff: 35
Waking Staff: 26
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