Inspection Report
Complaint Investigation
Census: 105
Capacity: 119
Deficiencies: 0
Sep 11, 2025
Visit Reason
The inspection was conducted as a complaint and incident investigation at the facility.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Complaint Details
The inspection was complaint-related and unannounced. No deficiencies were found, and no follow-up was required.
Report Facts
License Capacity: 119
Residents Served: 105
Secured Dementia Care Unit Capacity: 52
Secured Dementia Care Unit Residents Served: 52
Hospice Current Residents: 14
Resident Age 60 or Older: 105
Residents with Mobility Need: 55
Resident Support Staff: 0
Total Daily Staff: 160
Waking Staff: 120
Inspection Report
Follow-Up
Census: 107
Capacity: 119
Deficiencies: 5
Aug 5, 2025
Visit Reason
The inspection was a partial, unannounced follow-up visit conducted on 08/05/2025 to review the submitted plan of correction and verify compliance with prior deficiencies.
Findings
The facility was found to have fully implemented the submitted plan of correction. Deficiencies related to record confidentiality, abuse, combustible storage, medication storage procedures, and following prescriber's orders were addressed with corrective actions and ongoing quality assurance plans.
Deficiencies (5)
| Description |
|---|
| Laptop on medication cart was unlocked and accessible to residents' records in the Memory Care Resident Living Room/TV Common-Area. |
| Resident bruising and verbal abuse by staff person A, including rushed care and disrespectful behavior. |
| Large white blanket observed behind commercial dryer directly underneath external duct, posing combustible storage hazard. |
| Resident's PRN medication was missing from medication cart; continuous glucose monitoring device data inaccessible to staff. |
| Resident received incorrect insulin dose (8 units instead of 6 units) based on sliding scale blood glucose reading. |
Report Facts
License Capacity: 119
Residents Served: 107
Secured Dementia Care Unit Capacity: 52
Secured Dementia Care Unit Residents Served: 51
Current Hospice Residents: 12
Residents with Mobility Need: 54
Inspection Report
Renewal
Census: 101
Capacity: 119
Deficiencies: 18
Jun 12, 2025
Visit Reason
The inspection was conducted as a renewal visit with an incident review on 06/12/2025 at the facility CHESTNUT KNOLL.
Findings
The inspection identified multiple deficiencies including record confidentiality breaches, compliance with laws, criminal background check lapses, training deficiencies, unsafe storage of poisonous materials, uncovered trash receptacles, improper food storage, obstructed egress, incorrect fire department notification, combustible storage issues, overdue fire extinguisher inspections, smoking policy violations, medication storage and administration errors, incomplete preadmission screening forms, missing mobility assessments, and inadequate posting of key-locking device instructions. Plans of correction were accepted and many corrective actions were implemented by the time of report.
Deficiencies (18)
| Description |
|---|
| Laptop on medication cart was unlocked and accessible to residents' records. |
| Carbon monoxide monitor batteries were not labeled with installation dates. |
| Criminal background check was not requested prior to staff start date. |
| Staff did not receive required training on meeting residents' needs as described in preadmission screening and support plans. |
| Staff did not receive annual fire safety training by a fire safety expert. |
| Unlocked hand sanitizer accessible to residents in secure dementia unit. |
| Trash cans in kitchens were uncovered and unattended. |
| Opened and unsealed bowls of vanilla ice cream in freezer. |
| Exit door in personal care area required excessive force to open due to sticking. |
| Incorrect resident capacity listed in written notification to local fire department. |
| Lint observed blowing through exterior dryer vent lint bags. |
| Fire extinguishers on top floor not inspected by fire safety expert since May 2024. |
| Staff smoking and vaping in prohibited area outside ground floor exit. |
| PRN medications missing from medication cart; glucometer reading incorrectly recorded. |
| Medications administered contrary to prescriber's hold parameters based on blood pressure readings. |
| Preadmission screening forms incomplete or undated, missing key resident needs information. |
| Resident mobility assessment missing from resident's assessment. |
| Directions for operating key-locking device not conspicuously posted near exit door from Secure Dementia Care Unit. |
Report Facts
License Capacity: 119
Residents Served: 101
Memory Care Capacity: 52
Memory Care Residents Served: 50
Current Hospice Residents: 14
Residents Age 60 or Older: 101
Residents with Mobility Needs: 53
Total Daily Staff: 154
Waking Staff: 116
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff Person A | Named in criminal background check deficiency. | |
| Staff Person B | Named in training deficiencies and fire safety training deficiency. | |
| Staff Person C | Named in fire safety training deficiency; resigned employment. | |
| Staff Person D | Named in fire safety training deficiency. | |
| Staff Person E | Named in fire safety training deficiency. | |
| Staff Person F | Named in fire safety training deficiency. | |
| Staff Person G | Named in fire safety training deficiency. |
Inspection Report
Follow-Up
Census: 58
Capacity: 119
Deficiencies: 4
May 20, 2025
Visit Reason
The inspection was a partial, unannounced follow-up visit triggered by an incident to review the submitted plan of correction and verify compliance.
Findings
The facility was found to have medication administration errors including administering discontinued medications and not following prescriber's orders for medication strength and frequency. Additionally, residents did not sign their support plans as required. Corrective actions including re-education of staff, audits, and physician consultations were implemented and the plan of correction was accepted.
Deficiencies (4)
| Description |
|---|
| Medication administration error: failure to verify correct medication strength, resulting in a resident receiving incorrect medication. |
| Discontinued medication was found in the medication cart and administered in error. |
| Failure to follow prescriber's orders regarding medication strength and frequency, resulting in incorrect administration. |
| Residents participated in support plan development but did not sign the support plans. |
Report Facts
License Capacity: 119
Residents Served: 58
Secured Dementia Care Unit Capacity: 52
Secured Dementia Care Unit Residents Served: 51
Current Residents in Hospice: 13
Residents Age 60 or Older: 58
Residents with Mobility Need: 52
Total Daily Staff: 110
Waking Staff: 83
Inspection Report
Follow-Up
Census: 102
Capacity: 119
Deficiencies: 1
May 13, 2025
Visit Reason
The inspection visit on 05/13/2025 was conducted as a partial, unannounced follow-up to review the implementation of a previously submitted plan of correction related to an incident.
Findings
The submitted plan of correction was determined to be fully implemented as of the review date. The report details corrective actions taken to update resident support plans following falls and ongoing quality assurance measures to ensure compliance.
Deficiencies (1)
| Description |
|---|
| The support plan for a resident was not updated in a timely manner to address their fall history and ensure safety. |
Report Facts
License Capacity: 119
Residents Served: 102
Secured Dementia Care Unit Capacity: 52
Secured Dementia Care Unit Residents Served: 50
Current Hospice Residents: 10
Resident Mobility Need: 51
Inspection Report
Follow-Up
Census: 102
Capacity: 119
Deficiencies: 1
Mar 6, 2025
Visit Reason
The inspection visit was conducted as a follow-up to verify the implementation of a submitted plan of correction related to an incident at the facility.
Findings
The submitted plan of correction was determined to be fully implemented. The report details an incident involving abuse between residents, the immediate corrective actions taken, ongoing monitoring, and additional supportive measures including counseling and staff training.
Complaint Details
The visit was incident-related, triggered by an abuse complaint involving two residents. The abuse was substantiated with police and medical involvement, and ongoing monitoring and corrective actions were documented.
Deficiencies (1)
| Description |
|---|
| A resident was found lying on top of another resident inappropriately, with both residents' clothing disarranged, constituting abuse and neglect. |
Report Facts
License Capacity: 119
Residents Served: 102
Secured Dementia Care Unit Capacity: 52
Secured Dementia Care Unit Residents Served: 48
Hospice Current Residents: 12
Residents Age 60 or Older: 102
Residents with Mobility Need: 51
Staff Total Daily Staff: 153
Staff Waking Staff: 115
Inspection Report
Complaint Investigation
Census: 51
Capacity: 119
Deficiencies: 0
Jan 15, 2025
Visit Reason
The inspection was conducted as a complaint investigation with an unannounced partial inspection on 01/15/2025.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Complaint Details
The inspection was complaint-related, but no deficiencies or citations were found, indicating no substantiated issues.
Report Facts
License Capacity: 119
Residents Served: 51
Secured Dementia Care Unit Capacity: 52
Secured Dementia Care Unit Residents Served: 47
Hospice Current Residents: 13
Residents Age 60 or Older: 98
Residents with Mobility Need: 49
Resident Support Staff: 0
Total Daily Staff: 100
Waking Staff: 75
Inspection Report
Census: 101
Capacity: 119
Deficiencies: 0
Oct 22, 2024
Visit Reason
The inspection was an unannounced partial licensing inspection conducted due to an incident.
Findings
No regulatory citations or deficiencies were identified during the inspection.
Report Facts
Resident census served: 101
Licensed capacity: 119
Secured Dementia Care Unit capacity: 52
Secured Dementia Care Unit residents served: 47
Residents age 60 or older: 101
Residents with mobility need: 49
Resident Support Staff hours: 0
Total Daily Staff hours: 150
Waking Staff hours: 113
Inspection Report
Renewal
Census: 108
Capacity: 119
Deficiencies: 5
Jul 30, 2024
Visit Reason
The inspection was conducted as a renewal visit with an incident review, including a full unannounced inspection on 07/30/2024 and 07/31/2024.
Findings
The facility was found to have multiple deficiencies related to resident safety and medication management, including lack of operable bedside lighting, discontinued and expired medications present in the medication carts, incorrect medication labeling, and missing PRN medications. The submitted plan of correction was accepted and fully implemented.
Deficiencies (5)
| Description |
|---|
| Resident #1 did not have access to a source of light that can be turned on/off at bedside. |
| Resident #2 had discontinued medications (Simvastatin and Warfarin) still in the medication cart; Resident #4 had discontinued Levothyroxine in the med cart. |
| Resident #3 had expired medications (Humolog Kwikpen and Haloperidol) in the medication cart at time of inspection. |
| Resident #2's Warfarin medication label directions did not match the current order; Resident #5's medication label had incorrect directions. |
| Resident #3's Geritussin PRN and Resident #4's acetaminophen and eye drops PRN were missing from the medication cart at time of inspection. |
Report Facts
License Capacity: 119
Residents Served: 108
Secured Dementia Care Unit Capacity: 52
Secured Dementia Care Unit Residents Served: 50
Hospice Residents: 11
Residents with Mobility Need: 53
Total Daily Staff: 161
Waking Staff: 121
Inspection Report
Follow-Up
Census: 106
Capacity: 119
Deficiencies: 1
Apr 16, 2024
Visit Reason
The inspection visit on 04/16/2024 was a partial, unannounced follow-up to review the implementation of a previously submitted plan of correction related to an incident.
Findings
The submitted plan of correction was determined to be fully implemented as of the inspection date. The report details an incident involving resident abuse by a staff member, who was suspended and subsequently terminated. Ongoing monitoring and education measures were put in place.
Deficiencies (1)
| Description |
|---|
| A resident was physically abused by a staff member who struck the resident on the arm after the resident punched the staff member. |
Report Facts
License Capacity: 119
Residents Served: 106
Residents Served in Secured Dementia Care Unit: 49
Capacity of Secured Dementia Care Unit: 52
Current Hospice Residents: 16
Residents 60 Years or Older: 111
Residents with Mobility Need: 54
Total Daily Staff: 160
Waking Staff: 120
Inspection Report
Renewal
Census: 104
Capacity: 119
Deficiencies: 7
Aug 16, 2023
Visit Reason
The inspection was conducted as a renewal visit with an incident review, including an unannounced full inspection on 08/16/2023 and 08/17/2023.
Findings
The facility was found to have multiple deficiencies including abuse, hot water temperature exceeding limits, medication labeling and administration errors, glucometer calibration issues, and incomplete support plans. The submitted plan of correction was determined to be fully implemented as of the follow-up date.
Deficiencies (7)
| Description |
|---|
| Resident abuse incident involving inappropriate contact between residents. |
| Hot water temperature in resident-accessible areas exceeded 120°F. |
| Prescription medications lacked dosage information on pharmacy labels. |
| Glucometer was not calibrated to the correct time. |
| Medication Administration Record did not indicate dosage for a supplemental medication. |
| Medications were administered despite prescriber orders to hold under certain conditions. |
| Resident Assessment and Support Plan did not indicate dietary needs, only referred to MD orders. |
Report Facts
License Capacity: 119
Residents Served: 104
Secured Dementia Care Unit Capacity: 52
Secured Dementia Care Unit Residents Served: 48
Hospice Current Residents: 11
Resident with Mobility Need: 51
Staffing Hours - Total Daily Staff: 155
Staffing Hours - Waking Staff: 116
Water Temperature: 122.3
Water Temperature: 123.3
Water Temperature: 122.4
Inspection Report
Census: 97
Capacity: 119
Deficiencies: 0
May 25, 2023
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 the inspection conducted on 05/25/2023, 05/31/2023, and 06/02/2023.
Report Facts
License Capacity: 119
Residents Served: 97
Secured Dementia Care Unit Capacity: 52
Secured Dementia Care Unit Residents Served: 45
Current Residents in Hospice: 11
Residents Age 60 or Older: 97
Residents with Mental Illness: 1
Residents with Mobility Need: 46
Inspection Report
Complaint Investigation
Census: 99
Capacity: 119
Deficiencies: 4
Apr 12, 2023
Visit Reason
The inspection was conducted as a complaint investigation and incident review at the facility on 04/12/2023.
Findings
The inspection found violations related to failure to immediately report suspected resident abuse incidents involving residents in the secure dementia care unit. The facility submitted a plan of correction which was accepted and deemed fully implemented by the follow-up review.
Complaint Details
The complaint involved incidents of suspected resident abuse including inappropriate touching and sexual contact between residents in the secure dementia care unit. The facility initially did not report the incidents as abuse but was found to be non-compliant with reporting requirements. The facility disagreed with the abuse determination but implemented corrective actions including staff education, increased supervision, and updated support plans.
Deficiencies (4)
| Description |
|---|
| Failure to immediately report suspected abuse of Resident #1 exposing themselves and grabbing Resident #2's hand in the secure dementia care unit. |
| Failure to report the incident to the Department’s personal care home regional office within 24 hours as required. |
| Resident #1 and Resident #3 involved in inappropriate sexual contact in Resident #1's bedroom in the secure dementia care unit, not reported as abuse. |
| Resident #1's support plan was not updated to reflect interactions and behaviors requiring periodic 1:1 care. |
Report Facts
License Capacity: 119
Residents Served: 99
Secure Dementia Care Unit Capacity: 52
Secure Dementia Care Unit Residents Served: 44
Current Hospice Residents: 9
Residents Age 60 or Older: 99
Residents Diagnosed with Mental Illness: 1
Residents with Mobility Need: 46
Inspection Report
Complaint Investigation
Census: 110
Capacity: 119
Deficiencies: 1
Feb 9, 2023
Visit Reason
The inspection was conducted as a complaint and incident investigation following an event involving two residents that resulted in injury.
Findings
The investigation found that Resident 1 grabbed Resident 2 after an argument over the TV, leading to both residents falling and Resident 2 fracturing their hip, requiring hospitalization. The facility implemented corrective actions including monitoring, psychiatric evaluations, and behavior agreements signed by both residents.
Complaint Details
The visit was complaint-related and involved an incident where Resident 1 and Resident 2 had a physical altercation resulting in Resident 2's hip fracture and hospitalization. The incident was reported to families, physicians, Office of Aging, Eastern Berks Regional Police, and BHSL. Psychiatric evaluations and behavior agreements were implemented. No further incidents have occurred since Resident 2's return.
Deficiencies (1)
| Description |
|---|
| Resident 1 grabbed Resident 2 after an argument over the TV, causing both to fall and Resident 2 to fracture their hip requiring hospitalization. |
Report Facts
License Capacity: 119
Residents Served: 110
Secured Dementia Care Unit Capacity: 52
Secured Dementia Care Unit Residents Served: 51
Current Hospice Residents: 12
Residents Age 60 or Older: 110
Residents with Mobility Need: 53
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Holly Heydt | Administrator | Named as facility administrator in report |
| Unnamed Executive Director | Executive Director | Involved in managing the incident between residents and follow-up actions |
Inspection Report
Census: 107
Capacity: 119
Deficiencies: 0
Aug 22, 2022
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
Resident Support Staff: 107
Total Daily Staff: 264
Waking Staff: 198
License Capacity: 119
Residents Served: 107
Secured Dementia Care Unit Capacity: 52
Secured Dementia Care Unit Residents Served: 47
Hospice Current Residents: 18
Residents Who Have Mobility Need: 50
Residents Who Are 60 Years of Age or Older: 107
Inspection Report
Renewal
Census: 108
Capacity: 119
Deficiencies: 2
May 24, 2022
Visit Reason
The inspection was conducted as a renewal visit with an incident review, unannounced, to assess compliance with licensing requirements.
Findings
The facility was found to have previously not posted the current license inspection summary conspicuously, which was corrected during the inspection. Medication administration errors related to not following prescriber's orders with parameters were identified and addressed with staff re-education and ongoing monitoring.
Deficiencies (2)
| Description |
|---|
| The home's license inspection summary report dated 03/31/21 was not posted conspicuously in the home. |
| Failure to follow prescriber's orders regarding medication administration parameters for multiple residents, resulting in medications not being held as ordered. |
Report Facts
License Capacity: 119
Residents Served: 108
Secured Dementia Care Unit Capacity: 52
Secured Dementia Care Unit Residents Served: 18
Hospice Residents: 18
Residents with Mobility Need: 56
Total Daily Staff: 164
Waking Staff: 123
Inspection Report
Routine
Deficiencies: 0
Feb 4, 2022
Visit Reason
The inspection was conducted as a routine licensing inspection by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Inspection Report
Renewal
Deficiencies: 0
Jan 12, 2022
Visit Reason
The inspection visits on 01/12/2022, 01/14/2022, and 01/18/2022 were 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 these inspections.
Notice
Capacity: 119
Deficiencies: 0
Jun 16, 2021
Visit Reason
The document serves as a certificate of compliance and notification of license renewal for the Personal Care Home 'Chestnut Knoll'. It informs the facility that an annual onsite inspection will be conducted within the next twelve months as required by regulation.
Findings
No inspection findings are reported in this document. It confirms issuance of a regular license following the renewal application and advises that enforcement action will be taken if noncompliance is found during future inspections.
Report Facts
Maximum capacity: 119
Secure Dementia Care Unit capacity: 52
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary, Office of Long-term Living | Signed the renewal license notification letter |
Inspection Report
Follow-Up
Census: 88
Capacity: 119
Deficiencies: 1
Apr 19, 2021
Visit Reason
The inspection was conducted as a follow-up to verify the implementation of a previously submitted plan of correction related to an incident at the facility.
Findings
The submitted plan of correction was determined to be fully implemented, with no long-term ill effects reported from the medication administration error. The facility has instituted a new process involving weekly pharmacy reports to prevent similar errors.
Deficiencies (1)
| Description |
|---|
| Chestnut Knoll staff failed to contact resident #1's ophthalmologist to clarify medication orders, resulting in missed administration of Prednisolone acetate 1% eye drops after 3/31/21 as prescribed. |
Report Facts
Residents Served: 88
License Capacity: 119
Secured Dementia Care Unit Capacity: 52
Secured Dementia Care Unit Residents Served: 43
Residents with Mobility Need: 48
Residents Age 60 or Older: 88
Inspection Report
Renewal
Census: 89
Capacity: 119
Deficiencies: 6
Mar 30, 2021
Visit Reason
The inspection was conducted as a renewal review of the facility's compliance with licensing requirements on 03/30/2021 and 03/31/2021.
Findings
The facility was found to have multiple deficiencies related to record confidentiality, sanitary conditions, lint removal, medication prescription currency, medication labeling, and medication storage procedures. All deficiencies had plans of correction accepted and were implemented by the facility.
Deficiencies (6)
| Description |
|---|
| EMARS were unlocked and accessible on the medication cart, exposing confidential resident information. |
| Blood glucose monitor for Resident #1 had dried blood on the front of the machine. |
| Accumulation of lint approximately the size of a golf ball in the lint trap of the dryer in the resident laundry room. |
| Medication cart contained an expired Advair Diskus prescribed for Resident #2. |
| Medication label for Resident #1's Lantus insulin had incorrect dosage instructions compared to the medication record. |
| Narcotic sheet was not signed by the outgoing 1st shift staff member on 3/4 and 3/5/21 as required by medication policy. |
Report Facts
License Capacity: 119
Residents Served: 89
Secured Dementia Care Unit Capacity: 52
Secured Dementia Care Unit Residents Served: 38
Current Hospice Residents: 9
Residents Age 60 or Older: 89
Residents with Mobility Need: 43
Total Daily Staff: 132
Waking Staff: 99
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