Inspection Report
Renewal
Census: 24
Capacity: 50
Deficiencies: 10
Aug 7, 2025
Visit Reason
The inspection was an unannounced full renewal inspection conducted on 08/07/2025 to review the facility's compliance with licensing requirements.
Findings
The inspection identified multiple deficiencies related to criminal background checks, food storage, staff training, medication records and storage, medication administration documentation, support plan documentation, and resident record content. All deficiencies had plans of correction accepted and were reported as fully implemented by 09/11/2025.
Deficiencies (10)
| Description |
|---|
| Staff person A did not have a PA Patch criminal background check in their file. |
| Four 5-gallon containers of ice cream did not have lids securely closed in the ice cream freezer. |
| Unlabeled, undated plate of sausage, bacon and potatoes found in the microwave in the personal care kitchen. |
| Staff persons B and C transported residents unaccompanied by direct care staff without completing required training. |
| Resident 1's record did not include a current list of medications for self-administered drugs. |
| Brimonidine Tartrate eye drops in medication cart were open without an open date noted. |
| Resident 3's prescribed PRN Tylenol medication was not available in the home. |
| Medication administration records for residents 4 and 5 lacked staff initials for certain medication administrations. |
| Support plans for residents 1 and 2 did not document how identified needs would be met. |
| Resident 2 and 4's records did not include a photograph no more than 2 years old. |
Report Facts
License Capacity: 50
Residents Served: 24
Total Daily Staff: 24
Waking Staff: 18
Number of 5-gallon ice cream containers improperly stored: 4
Medication administration record missing initials: 5
Inspection Report
Follow-Up
Census: 21
Capacity: 50
Deficiencies: 3
Feb 27, 2025
Visit Reason
The visit was a partial, unannounced follow-up inspection conducted due to an incident, to verify that the submitted plan of correction was fully implemented.
Findings
The inspection found that the facility had fully implemented the submitted plan of correction addressing deficiencies related to assistance with activities of daily living, treatment of residents with dignity and respect, and accurate documentation of residents' ability to self-administer medications.
Deficiencies (3)
| Description |
|---|
| Failure to provide required assistance with eating to a resident with poor vision as indicated in their support plan. |
| Staff member verbally yelled at a resident in a loud voice, failing to treat the resident with dignity and respect. |
| Resident's support plan incorrectly documented the resident's ability to self-administer medications. |
Report Facts
Residents served: 21
License capacity: 50
Total daily staff: 21
Waking staff: 16
Inspection Report
Renewal
Census: 19
Capacity: 50
Deficiencies: 2
Mar 15, 2023
Visit Reason
The inspection was conducted as a renewal visit to review compliance and verify the submitted plan of correction for the facility.
Findings
The facility was found to have implemented the submitted plan of correction fully. Two deficiencies were noted: failure to conduct fire drills during sleeping hours every six months, and improper documentation of blood glucose readings, both of which were corrected with plans accepted and implemented.
Deficiencies (2)
| Description |
|---|
| Failure to conduct fire drills during sleeping hours once every six months. |
| Improper documentation of blood glucose readings and improper use of glucometers. |
Report Facts
License Capacity: 50
Residents Served: 19
Total Daily Staff: 19
Waking Staff: 14
Inspection Report
Renewal
Census: 22
Capacity: 50
Deficiencies: 8
Apr 20, 2022
Visit Reason
The inspection was a renewal visit conducted on 04/20/2022 to assess compliance with licensing requirements at Cathedral Village.
Findings
The inspection identified multiple deficiencies including lack of training on memory support, improper storage of medical equipment, limited use of alternate exit routes during fire drills, incomplete medical evaluations, medication storage and administration issues, lack of resident activity programs due to staffing shortages, and incomplete support plans for communication needs.
Deficiencies (8)
| Description |
|---|
| The home's staff training plan does not include training on memory support for residents with dementia. |
| Injection pen for resident #2 was not properly stored and had a smear of blood on it. |
| The main lobby was the only exit route used during fire drills from January to March 2022. |
| Medical evaluation for resident #1 did not include general physical examination, immunization history, or special health/dietary needs. |
| Medication prescribed as needed for resident #2 was not available in the home. |
| Resident #1 was administered incorrect medication on 2/16/22 at 4:00 pm. |
| The home does not have a program of activities designed to promote active involvement of residents with families and community due to staffing shortage. |
| Resident #3's support plan does not document how communication needs due to aphasia will be met. |
Report Facts
License Capacity: 50
Residents Served: 22
Total Daily Staff: 23
Waking Staff: 17
Inspection Report
Follow-Up
Census: 20
Capacity: 50
Deficiencies: 1
Dec 10, 2021
Visit Reason
The inspection was a follow-up visit to verify the implementation of a previously submitted plan of correction related to incident reporting.
Findings
The facility was found to have fully implemented the plan of correction regarding the submission of a final incident report, which had previously not been submitted. Continued compliance must be maintained.
Deficiencies (1)
| Description |
|---|
| The home did not submit a final incident report to the Department following an initial incident report. |
Report Facts
License Capacity: 50
Residents Served: 20
Inspection Report
Monitoring
Census: 24
Capacity: 50
Deficiencies: 1
Oct 13, 2021
Visit Reason
The inspection was a monitoring visit conducted on 10/13/2021 to review the facility's compliance status and plan of correction implementation.
Findings
The submitted plan of correction related to medication administration and glucometer reading documentation was found to be fully implemented. Continued compliance is required.
Deficiencies (1)
| Description |
|---|
| Failure to properly document blood glucose readings in the Medication Administration Record (MAR) as verified by glucometer readings for Resident #1 on multiple dates. |
Report Facts
License Capacity: 50
Residents Served: 24
Total Daily Staff: 28
Waking Staff: 21
Inspection Report
Original Licensing
Capacity: 41
Deficiencies: 1
Jul 1, 2021
Visit Reason
The inspection was conducted as a licensing inspection for the newly licensed personal care home facility, Cathedral Village, to assess compliance with 55 Pa. Code Chapter 2600.
Findings
The facility was found to be in substantial compliance with applicable regulations, but citations were issued related to emergency procedures not including local municipality information. A plan of correction was accepted and implemented.
Deficiencies (1)
| Description |
|---|
| The home’s emergency procedures posted did not include the emergency procedures of the local municipality. |
Report Facts
License Capacity: 41
Residents Served: 0
Deficiencies cited: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jamie Buchenauer | Deputy Secretary | Signed licensing letter and correspondence |
Inspection Report
Renewal
Census: 17
Capacity: 50
Deficiencies: 5
Jun 14, 2021
Visit Reason
The inspection was conducted as a renewal inspection of the facility's license.
Findings
The inspection found several deficiencies including failure to provide timely refunds to discharged residents, failure to post weekly menus in a conspicuous place, unsecured medications in a resident's room, medication administration errors, and incomplete initial assessments for newly admitted residents. Plans of correction were accepted and implemented.
Deficiencies (5)
| Description |
|---|
| Failure to provide required refund to discharged resident within 30 days. |
| Menus for the weeks of June 14 and June 21, 2021 were not posted in a conspicuous and public place. |
| Medications stored unlocked and unattended in resident #2's room. |
| Resident #2 was administered incorrect dosage of Clonazepam (1 mg instead of 0.5 mg). |
| Initial assessment was not completed within 15 days for resident #3. |
Report Facts
License Capacity: 50
Residents Served: 17
Total Daily Staff: 18
Waking Staff: 14
Notice
Capacity: 50
Deficiencies: 0
Jun 3, 2021
Visit Reason
The document serves as a renewal notification and issuance of a regular license for Cathedral Village Personal Care Home, confirming compliance and informing about the requirement for an annual onsite inspection within the next twelve months.
Findings
The Department has approved the renewal application and issued a regular license. It advises that an onsite inspection will be conducted within the next twelve months to ensure compliance with applicable regulations.
Report Facts
Maximum capacity: 50
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary, Office of Long-term Living | Signed the renewal notification letter. |
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