Inspection Reports for
Christ the King Manor
1100 WEST LONG AVENUE,, DUBOIS, PA, 15801
Back to Facility Profile22 Reports
Inspection Report — May 6, 2026
Complaint Investigation
Date: May 6, 2026
Visit Reason
The inspection was conducted as a partial, unannounced visit due to a complaint and incident involving resident abuse.
Complaint Details
The visit was complaint-related due to an incident where a resident scratched another resident causing significant bleeding. The allegation of abuse was not reported to the local Area Agency on Aging as required.
Findings
The inspection found a failure to immediately report suspected resident abuse to the local Area Agency on Aging, incomplete medical evaluations missing immunization history and secured dementia care unit needs, incomplete resident support plans lacking contact information for outside agencies, and support plans not revised to reflect changes in resident condition. Corrective actions and reeducation were implemented.
Citations (5)
15a - Resident Abuse Report: The facility failed to immediately report suspected abuse when a resident scratched another resident's hand causing significant bleeding.
141a - Medical Evaluation Information: Resident medical evaluations did not include immunization history or the need for a secured dementia care unit.
227d - Support Plan Medical/Dental: Resident support plans did not include contact information for all outside agencies providing health care support.
234d - Support Plan Revision: A resident's support plan was not revised to address increased aggression and was incomplete in areas such as hallucinations and communication of needs.
251c - Standardized Forms: Resident medical evaluation was not completed on the Department’s current standardized form.
Report Facts
Residents Served: 50
Secured Dementia Care Unit Residents Served: 15
Residents Age 60 or Older: 50
Residents with Mobility Need: 17
Inspection Report — Jan 20, 2026
Follow-Up
Date: Jan 20, 2026
Visit Reason
The inspection was a partial, unannounced follow-up visit triggered by a complaint and incident to review the submitted plan of correction for the facility.
Complaint Details
The visit was complaint-related and incident-driven, involving physical aggression between residents and other care concerns. The submitted plan of correction was reviewed and accepted.
Findings
The facility was found to have multiple deficiencies related to resident care including physical aggression incidents, privacy violations due to video recording without signage, medication administration record errors, refusal of medication documentation failures, and support plan revision delays. The submitted plans of correction were accepted and implemented.
Citations (6)
23a - Activities of Daily Living Assistance: Residents were involved in physical confrontations causing injuries including falls and pain. Staff failed to prevent or adequately manage these incidents.
42c - Treatment of Residents: An act of physical aggression occurred involving three residents, resulting in significant physical pain and injuries requiring medical attention.
42s - Privacy: Multiple common areas were video recorded without signage indicating recording was in progress.
187a - Medication Record: Medication administration was not properly documented on the Medication Administration Record for a prescribed medication.
187c - Refusal of Medication: The facility failed to notify the prescribing physician within 24 hours after residents refused medications on multiple occasions.
227c - Support Plan Revision: A resident's support plan was not revised timely despite documented hallucinations and behavioral changes.
Report Facts
Residents Served: 52
Residents Served in Secured Dementia Care Unit: 17
Current Hospice Residents: 1
Inspection Report — Jul 1, 2025
Renewal
Date: Jul 1, 2025
Visit Reason
The inspection was conducted as a renewal, complaint, and incident investigation with multiple on-site and off-site review dates between 07/01/2025 and 08/04/2025.
Complaint Details
The inspection included a complaint investigation related to financial abuse by a staff member who forged resident #1's signature on checks. The staff member was terminated prior to discovery, and the facility conducted re-education and notified appropriate authorities. The facility requested removal of the citation based on thorough pre-employment screening.
Findings
The facility was found to have multiple deficiencies including medication administration documentation errors, abuse related to financial exploitation by a staff member, inadequate posting of emergency phone numbers, unlabeled soap in bathrooms, missing thermometer in a freezer, incomplete fire drill records, and issues with key-locking device signage. The submitted plan of correction was fully implemented and compliance was maintained.
Citations (11)
Failure to offer prescribed medication (boric acid/cornstarch) to resident #1 as documented.
Staff person forged resident #1's signature on checks and deposited funds into their own account.
Trash can lid was pushed to the side and garbage was on the floor in men's common bathroom.
Puddle of water approximately 5' x 2' on floor in mechanical room between personal care and secure dementia care unit.
No emergency telephone numbers posted by telephone in personal care kitchenette.
Unlabeled bar of soap found in community shower room of secure dementia care unit.
No thermometer in freezer section of white refrigerator/freezer in personal care activity room.
Fire drill records did not accurately document number of residents evacuated during drills on 4/18/25, 5/5/25, and 6/2/25.
Medication administration records for residents #3 and #4 were not initialed at time of medication administration.
Annual assessments for residents #3 and #5 did not identify use and risks of mobility devices or need for enabler bars; resident #6's assessment did not address increased aggressive behavior and unfounded accusations.
Directions for operating key-locking devices were not conspicuously posted near exit door #11 and exterior activity gate in secure dementia care unit.
Report Facts
Residents Served: 51
Residents in Secured Dementia Care Unit: 15
Residents with Mental Illness: 35
Residents with Mobility Need: 41
Residents 60 Years or Older: 51
Staff Total Daily: 92
Staff Waking: 69
Fire Drill Resident Counts: 54
Fire Drill Residents Evacuated: 52
Fire Drill Resident Counts: 60
Fire Drill Residents Evacuated: 50
Fire Drill Resident Counts: 61
Fire Drill Residents Evacuated: 52
Inspection Report — Mar 21, 2024
Renewal
Date: Mar 21, 2024
Visit Reason
The inspection was conducted as a renewal and complaint investigation to review compliance and the submitted plan of correction.
Findings
Multiple deficiencies were identified including lack of operable bedside lamps, presence of dented food cans, no emergency food supply, dietary needs not met as prescribed, discontinued medications kept, medication labeling inaccuracies, incomplete support plans, and failure to update support plans reflecting resident behavior changes. All corrective actions were accepted and implemented by the facility.
Citations (8)
Resident did not have access to a source of light that could be turned on/off at bedside.
Presence of a dented 4-pound, 2.5 ounce can of tuna in the pantry.
No emergency food and no contract with a food supplier to provide in the event of an emergency.
Resident #5 was served a whole, unaltered slice of pizza despite prescribed diabetic, dysphagia texture diet.
Discontinued medication (Dimetapp Cold and Cough Soln) was kept in the medication cart.
Pharmacy label for resident #3's Loperamide indicated incorrect duration of use.
Resident #2 and #3 assessments did not address need for enabler, intended use, risks, and safety related to device use.
Support plan for resident #4 was not updated to address exit seeking behaviors, aggression, and statements of wanting to die.
Report Facts
Residents served: 54
Staffing hours: 81
Waking staff: 61
Secured Dementia Care Unit residents served: 17
Hospice residents: 1
Residents with mental illness: 21
Residents with mobility need: 27
Residents 60 years or older: 54
Residents receiving Supplemental Security Income: 1
Inspection Report — Nov 21, 2023
Complaint Investigation
Date: Nov 21, 2023
Visit Reason
The inspection was conducted as a complaint investigation following an unwitnessed fall incident involving a resident that was not reported to the Department as required.
Complaint Details
The complaint involved a resident who had an unwitnessed fall in their bedroom, resulting in multiple injuries including a broken nose and abrasions. The incident was not reported to the Department as required by regulations.
Findings
The facility failed to report a resident's unwitnessed fall and injuries to the Department within 24 hours as mandated. The submitted plan of correction was accepted and later fully implemented.
Citations (1)
Failure to report a resident's unwitnessed fall and injuries to the Department within 24 hours as required.
Report Facts
Residents Served: 55
Secured Dementia Care Unit Residents Served: 18
Current Hospice Residents: 2
Residents with Mental Illness: 15
Residents with Mobility Need: 28
Residents 60 Years or Older: 55
Inspection Report — Mar 14, 2023
Renewal
Date: Mar 14, 2023
Visit Reason
The inspection was conducted as a renewal review of the facility's license to ensure compliance with regulatory requirements.
Findings
The inspection identified multiple deficiencies including unsecured enabler bars posing entrapment hazards, lack of emergency telephone numbers by a phone, inaccessible operable lamps at bedside for residents, incomplete fire drill records, improper scheduling and staffing during fire drills, and unclear posting of key locking device operation instructions. Corrective actions were taken and plans of correction were accepted with completion dates in April 2023.
Citations (6)
Unsecured enabler bars attached to beds posed an entrapment hazard for multiple residents.
No emergency telephone numbers posted on or by the telephone in the smoking hut.
Residents #5 and #7 did not have access to a source of light that can be turned on/off at bedside.
Fire drill records did not include that all residents evacuated during multiple fire drills.
Fire drills were routinely held with additional staff persons present, not in compliance with regulations.
Directions for operating the home's locking mechanism were posted but did not clearly indicate the sequential order needed, preventing immediate egress from the Secure Dementia Care Unit.
Report Facts
Residents Served: 55
Residents Served in Alzheimer’s Unit: 18
Fire Drill Resident Counts: 56
Fire Drill Resident Counts: 37
Fire Drill Resident Counts: 53
Fire Drill Resident Counts: 19
Fire Drill Resident Counts: 50
Fire Drill Resident Counts: 35
Fire Drill Resident Counts: 54
Fire Drill Resident Counts: 18
Fire Drill Resident Counts: 53
Fire Drill Resident Counts: 33
Fire Drill Resident Counts: 52
Fire Drill Resident Counts: 19
Total Daily Staff: 74
Waking Staff: 56
Inspection Report — Mar 15, 2022
Renewal
Date: Mar 15, 2022
Visit Reason
The inspection was conducted as a renewal visit with an incident review at Christ The King Manor on March 15-17, 2022.
Findings
The inspection identified multiple deficiencies including failure to implement a plan of supervision after an abuse allegation, refrigerator temperature violations, lint accumulation in dryer vents, medication labeling issues, and improper locking devices on egress doors. Plans of correction were accepted and implemented with follow-up submissions.
Citations (5)
Failure to immediately develop and implement a plan of supervision or suspend staff after an allegation of abuse, allowing unsupervised direct care by involved staff on multiple occasions.
Refrigerator temperatures exceeded required limits, measuring 45°F and 42°F instead of at or below 40°F.
One inch layer of lint found in the industrial lint trap of dryer #2, posing fire hazard risk.
Prescription medications for residents #2 and #4 lacked proper pharmacy labels including resident name, medication name, and instructions.
Interior double glass doors at administration entrance were locked with a magnetic locking system preventing immediate egress, restricting some residents' ability to exit independently.
Report Facts
Residents Served: 55
Residents Served in Dementia Unit: 18
Temperature Reading: 45
Temperature Reading: 42
Lint Layer Thickness: 1
Inspection Report — Dec 8, 2021
Complaint Investigation
Date: Dec 8, 2021
Visit Reason
The inspection was conducted as a complaint investigation with unannounced partial licensing inspections on 12/08/2021 and 12/09/2021.
Complaint Details
The inspection was complaint-related, but no deficiencies were found and no follow-up was required.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Residents Served: 38
Residents Served in Secure Unit: 16
Current Hospice Residents: 1
Residents Age 60 or Older: 54
Residents with Mobility Need: 16
Residents Receiving Supplemental Security Income: 2
Total Daily Staff: 54
Waking Staff: 41
Inspection Report — Jul 7, 2021
Renewal
Date: Jul 7, 2021
Visit Reason
The inspection was conducted as a full, unannounced renewal inspection with complaint components on 07/07/2021 and 07/08/2021 to assess compliance with Department statutes and regulations.
Findings
The inspection identified multiple deficiencies including improper placement of carbon monoxide detectors, lack of signage for video surveillance, unauthorized locking devices, missing emergency procedure postings, incomplete evacuation diagrams, and incomplete resident assessments. Plans of correction were accepted and implemented with follow-up submissions and documentation.
Citations (7)
Carbon monoxide alarms were installed too close to fossil-fuel burning devices, violating the Care Facility Carbon Monoxide Alarms Standards Act.
No signs posted indicating video recording in entrances/exits and medication rooms, and no documentation that residents were informed.
An egress door in the secured dementia care unit was equipped with a magnetic locking system without keypad or immediate unlocking means nearby.
Local municipality emergency procedures were not posted in a conspicuous and public place in the home.
Emergency evacuation diagram in the secured dementia care unit did not indicate all locations of fire extinguishers.
Resident #1’s assessment did not include the use of an enabler bar for safety.
The home lacked written approval for the electronic card system used on the exit door from the secured dementia care unit adult daycare room to the outside parking lot.
Report Facts
Residents Served: 57
Residents Served in Secured Dementia Care Unit: 18
Total Daily Staff: 75
Waking Staff: 56
Residents 60 Years or Older: 57
Residents with Mobility Need: 18
Residents Receiving Supplemental Security Income: 2
Notice — Jun 20, 2021
Date: Jun 20, 2021
Visit Reason
The document serves as a certificate of compliance granting Christ the King Manor the authority to operate as a Personal Care Home and includes a renewal notice confirming receipt of the renewal application and advising of an upcoming annual inspection within the next twelve months.
Findings
No inspection findings are reported; the document confirms issuance of a regular license following the renewal application and states that an annual inspection will be conducted within the next twelve months.
Report Facts
Notice — Mar 4, 2020
Date: Mar 4, 2020
Visit Reason
This document serves as a renewal notification and license issuance for Christ the King Manor, a Personal Care Home, confirming the facility's authorized capacity and informing about the requirement for an annual onsite inspection within the next twelve months.
Findings
No inspection findings are reported in this document. It is a license renewal notice and certificate of compliance.
Report Facts
Inspection Report — Jan 15, 2020
Renewal
Date: Jan 15, 2020
Visit Reason
The inspection was an unannounced renewal inspection conducted by the Pennsylvania Department of Human Services, Bureau of Human Services Licensing.
Findings
The facility was found to have multiple violations including telephone access, poisonous material storage, trash receptacles, food protection, refrigerator/freezer temperatures, medical evaluation documentation, preadmission screening, and no objection statement documentation. All violations were corrected with plans of correction implemented and staff reeducation performed.
Citations (8)
Regulation 42e: A resident shall have access to a telephone in the home to make calls in privacy. Directions to operate phones requiring dialing 9 for outside lines were not posted on or near multiple telephones.
Regulation 82b: Poisonous materials were stored next to food containers on shelves in the food preparation room, risking contamination.
Regulation 85d: There was a half-full, uncovered trash can in the main kitchen, allowing potential penetration of insects and rodents.
Regulation 103c: Food was stored uncovered with actively leaking blood on baking sheets in the main kitchen's walk-in refrigerator.
Regulation 103f: Refrigerator and freezer temperatures were not maintained at required levels; ice cream freezer was 8°F and cooler was 50°F at inspection times.
Regulation 141a: Resident #1's initial medical evaluation did not indicate the resident's height or ability to self-administer medications.
Regulation 224a: Resident #2's preadmission screening form indicated the home could not meet the resident's needs.
Regulation 231e: Resident #2 was admitted to the secured dementia care unit without documentation that the resident or designated person objected to the admission.
Report Facts
Residents Served: 56
Residents Served in Alzheimer's Unit: 19
Current Hospice Residents: 2
Residents with Mobility Need: 20
Residents 60 Years or Older: 56
Inspection Report — Mar 7, 2019
Renewal
Date: Mar 7, 2019
Visit Reason
This document is a renewal application and license issuance for Christ the King Manor, a Personal Care Home, confirming the facility's authorization to operate and stating that the Department will conduct an onsite inspection within the next twelve months as required by law.
Findings
No inspection findings are reported in this document. It serves as a license renewal notification and outlines the requirement for a future inspection.
Report Facts
Inspection Report — Jan 30, 2019
Renewal
Date: Jan 30, 2019
Visit Reason
The inspection was a renewal visit conducted by the Department's Bureau of Human Services Licensing to assess compliance with 55 Pa. Code Chapter 2600 for Christ the King Manor.
Findings
The inspection identified multiple violations including failure to provide quarterly itemized financial statements to a resident, lack of annual fire extinguisher inspections, medication administration errors, and incomplete resident support plans. Plans of correction were submitted and partially implemented with adequate progress noted.
Citations (4)
55 Pa.Code §2600.20(b)(8) - The home failed to provide an itemized account of financial transactions on a quarterly basis to Resident #1 or her designated person.
55 Pa.Code §2600.131(f) - The ansul fire suppression system in the main and small kitchens had not been inspected by a fire safety expert since August 2017.
55 Pa.Code §2600.187(d) - Resident #2 was administered the wrong dosage of Amlodipine Besylate daily from 1/24/19 through 1/30/19.
55 Pa.Code §2600.227(d) - Resident support plans for Residents #1, #3, and #4 lacked necessary details to assist residents with needs such as grab bars and post-transient ischemic attack care.
Report Facts
Number of Residents Served: 56
Number of Deficiencies: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Angela L. Amundson | Administrator | Named as administrator and legal entity representative signing plans of correction. |
Notice — Mar 6, 2018
Date: Mar 6, 2018
Visit Reason
The document serves as a renewal notification and license issuance for Christ the King Manor's Personal Care Home, confirming the facility's authorization to operate and informing about the requirement for annual inspections.
Findings
No inspection findings are reported in this document. It confirms the issuance of a regular license following the renewal application.
Report Facts
Inspection Report — Feb 7, 2018
Renewal
Date: Feb 7, 2018
Visit Reason
The inspection was conducted as an annual licensing renewal inspection for Christ the King Manor, a personal care home, to assess compliance with 55 Pa.Code Chapter 2600.
Findings
The inspection identified violations related to inoperative bedside lamps, delayed fire drill scheduling, and incomplete medical evaluations for residents admitted to the secured dementia care unit. Plans of correction were submitted to address these issues with timelines and responsible staff.
Citations (3)
55 Pa.Code §2600.101(7) - The bedside lamp in resident bedroom #536 was not operational and there was no other source of light at the bedside. Resident bedroom #617 also lacked a lamp or source of light near the bed.
55 Pa.Code §2600.132(e) - The home failed to conduct the required sleeping hour fire drill on time; the drill scheduled for 1/6/18 was delayed past the required six-month interval.
55 Pa.Code §2600.231(b) - Resident #22 was admitted to the secured dementia unit without a completed medical evaluation within 60 days prior to admission as required.
Report Facts
Number of Residents Served: 49
Total Daily Staff: 69
Waking Staff: 52
Number of Residents Served in Secured Dementia Care Unit: 19
Number of Current Hospice Residents: 1
Number of Hospice Residents in Past Year: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Angela L. Amundson | Administrator | Named as legal entity representative and signer of plans of correction |
Notice — Aug 10, 2017
Date: Aug 10, 2017
Visit Reason
Notification of a revised Personal Care Home license and Certificate of Compliance number change due to regional office realignment.
Findings
The document communicates the issuance of a revised license with a maximum capacity of 60 residents and a secure dementia care unit capacity of 20. No inspection findings or deficiencies are reported.
Report Facts
Notice — Mar 2, 2017
Date: Mar 2, 2017
Visit Reason
Notification of renewal application receipt and information about the requirement for an annual onsite inspection within the next twelve months.
Findings
No inspection findings are reported in this document. It serves as a renewal application acknowledgment and license issuance notice.
Report Facts
Inspection Report — Feb 8, 2017
Renewal
Date: Feb 8, 2017
Visit Reason
The inspection was conducted as part of the Department of Human Services' annual licensing renewal inspections on February 8 and 9, 2017, for Christ the King Manor.
Findings
The inspection identified violations related to resident privacy, fire drill evacuation procedures, and resident support plans. Plans of correction were submitted and partially implemented as of June 28, 2017.
Citations (4)
55 Pa.Code §2600 - Resident records were not kept confidential as a posted violation report contained resident names.
55 Pa.Code 2600.132(c) - Fire drill records showed residents in the Secured Dementia Unit did not evacuate to the designated fire safe area during multiple drills.
55 Pa.Code 2600.132(h) - Residents failed to evacuate to a designated meeting place away from the building or fire-safe area during fire drills on specified dates.
55 Pa.Code 2600.227(d) - Resident #1's support plan did not address how the home would meet the needs related to physical therapy and wheelchair use.
Report Facts
Number of Residents Served: 58
Number of Residents Served in Secured Dementia Care Unit: 19
Number of Current Hospice Residents: 2
Number of Residents 60 Years or Older: 58
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Angila L. Amundson | RN Administrator | Named as legal entity representative and administrator signing violation reports and plans of correction. |
Notice — May 3, 2016
Date: May 3, 2016
Visit Reason
Notification of renewal application receipt and information about the requirement for an annual onsite inspection within the next twelve months.
Findings
No inspection findings are reported in this document; it serves as a license renewal notice and certificate of compliance.
Report Facts
Inspection Report — Jan 13, 2016
Renewal
Date: Jan 13, 2016
Visit Reason
The inspection was an annual licensing inspection conducted on January 13, 2016, for renewal of the facility license.
Findings
Multiple violations of 55 Pa.Code Chapter 2600 were found related to resident record confidentiality, sanitary conditions, snow removal, first aid kits in transport vehicles, and medication administration documentation. Plans of correction were submitted and partially implemented as of March 2, 2016.
Citations (7)
55 Pa.Code §2600.17 - Resident records were accessible to unauthorized personnel due to an unlocked administrator's office.
55 Pa.Code §2600.85(a) - Sanitary conditions were not maintained as Resident #1's glucometer had blood on it.
55 Pa.Code §2600.100(b) - Snow and obstructions were not removed from exits, making the sidewalk impassable due to snow accumulation.
55 Pa.Code §2600.171(b)(5) - First aid kits in vehicles used to transport residents were inspected and found missing items previously.
55 Pa.Code §2600.187(a) - Medication records lacked complete documentation of blood glucose test results and insulin administration for multiple residents.
55 Pa.Code §2600.187(d) - The home failed to follow prescriber directions for insulin administration based on sliding scale blood glucose readings for several residents.
55 Pa.Code §2600.262 - Resident records did not include identifying marks for residents #6 through #11 due to computer system changes.
Report Facts
Number of Residents Served: 60
Number of Current Hospice Residents: 4
Number of Hospice Residents in Past Year: 10
Residents Age 60 or Older: 60
Residents with Mental Illness: 2
Residents with Mobility Need: 20
Residents Receiving Supplemental Security Income: 4
Notice — June 8, 2023
Date: June 8, 2023
Visit Reason
This document serves as a license renewal notification for Christ the King Manor to operate as a Personal Care Home. It informs the facility that an onsite annual inspection will be conducted within the next twelve months as required by regulation.
Findings
No inspection findings are reported in this document. It only confirms issuance of a regular license following the renewal application.
Report Facts
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Juliet Marsala | Deputy Secretary | Signed the renewal notification letter. |
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