Inspection Report
Complaint Investigation
Census: 64
Capacity: 74
Deficiencies: 0
Sep 3, 2025
Visit Reason
The inspection was conducted as a complaint investigation with an unannounced partial inspection on 09/03/2025.
Findings
No regulatory citations or deficiencies were identified during the inspection.
Complaint Details
The inspection was complaint-related, but no deficiencies or citations were found, indicating no substantiated issues.
Report Facts
License Capacity: 74
Residents Served: 64
Special Care Unit Capacity: 22
Special Care Unit Residents Served: 20
Hospice Current Residents: 5
Residents Diagnosed with Mental Illness: 10
Residents with Mobility Need: 29
Residents Age 60 or Older: 64
Residents Receiving Supplemental Security Income: 0
Residents Diagnosed with Intellectual Disability: 0
Residents with Physical Disability: 0
Total Daily Staff: 93
Waking Staff: 70
Inspection Report
Follow-Up
Census: 58
Capacity: 74
Deficiencies: 4
Jul 11, 2025
Visit Reason
The inspection was conducted as a follow-up to verify the implementation of a previously submitted plan of correction related to complaints and incidents at the facility.
Findings
The facility was found to have fully implemented the submitted plan of correction addressing issues including resident dignity and respect, medication storage and administration, and support plan elements. Continued compliance must be maintained.
Complaint Details
The inspection was complaint-related, triggered by incidents and complaints involving resident interactions and medication management. The submitted plan of correction was accepted and fully implemented.
Deficiencies (4)
| Description |
|---|
| Resident altercation involving shaking a resident's chair, physical contact, and emotional distress. |
| Failure to follow medication storage procedures, including incomplete or missing controlled substances count sheets and unaccounted medication tablets. |
| Failure to follow prescriber’s orders with multiple instances of residents not receiving prescribed medications at scheduled times. |
| Support plan did not address how a resident’s behavioral needs would be met after an altercation and hospital evaluation. |
Report Facts
License Capacity: 74
Residents Served: 58
Staffing Hours: 87
Waking Staff: 65
Current Residents in Hospice: 5
Special Care Unit Capacity: 22
Special Care Unit Residents Served: 22
Residents Age 60 or Older: 58
Residents with Mobility Need: 29
Residents Diagnosed with Mental Illness: 2
Residents with Physical Disability: 1
Inspection Report
Complaint Investigation
Census: 54
Capacity: 74
Deficiencies: 6
Apr 29, 2025
Visit Reason
The inspection was conducted as a complaint and incident investigation following allegations of staff abuse and neglect at the facility.
Findings
The inspection found multiple violations related to resident abuse reporting delays, failure to suspend a staff member involved in alleged abuse, improper handling causing resident injury, failure to implement positive interventions for aggressive behavior, and inadequate reassessment of resident transfer needs. The facility submitted plans of correction which were accepted and implemented.
Complaint Details
The visit was complaint-related due to allegations of staff member abuse and neglect towards residents. The complaint was substantiated with findings of delayed reporting, failure to suspend involved staff, and resident injury due to improper handling.
Deficiencies (6)
| Description |
|---|
| Failure to immediately report suspected abuse of a resident to the local Area Agency on Aging. |
| Staff member involved in alleged abuse continued to provide services without an approved supervision plan or suspension. |
| Failure to notify the Department’s assisted living residence office or complaint hotline within 24 hours of an incident. |
| Resident was injured during a one-person transfer attempt by staff, resulting in an acute impacted fracture of the left shoulder. |
| Failure to implement positive interventions to modify or eliminate a resident's physically aggressive behavior. |
| Failure to complete additional written assessments after significant change in resident's transfer needs requiring two-person assist. |
Report Facts
License Capacity: 74
Residents Served: 54
Special Care Unit Capacity: 22
Special Care Unit Residents Served: 27
Hospice Current Residents: 7
Residents with Mobility Need: 25
Residents Age 60 or Older: 54
Pain Level: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Resident Wellness Director | Named as responsible party for abuse reporting, staff training, incident reporting, and reassessment plans. | |
| Executive Operations Officer | Responsible party for immediate suspension of staff member involved in abuse allegation. |
Inspection Report
Complaint Investigation
Census: 57
Capacity: 74
Deficiencies: 0
Apr 2, 2025
Visit Reason
The inspection was conducted as a complaint and incident investigation during an unannounced partial inspection visit.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Complaint Details
The inspection was triggered by a complaint and incident, but no deficiencies or citations were found.
Report Facts
License Capacity: 74
Residents Served: 57
Special Care Unit Capacity: 22
Special Care Unit Residents Served: 21
Current Hospice Residents: 4
Residents Age 60 or Older: 57
Residents Diagnosed with Mental Illness: 2
Residents with Mobility Need: 31
Residents with Physical Disability: 1
Inspection Report
Renewal
Census: 54
Capacity: 74
Deficiencies: 12
Jan 9, 2025
Visit Reason
The inspection was conducted as a renewal inspection of the facility license.
Findings
The inspection identified multiple deficiencies related to staff training, resident equipment safety, fire safety evacuation procedures, medical evaluations, medication management, support plan documentation, and staff training compliance. Plans of correction were submitted and accepted with follow-up dates.
Deficiencies (12)
| Description |
|---|
| Direct care staff person A did not receive training in medication self-administration during the training year 1/1/24 to 12/31/24. |
| Resident #1's bed cane was not secured to the bed, allowing the bed cane to move/tip side to side approximately 10 inches causing a potential fall risk. |
| There was an approximate 1/8-inch accumulation of lint in the lint trap of the first commercial dryer in the main laundry room. |
| The residence has a safe evacuation time of 15 minutes, 0 seconds established by a fire safety expert on 6/27/23; however, on 4/25/24, residents evacuated in 15 minutes and .0024 seconds, exceeding the safe time. |
| During the fire drill on 6/25/24, 58 residents were present but only 56 evacuated. |
| The medical evaluation for resident #2 did not include immunization history; this area of the form was blank. |
| Discontinued medications were found in the medication cart for residents #3 and #4. |
| Resident #1's Lantus Solostar medication did not include a pharmacy label; repeat violation. |
| Resident #1's Albuterol and resident #4's Ondansetron medications were not available in the residence on 1/9/25. |
| Resident #1's support plan was not updated to address use and safety needs of a bed cane; resident #4's support plan was not updated to address hospice services; repeat violation. |
| Resident #2 and resident #3 did not sign their support plans and no notation of refusal or inability to sign was documented. |
| Direct care staff person A had only 6 hours of dementia care training during the 1/1/24 to 12/31/24 training year, less than the required 8 hours. |
Report Facts
License Capacity: 74
Residents Served: 54
Special Care Unit Capacity: 22
Special Care Unit Residents Served: 17
Hospice Residents: 5
Residents Present During Fire Drill: 58
Residents Evacuated During Fire Drill: 56
Staff Training Hours: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Direct care staff person A | Named in findings related to medication self-administration training deficiency and dementia care training deficiency. | |
| Resident Wellness Director | Responsible party for multiple plans of correction including medication management, support plan updates, and staff training. | |
| Administrative Services Director | Responsible party for staff training plans related to medication self-administration and dementia care. | |
| Safety and Maintenance Engineer | Responsible party for plans of correction related to equipment safety and fire safety training. | |
| Executive Operations Officer | Responsible party for training and support plan documentation oversight. |
Inspection Report
Renewal
Census: 64
Capacity: 74
Deficiencies: 5
Jan 25, 2024
Visit Reason
The inspection was conducted as a renewal review of the facility's compliance with licensing requirements.
Findings
The facility was found to have multiple deficiencies related to fire safety evacuation times, medication storage and labeling, medication administration, and resident support plans. All deficiencies had plans of correction accepted and were implemented by April 26, 2024.
Deficiencies (5)
| Description |
|---|
| The residence exceeded the maximum safe evacuation time during a fire drill, taking 15 minutes 20 seconds instead of the required 15 minutes. |
| Resident #6's insulin was stored in the refrigerator contrary to manufacturer instructions which require room temperature storage after opening. |
| Resident #6's prescription medication container lacked proper directions, with the label stating 'Please see attached for detailed directions' but no directions were attached. |
| Resident #6 was not administered a prescribed medication because it was not available in the residence. |
| Resident #6's support plan did not specify risks associated with the use of a mobile couch cane or the resident's ability to use the device safely. |
Report Facts
License Capacity: 74
Residents Served: 64
Special Care Unit Capacity: 22
Special Care Unit Residents Served: 19
Current Hospice Residents: 3
Residents Age 60 or Older: 64
Residents Diagnosed with Mental Illness: 1
Residents with Mobility Need: 26
Total Daily Staff: 90
Waking Staff: 68
Inspection Report
Complaint Investigation
Census: 64
Capacity: 74
Deficiencies: 0
Sep 29, 2023
Visit Reason
The inspection was conducted as a complaint 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, but no deficiencies were found and no follow-up was required.
Report Facts
License Capacity: 74
Residents Served: 64
Special Care Unit Capacity: 22
Special Care Unit Residents Served: 18
Hospice Residents: 3
Resident Support Staff Hours: 0
Total Daily Staff: 95
Waking Staff: 71
Residents Age 60 or Older: 64
Residents with Mobility Need: 31
Inspection Report
Complaint Investigation
Census: 63
Capacity: 74
Deficiencies: 4
Jul 13, 2023
Visit Reason
The inspection was conducted as a complaint and incident investigation related to multiple physical altercations between residents at the facility.
Findings
The facility failed to report incidents of resident altercations to the Department within the required timeframe and did not implement adequate safety precautions to prevent repeated physical altercations between residents. Plans of correction including staff education, increased monitoring, and support plan updates were implemented and accepted.
Complaint Details
The complaint investigation was substantiated with findings that residents #1 and #2 had multiple physical altercations, including pushing and kicking incidents, some resulting in injury or hospital transport. The facility did not report one incident as required and lacked adequate safety measures. Behavioral health interventions, increased monitoring, and family involvement were part of the corrective actions.
Deficiencies (4)
| Description |
|---|
| Failure to report an incident of resident altercation to the Department within 24 hours as required. |
| Inadequate safety precautions to prevent multiple physical altercations between residents. |
| Resident assessments did not fully reflect aggressive behaviors and risks. |
| Support plan did not address supervision needs due to aggressive behaviors. |
Report Facts
Residents served: 63
License capacity: 74
Total daily staff: 95
Waking staff: 71
Special care unit capacity: 22
Special care unit residents served: 22
Hospice current residents: 5
Residents age 60 or older: 63
Residents with mobility need: 32
Residents with physical disability: 2
Inspection Report
Complaint Investigation
Census: 65
Capacity: 74
Deficiencies: 0
Jun 23, 2023
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 triggered by a complaint and incident, but no deficiencies or citations were found, indicating no substantiated issues.
Report Facts
Total Daily Staff: 102
Waking Staff: 77
Residents Served: 65
License Capacity: 74
Special Care Unit Capacity: 22
Special Care Unit Residents Served: 22
Current Hospice Residents: 7
Residents Diagnosed with Mental Illness: 4
Residents with Mobility Need: 37
Residents Age 60 or Older: 65
Inspection Report
Complaint Investigation
Census: 66
Capacity: 74
Deficiencies: 2
Jun 7, 2023
Visit Reason
The inspection was conducted as a complaint and incident investigation to review compliance and assess the facility's plan of correction.
Findings
The inspection found deficiencies related to resident self-administration of medications without proper assessment and incomplete support plans addressing residents' physical and behavioral needs. The facility implemented corrective actions including medication removal, support plan updates, and staff training.
Complaint Details
The visit was complaint-related with substantiation implied by the findings of medication mismanagement and inadequate support plans.
Deficiencies (2)
| Description |
|---|
| Resident #1 was found with medications on the floor and had not been assessed by a qualified professional regarding ability to self-administer medications. |
| Support plans for Resident #1 and Resident #2 did not adequately address the resident's needs for Foley catheter care and management of aggressive behaviors, respectively. |
Report Facts
License Capacity: 74
Residents Served: 66
Special Care Unit Capacity: 22
Special Care Unit Residents Served: 22
Current Hospice Residents: 6
Residents with Mobility Need: 33
Residents Age 60 or Older: 66
Inspection Report
Renewal
Census: 58
Capacity: 74
Deficiencies: 11
Jan 18, 2023
Visit Reason
The inspection was conducted as a renewal, complaint, and incident review of the facility.
Findings
The inspection identified multiple deficiencies including missing posters in the special care unit, inadequate staffing during certain shifts, exterior hazards, inoperable bedside lamps, evacuation time exceeding limits during a fire drill, unsafe smoking area location, medication errors including discontinued medications still in carts, inaccurate pharmacy labels, and medication record discrepancies. Plans of correction were accepted and implemented by May 2, 2023.
Deficiencies (11)
| Description |
|---|
| Influenza Awareness poster was not posted in the residence's special care unit. |
| Department's poster of resident's rights was not posted in the residence's special care unit. |
| Staffing schedule occasionally had only 3 staff on 11:15pm-6:45am shift, inadequate for emergency evacuation needs. |
| Exterior embankment with standing water posed a potential fall hazard. |
| Resident #3 did not have access to an operable lamp at bedside. |
| Fire drill evacuation time exceeded the maximum safe evacuation time of 15 minutes. |
| Designated smoking area was located alongside a common walkway, posing a safety risk. |
| Discontinued medications for resident #3 were found in the medication cart. |
| Pharmacy labels for resident #5's medications did not include prescribed dosages. |
| Medication administration record (MAR) discrepancies for residents #3 and #4. |
| Weekly activity calendar was not posted in a public and conspicuous place in the special care unit. |
Report Facts
License Capacity: 74
Residents Served: 58
Staff Total Daily: 81
Staff Waking: 61
Special Care Unit Capacity: 22
Special Care Unit Residents Served: 19
Current Hospice Residents: 1
Residents Diagnosed with Mental Illness: 4
Residents with Mobility Need: 23
Residents Age 60 or Older: 58
Residents with Physical Disability: 2
Discontinued Medication Units: 300
Fire Drill Evacuation Time: 947
Inspection Report
Complaint Investigation
Census: 60
Capacity: 74
Deficiencies: 3
Sep 13, 2022
Visit Reason
The inspection was conducted as a complaint investigation during an unannounced partial inspection on 09/13/2022.
Findings
The inspection identified deficiencies related to resident equipment and facility cleanliness, including torn wheelchair armrests posing skin tear hazards and dirty carpets with chewing gum and debris. Plans of correction were submitted and accepted with retraining and monitoring measures implemented.
Complaint Details
The inspection was triggered by a complaint as indicated under Inspection Information with Reason: Complaint.
Deficiencies (3)
| Description |
|---|
| The right armrest of resident #1’s wheelchair had a 6 inch tear exposing padding, creating a potential skin tear hazard. |
| The right armrest of resident #2’s wheelchair was torn exposing a 3 inch diameter area of padding, and the left armrest was wrapped in medical tape. |
| The carpet in a resident's bedroom had multiple dried pieces of chewing gum stuck in the fibers, was dirty and discolored, with paper wrappers and food crumbs on the floor. |
Report Facts
License Capacity: 74
Residents Served: 60
Special Care Unit Capacity: 22
Special Care Unit Residents Served: 22
Hospice Current Residents: 1
Residents 60 Years or Older: 60
Residents Diagnosed with Mental Illness: 3
Residents with Mobility Need: 34
Inspection Report
Renewal
Deficiencies: 0
Feb 15, 2022
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
Census: 57
Capacity: 74
Deficiencies: 5
Dec 15, 2021
Visit Reason
The inspection was conducted as a renewal inspection of the facility license for Colonial Courtyard at Clearfield.
Findings
The inspection found multiple deficiencies including a direct care staff member lacking required qualifications, lint accumulation in laundry areas posing fire hazards, missing exit signs and directional signage in memory care and residence courtyards, and incomplete medication records for a resident self-administering medication. Plans of correction were accepted and documented as implemented.
Deficiencies (5)
| Description |
|---|
| Direct care staff person hired in 2021 did not have a high school diploma, GED, or active registry status on the Pennsylvania nurse aide registry. |
| Approximate 1/8 inch accumulation of lint on the back of the washing machine and on the floor behind the dryer in the Memory Care laundry room. |
| No exit signs over the doors exiting from the memory care courtyard to the memory care dining area and from the residence courtyard to the residence’s main dining area. |
| No direct visual line to the nearest exits at the memory care dining area and residence’s main dining area from the gates separating the courtyards. |
| Resident #1 self-administers medication but the medication list did not include a bottle of Mucinex 600mg found in the resident's drawer. |
Report Facts
License Capacity: 74
Residents Served: 57
Memory Care Capacity: 22
Memory Care Residents Served: 19
Hospice Residents: 4
Residents with Mobility Need: 32
Residents 60 Years or Older: 57
Residents Diagnosed with Mental Illness: 2
Inspection Report
Complaint Investigation
Census: 59
Capacity: 74
Deficiencies: 2
Sep 9, 2021
Visit Reason
The inspection was conducted as a complaint investigation with unannounced partial visits on 09/09/2021, 09/10/2021, and 09/14/2021 to review compliance and follow-up on a plan of correction submission.
Findings
The inspection found deficiencies related to failure to follow prescriber’s orders for feeding assistance and incomplete resident assessment content, specifically regarding aspiration risk, assistance needs, and hospice services. Plans of correction were accepted and fully implemented with staff education and updated assessments.
Complaint Details
The visit was complaint-related with a follow-up type of Plan of Correction (POC) submission. The submitted plan of correction was determined to be fully implemented.
Deficiencies (2)
| Description |
|---|
| Resident #1 was prescribed assistance with feeding due to aspiration risk but was not assisted by staff on 9/9/21 for breakfast and lunch. |
| Resident #1's assessment did not address the need for assistance with feeding, ambulation, repositioning, or hospice services. |
Report Facts
License Capacity: 74
Residents Served: 59
Special Care Unit Capacity: 22
Special Care Unit Residents Served: 17
Hospice Residents: 2
Total Daily Staff: 89
Waking Staff: 67
Inspection Report
Renewal
Deficiencies: 0
Jul 2, 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
Capacity: 74
Deficiencies: 0
Apr 2, 2021
Visit Reason
The document is a renewal application and license issuance for Colonial Courtyard at Clearfield, an Assisted Living-Special Care facility, with a reminder that an annual inspection will be conducted within the next twelve months as required by regulation.
Findings
The Department has issued a regular license in response to the renewal application and advises that an onsite inspection will be conducted within the next twelve months. If noncompliance is found during the inspection, enforcement action will be taken.
Report Facts
Maximum licensed capacity: 74
Special Care Unit capacity: 22
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