Inspection Report
Complaint Investigation
Census: 72
Capacity: 83
Deficiencies: 3
May 29, 2025
Visit Reason
The inspection was conducted as a complaint investigation to review compliance with regulations and to verify the submitted plan of correction for the facility.
Findings
The inspection identified three main deficiencies: a breach of resident record confidentiality due to a staff member posting a video revealing confidential information, failure to provide required assistance with eating/feeding to a resident as per their support plan, and unsecured medication found on the floor in the dining room. Corrective actions including staff termination, education, and monitoring were implemented.
Complaint Details
The visit was complaint-related as indicated by the inspection information section stating the reason as 'Complaint'.
Deficiencies (3)
| Description |
|---|
| Resident records confidentiality was breached when a staff member posted a video on social media showing confidential resident information. |
| A resident did not receive required assistance with eating/feeding during mealtimes as indicated in their support plan. |
| A prescription medication pill was found unsecured on the floor of the main dining room. |
Report Facts
License Capacity: 83
Residents Served: 72
Secured Dementia Care Unit Capacity: 16
Secured Dementia Care Unit Residents Served: 14
Hospice Current Residents: 8
Residents Age 60 or Older: 72
Residents with Mobility Need: 32
Residents with Physical Disability: 1
Inspection Report
Complaint Investigation
Census: 73
Capacity: 83
Deficiencies: 0
Apr 1, 2025
Visit Reason
The inspection was conducted as a complaint investigation with an unannounced partial inspection on 04/01/2025.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Complaint Details
The inspection was triggered by a complaint; however, no deficiencies or citations were found.
Report Facts
License Capacity: 83
Residents Served: 73
Secured Dementia Care Unit Capacity: 16
Secured Dementia Care Unit Residents Served: 15
Current Hospice Residents: 7
Residents Age 60 or Older: 73
Residents with Mobility Need: 40
Residents with Physical Disability: 1
Inspection Report
Complaint Investigation
Census: 74
Capacity: 83
Deficiencies: 0
Jan 7, 2025
Visit Reason
The inspection was conducted as a complaint investigation with an unannounced partial inspection.
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: 83
Residents Served: 74
Secured Dementia Care Unit Capacity: 16
Secured Dementia Care Unit Residents Served: 14
Current Hospice Residents: 6
Residents Age 60 or Older: 74
Residents with Mobility Need: 37
Inspection Report
Complaint Investigation
Census: 78
Capacity: 83
Deficiencies: 0
Nov 13, 2024
Visit Reason
The inspection was conducted as a complaint 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, but no deficiencies or citations were found, indicating no substantiated issues.
Report Facts
Residents Served: 78
License Capacity: 83
Secured Dementia Care Unit Capacity: 16
Secured Dementia Care Unit Residents Served: 14
Hospice Current Residents: 6
Resident Mobility Need: 37
Total Daily Staff: 115
Waking Staff: 86
Inspection Report
Renewal
Census: 60
Capacity: 83
Deficiencies: 6
Aug 15, 2023
Visit Reason
The inspection was conducted as a renewal review of the facility's license to ensure continued compliance with regulatory requirements.
Findings
The report found multiple deficiencies related to criminal background checks, medical evaluations, medication storage procedures, and support plan documentation. The facility submitted plans of correction which were accepted and implemented by early September 2023.
Deficiencies (6)
| Description |
|---|
| Staff members did not have Pennsylvania State Police background checks completed until the inspection date. |
| Medical evaluation for resident #1 was not completed within 60 days prior to admission. |
| Resident #4's annual medical evaluation was not completed as required. |
| The glucometer for resident #3 was not calibrated correctly, resulting in incorrect blood glucose measurements recorded on the Medication Administration Record. |
| Resident #3's support plan was not revised within 30 days upon completion of the annual assessment or changes in needs. |
| The support plan for resident #2 lacked signatures of participants who developed the plan. |
Report Facts
License Capacity: 83
Residents Served: 60
Secured Dementia Care Unit Capacity: 16
Secured Dementia Care Unit Residents Served: 13
Current Hospice Residents: 9
Residents with Mobility Need: 17
Total Daily Staff: 77
Waking Staff: 58
Inspection Report
Follow-Up
Census: 59
Capacity: 83
Deficiencies: 4
Apr 5, 2023
Visit Reason
The inspection was a partial, unannounced follow-up visit triggered by an incident to verify the implementation of a previously submitted plan of correction.
Findings
The facility was found to have fully implemented the submitted plan of correction related to abuse, criminal background checks, and staff orientation deficiencies. Continued compliance is required.
Deficiencies (4)
| Description |
|---|
| A resident was verbally abused and demeaned by a staff person, with the staff remaining on shift for approximately one more hour after the incident. |
| Criminal background checks were not completed for four staff persons, including missing Pennsylvania State Police and FBI checks as required. |
| Four staff persons did not receive required orientation on fire safety and emergency preparedness topics prior to or during their first work day. |
| Four staff persons who completed 40 hours of work did not receive orientation on resident rights, emergency medical plan, mandatory abuse reporting, and reporting of reportable incidents. |
Report Facts
License Capacity: 83
Residents Served: 59
Secured Dementia Care Unit Capacity: 16
Secured Dementia Care Unit Residents Served: 11
Hospice Current Residents: 7
Residents Age 60 or Older: 59
Residents with Mobility Need: 16
Total Daily Staff: 75
Waking Staff: 56
Inspection Report
Renewal
Census: 42
Capacity: 83
Deficiencies: 17
Jul 12, 2022
Visit Reason
The inspection was conducted as a renewal inspection of the facility license.
Findings
The inspection identified multiple deficiencies including failure to post current licensing summaries, failure to report resident abuse timely, improper financial record keeping, incomplete staff training, unsafe storage of poisonous materials and medications, failure to conduct monthly fire drills, and incomplete resident assessments. Plans of correction were accepted and implemented for all deficiencies.
Deficiencies (17)
| Description |
|---|
| The home's most current licensing summaries issued by the Department were not posted in a conspicuous and public place. |
| The home did not immediately report an allegation of resident-to-resident abuse to Older Adult Protective Services. |
| The home did not report a resident-to-resident abuse incident to the Department within required timeframes. |
| Quarterly financial reviews for residents' funds were not completed timely. |
| Direct care staff provided unsupervised ADL services before completing Department-approved training and competency testing. |
| Poisonous materials were not stored in original labeled containers and were accessible to residents. |
| Lint was accumulated in the lint trap of the clothes dryer, posing a fire hazard. |
| An unannounced fire drill was not held during the month of April 2022. |
| Resident did not evacuate to a designated meeting place during a fire drill. |
| Smoking policy signs were not posted at the home's entrances. |
| The designated smoking area did not provide fireproof receptacles and ashtrays. |
| Prescription medications and syringes were found unlocked and accessible in residents' rooms. |
| Discontinued and expired medications were found in residents' possession. |
| Controlled substance administration was not properly documented by staff. |
| Medication administration records (MAR) lacked documentation of special precautions and proper dosage amounts. |
| Medications and treatments were not always administered following prescriber's orders. |
| Resident assessments did not include all care needs and medical diagnoses as required. |
Report Facts
License Capacity: 83
Residents Served: 42
Current Hospice Residents: 5
Total Daily Staff: 53
Waking Staff: 40
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Executive Operations Officer | Named in multiple findings related to plan of correction implementation, staff education, and monitoring. | |
| Wellness Director | Named in multiple findings related to staff education, medication administration, abuse reporting, and assessment completion. | |
| Maintenance Supervisor | Named in findings related to poisonous materials storage, fire safety, and smoking area compliance. | |
| Administrator | Responsible for reviewing incident reports and conducting audits as part of corrective actions. | |
| Regional Director | Provided education and training related to financial management and staff training. | |
| ASD (Assistant Service Director) | Involved in financial management training and record keeping. |
Inspection Report
Renewal
Capacity: 83
Deficiencies: 0
Jun 5, 2021
Visit Reason
The document is a renewal application and license issuance for the Personal Care Home 'Colonial Courtyard at Bedford' pursuant to Title 55, PA Code, Chapter 2600.
Findings
A regular license is being issued in response to the renewal application. The Department will conduct an onsite inspection within the next twelve months to ensure compliance with applicable regulations.
Report Facts
Maximum licensed capacity: 83
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary | Signed the renewal license letter |
Report
Sep 23, 2025
File
20250923_32948.pdf
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