Inspection Report
Plan of Correction
Census: 54
Capacity: 70
Deficiencies: 3
Sep 11, 2025
Visit Reason
The inspection was a partial, unannounced visit conducted on 09/11/2025 due to an incident and interim review.
Findings
The inspection identified deficiencies including mistreatment of a resident in the secure dementia unit, lack of operable bedside lamps in resident rooms, and medication storage issues where a prescribed as-needed medication was unavailable due to expiration and refill issues. Corrective actions and staff training were implemented with ongoing monitoring.
Deficiencies (3)
| Description |
|---|
| Resident in secure dementia unit was mistreated by staff who poured soapy water over the resident's head after the resident refused shower assistance. |
| Beds in resident rooms did not have access to operable bedside lamps; bulbs were blown or lamps were controlled by wall switches away from the bed. |
| A prescribed as-needed medication was not available on the medication cart due to expiration and lack of refill authorization. |
Report Facts
Residents Served: 54
License Capacity: 70
Residents Served in Secured Dementia Care Unit: 21
Capacity of Secured Dementia Care Unit: 25
Current Hospice Residents: 3
Residents Age 60 or Older: 54
Residents with Mobility Need: 22
Residents with Physical Disability: 1
Total Daily Staff: 76
Waking Staff: 57
Inspection Report
Census: 52
Capacity: 70
Deficiencies: 0
Sep 3, 2025
Visit Reason
The inspection was conducted as a licensing inspection due to an incident, with an unannounced partial inspection type.
Findings
No regulatory citations or deficiencies were identified during the inspection.
Report Facts
License Capacity: 70
Residents Served: 52
Secured Dementia Care Unit Capacity: 25
Secured Dementia Care Unit Residents Served: 17
Hospice Current Residents: 2
Residents Age 60 or Older: 52
Residents Diagnosed with Intellectual Disability: 2
Residents with Mobility Need: 22
Residents with Physical Disability: 1
Inspection Report
Renewal
Census: 51
Capacity: 70
Deficiencies: 16
Jul 16, 2025
Visit Reason
The inspection was conducted as a renewal visit to review compliance with licensing regulations and verify the submitted plan of correction was fully implemented.
Findings
The inspection identified multiple deficiencies including delays in providing requested records, late incident reporting, confidentiality breaches, outdated staff contact lists, unsecured poisonous materials, trash outside the home, inoperable bathroom ventilation, water pressure issues, unsecured light fixtures, lack of bedside lighting, missing freezer thermometers, lack of fire department notification documentation, incomplete fire drill records, incomplete resident evacuation during fire drills, discontinued medications on the medication cart, and missing directions for key-locking devices. All deficiencies had plans of correction accepted and were implemented by September 2025.
Deficiencies (16)
| Description |
|---|
| Delay in providing requested medication administration training records. |
| Incident reports for resident death and smoke detector activation were not reported within required 24 hours. |
| Resident medical records were accessible on an unlocked medication cart computer and binders. |
| Outdated staff contact list provided to the Department including staff not employed for over 2 years. |
| Hand sanitizer with poison warning was unlocked and accessible in the Memory Care Unit Kitchenette. |
| Trash including cardboard, empty bags, wood pallets, and furniture was found outside the dumpster. |
| Bathroom in resident room lacked operable window or ventilation fan; fan was inoperable. |
| No water coming out of bathroom sink faucet in resident room. |
| Light fixture on porch outside Secure Dementia Care Unit exit was hanging down approximately 2 inches. |
| Resident room lacked an operable lamp or other source of lighting at bedside. |
| No thermometer in small freezer in the Secured Dementia Care Unit kitchenette. |
| No documentation of written notification to local fire department regarding home address, bedroom locations, and evacuation assistance. |
| Fire drill records lacked am/pm designation, time, number of residents in home, and number evacuated. |
| During fire drill, one resident did not evacuate to designated meeting place away from building or within fire-safe area. |
| Discontinued medication found on medication cart. |
| Directions for operating key-locking devices at Secure Dementia Care Unit exit gate were not conspicuously posted. |
Report Facts
License Capacity: 70
Residents Served: 51
Secured Dementia Care Unit Capacity: 25
Secured Dementia Care Unit Residents Served: 21
Current Hospice Residents: 4
Residents Age 60 or Older: 51
Residents with Mobility Need: 22
Residents with Physical Disability: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director | Executive Director | Named in multiple findings including delay in providing records, incident reporting, confidentiality breaches, and training. |
| Director of Nursing | Director of Nursing | Named in findings related to delay in providing records, incident reporting, confidentiality, training, and monitoring. |
| Memory Care Coordinator | Memory Care Coordinator | Named in findings related to incident reporting, confidentiality, medication audit, and training. |
| Regional Director of Operations | Regional Director of Operations | Provided training on multiple regulations including incident reporting, confidentiality, criminal background checks, and fire safety. |
| Regional Maintenance Director | Regional Maintenance Director | Responsible for repairs and audits related to bathroom ventilation, water pressure, and light fixtures. |
| Dining Director | Dining Director | Involved in training and monitoring related to poisonous materials and trash management. |
Inspection Report
Census: 50
Capacity: 70
Deficiencies: 0
May 22, 2025
Visit Reason
The inspection was conducted as a partial, unannounced visit due to an incident at the facility.
Findings
No regulatory citations or deficiencies were identified during this inspection.
Report Facts
License Capacity: 70
Residents Served: 50
Secured Dementia Care Unit Capacity: 24
Secured Dementia Care Unit Residents Served: 21
Current Hospice Residents: 5
Residents Age 60 or Older: 50
Residents with Mobility Need: 30
Inspection Report
Census: 59
Capacity: 70
Deficiencies: 0
Nov 8, 2024
Visit Reason
The inspection was conducted as a licensing inspection by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing, with the reason stated as 'Incident'.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
License Capacity: 70
Residents Served: 59
Secured Dementia Care Unit Capacity: 25
Secured Dementia Care Unit Residents Served: 21
Hospice Current Residents: 4
Residents Age 60 or Older: 59
Residents with Mobility Need: 37
Residents with Physical Disability: 3
Resident Support Staff: 0
Total Daily Staff: 96
Waking Staff: 72
Inspection Report
Renewal
Census: 57
Capacity: 70
Deficiencies: 7
Sep 19, 2024
Visit Reason
The inspection was conducted as a renewal visit for the facility's license, including a full unannounced inspection on 09/19/2024 and 09/25/2024.
Findings
The inspection found multiple deficiencies related to staff qualifications, food safety, medication administration documentation, emergency egress, support plan documentation, and key-locking device signage. All deficiencies had plans of correction accepted and were implemented by 10/22/2024.
Deficiencies (7)
| Description |
|---|
| Direct care staff person A lacked documentation of a U.S. high school diploma or GED. |
| Unlabeled and undated leftover food items found in refrigerators in the 200 and 300 commons areas. |
| Ice cream freezer temperature was 15 degrees, above the required 0°F. |
| A walker was blocking the emergency exit to the courtyard, and the 200 hallway exit door required excessive force to open. |
| A dose of PRN morphine was administered but not documented on the Medication Administration Record (MAR). |
| Resident #1's support plan did not include required documentation for the use of a Halo Safety Ring device. |
| Directions for operating an electronic locking device on the courtyard gate were not posted. |
Report Facts
License Capacity: 70
Residents Served: 57
Secured Dementia Care Unit Capacity: 25
Secured Dementia Care Unit Residents Served: 20
Current Hospice Residents: 3
Residents with Mobility Need: 28
Residents 60 Years or Older: 57
Residents with Physical Disability: 3
Inspection Report
Follow-Up
Census: 59
Capacity: 70
Deficiencies: 2
Aug 20, 2024
Visit Reason
The inspection was a partial, unannounced visit conducted due to an incident, with a focus on reviewing the submitted plan of correction.
Findings
The facility was found to have deficiencies related to incomplete medical evaluations and failure to follow prescriber's orders for medication administration. The submitted plan of correction was determined to be fully implemented as of the follow-up review.
Deficiencies (2)
| Description |
|---|
| Resident Document of Medical Evaluation (DME) did not include an indication of mobility need; the section was blank. |
| Resident's blood sugar was not tested as ordered and medication was not administered according to prescriber's directions. |
Report Facts
License Capacity: 70
Residents Served: 59
Memory Care Unit Capacity: 25
Memory Care Unit Residents Served: 21
Hospice Current Residents: 4
Residents Age 60 or Older: 59
Residents with Mobility Need: 37
Residents with Physical Disability: 3
Total Daily Staff: 96
Waking Staff: 72
Inspection Report
Complaint Investigation
Census: 59
Capacity: 70
Deficiencies: 0
Jul 31, 2024
Visit Reason
The inspection was conducted as a complaint and incident investigation during an unannounced partial licensing inspection.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Complaint Details
The inspection was complaint-related and incident-related; no deficiencies or citations were substantiated.
Report Facts
License Capacity: 70
Residents Served: 59
Secured Dementia Care Unit Capacity: 25
Secured Dementia Care Unit Residents Served: 23
Hospice Current Residents: 7
Residents Age 60 or Older: 59
Residents with Mobility Need: 32
Residents with Physical Disability: 3
Inspection Report
Follow-Up
Census: 52
Capacity: 70
Deficiencies: 1
May 9, 2024
Visit Reason
The inspection was a partial, unannounced follow-up visit triggered by an incident to review the submitted plan of correction for the facility.
Findings
The submitted plan of correction was determined to be fully implemented, with continued compliance required. The main deficiency involved incomplete or inadequate documentation of medical evaluations for residents in the secured dementia care unit, specifically lacking the required diagnosis terminology.
Deficiencies (1)
| Description |
|---|
| Resident documentation of medical evaluation (DME) form indicating the resident requires secure dementia care was not completed timely and did not indicate the resident has a diagnosis of dementia or Alzheimer's disease as required. |
Report Facts
License Capacity: 70
Residents Served: 52
Secured Dementia Care Unit Capacity: 25
Residents in Secured Dementia Care Unit: 18
Current Hospice Residents: 4
Resident Support Staff: 79
Waking Staff: 59
Residents with Mobility Need: 27
Residents with Physical Disability: 2
Residents 60 Years or Older: 52
Inspection Report
Census: 50
Capacity: 70
Deficiencies: 0
Mar 27, 2024
Visit Reason
The inspection was an unannounced partial licensing inspection conducted as an interim visit on 03/27/2024.
Findings
No regulatory citations or deficiencies were identified during this inspection.
Report Facts
Residents Served: 50
License Capacity: 70
Current Hospice Residents: 4
Resident Support Staff: 1
Total Daily Staff: 69
Waking Staff: 52
Residents Age 60 or Older: 50
Residents with Mobility Need: 18
Residents with Physical Disability: 3
Inspection Report
Renewal
Census: 42
Capacity: 70
Deficiencies: 5
Nov 2, 2023
Visit Reason
The inspection was conducted as a renewal inspection of the facility's license.
Findings
The facility had several deficiencies related to annual staff training on Resident Rights, improper food storage, medication storage procedures, and medication record documentation. All deficiencies had accepted plans of correction which were fully implemented by the time of the report.
Deficiencies (5)
| Description |
|---|
| Staff person A did not have annual training in the required topic Resident Rights for the 2022 training year. |
| In the main kitchen's freezer there was a plastic bag of frozen chicken that was not sealed properly. |
| The home did not have proper procedures implemented for the safe storage, access, security, distribution and use of medications and medical equipment by trained staff persons. |
| Resident #1's medication administration record had an error in documentation of the 8am medication reading. |
| Resident #2's medication administration record was not accurately documented when a medication was held as ordered. |
Report Facts
License Capacity: 70
Residents Served: 42
Total Daily Staff: 53
Waking Staff: 40
Residents with Mobility Need: 11
Residents 60 Years or Older: 42
Inspection Report
Complaint Investigation
Census: 43
Capacity: 70
Deficiencies: 0
Mar 14, 2023
Visit Reason
The inspection was conducted as a complaint investigation at the facility on 03/14/2023.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Complaint Details
The inspection was complaint-related; no deficiencies or citations were substantiated.
Report Facts
License Capacity: 70
Residents Served: 43
Current Residents in Hospice: 3
Residents Age 60 or Older: 43
Residents with Mobility Need: 14
Residents with Physical Disability: 2
Total Daily Staff: 57
Waking Staff: 43
Inspection Report
Renewal
Census: 37
Capacity: 70
Deficiencies: 11
Aug 2, 2022
Visit Reason
The inspection was conducted as a renewal, complaint, and incident review of the facility.
Findings
Multiple deficiencies were identified including staff qualification documentation, fire safety orientation, hot water temperature exceeding limits, outdated food labeling, lack of furnace inspection documentation, fire drill scheduling issues, dietary needs documentation errors, and medication administration training deficiencies.
Deficiencies (11)
| Description |
|---|
| Direct care staff person A lacked documentation of high school diploma, GED, or active nurse aide registry status. |
| Staff persons A, B, and C did not complete first day orientation on fire safety and emergency preparedness. |
| Hot water temperature measured 125.6°F in a resident room, exceeding the 120°F limit. |
| Outdated or unlabeled food items found in the reach-in freezer. |
| No documentation that the gas boiler was cleaned or inspected annually as required. |
| Fire drills were routinely conducted between the 26th and 31st of the month, not on varied days and times. |
| Resident #1's dietary needs were not properly documented or followed according to prescribed orders. |
| Staff person B lacked documentation of completed medication administration training and annual practicum. |
| Staff person B did not successfully complete Department-approved medication administration course but was scheduled to administer medications. |
| No medication administration training record for staff person B who administered medications. |
| Resident #1 and Resident #2's support plans did not indicate they were on special diets as required. |
Report Facts
License Capacity: 70
Residents Served: 37
Staffing Hours: 49
Waking Staff: 37
Hot Water Temperature: 125.6
Completion Dates: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff person A | Named in deficiencies related to lack of qualification documentation and incomplete fire safety orientation. | |
| Staff person B | Med-Tech | Named in deficiencies related to medication administration training, insulin injection training, and lack of training records. |
| Staff person C | Named in deficiency related to incomplete fire safety orientation. | |
| Resident #1 | Named in deficiencies related to dietary needs and support plan documentation. | |
| Resident #2 | Named in deficiency related to support plan dietary documentation. |
Inspection Report
Renewal
Deficiencies: 0
Sep 24, 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
Renewal
Deficiencies: 0
Jul 12, 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.
Notice
Capacity: 70
Deficiencies: 0
Jun 30, 2021
Visit Reason
The document serves as a renewal notification and license issuance for the Personal Care Home 'Elmcroft of Reading' following receipt of the renewal application dated April 6, 2021.
Findings
The Department issued a regular license in response to the renewal application and advised that an onsite annual inspection will be conducted within the next twelve months to ensure compliance with applicable regulations.
Report Facts
Maximum licensed capacity: 70
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary, Office of Long-term Living | Signed the renewal notification letter |
Inspection Report
Renewal
Census: 31
Capacity: 70
Deficiencies: 9
Jun 22, 2021
Visit Reason
The inspection was conducted as a renewal inspection combined with a complaint investigation at Elmcroft of Reading.
Findings
The inspection identified multiple deficiencies including issues with contract signatures, combustible storage, smoke detector testing, medical evaluation documentation, medication storage procedures, medication record accuracy, following prescriber's orders, preadmission screening, and support plan signatures. Plans of correction were accepted and documented for all deficiencies.
Complaint Details
The inspection included a complaint investigation component as indicated by the reason for visit: Renewal, Complaint.
Deficiencies (9)
| Description |
|---|
| Resident #1 refused to sign the new resident contract despite not being incapacitated. |
| A dryer sheet was located behind the dryer near the kitchen, posing a possible fire hazard. |
| Smoke detectors and fire alarms were not tested monthly for operability as required. |
| Resident #1’s medical evaluation was incomplete, missing body positioning information. |
| Resident #3's glucometer was not calibrated with the correct day and time. |
| Staff incorrectly transcribed Resident #2’s daily weights on the medication administration record on multiple occasions. |
| Resident #2’s doctor was not contacted despite weight gains meeting parameters requiring notification. |
| Resident #1’s preadmission screening was incomplete and did not indicate if the home could meet the resident's needs. |
| Resident #1’s support plan was not signed by the resident, with no indication of refusal or inability to sign. |
Report Facts
License Capacity: 70
Residents Served: 31
Total Daily Staff: 42
Waking Staff: 32
Completion Dates: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff Person A | Named in medication record deficiency for incorrectly transcribing Resident #2’s daily weights. | |
| Nurse Manager | Nurse Manager | Re-educated staff on glucometer calibration and medication administration. |
Inspection Report
Renewal
Deficiencies: 0
Mar 23, 2021
Visit Reason
The inspection was conducted as part of the Pennsylvania Department of Human Services, Bureau of Human Service Licensing's licensing inspections of the facility.
Findings
No regulatory citations were identified as a result of this inspection.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Anne Graziano | Signed the inspection report letter |
Inspection Report
Renewal
Deficiencies: 0
Mar 17, 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.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Anne Graziano | Signed the inspection report letter |
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