Inspection Report
Complaint Investigation
Census: 39
Capacity: 70
Deficiencies: 4
Jul 2, 2025
Visit Reason
The inspection was conducted as a complaint investigation with an unannounced partial inspection on 07/02/2025.
Findings
The inspection found multiple deficiencies related to medication administration errors, use of chemical restraints, incomplete significant change assessments, and lack of documentation regarding resident support plan signatures. The facility submitted a plan of correction which was determined to be fully implemented.
Complaint Details
The inspection was complaint-driven and included a follow-up on the submitted plan of correction.
Deficiencies (4)
| Description |
|---|
| Resident #1 was administered ABH topical gel twice within less than 2 hours, not following prescriber's directions. |
| Resident #1 was prescribed Quetiapine for agitation which may qualify as a chemical restraint without proper review. |
| The home did not complete a significant change assessment when Resident #1 was moved to the secure dementia care unit. |
| Resident #1 could not sign the support plan and the home did not document the resident's inability to sign. |
Report Facts
License Capacity: 70
Residents Served: 39
Secured Dementia Care Unit Capacity: 11
Residents Served in Dementia Unit: 10
Hospice Residents: 5
Residents Age 60 or Older: 39
Residents with Mobility Need: 13
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Executive Operations Officer | Responsible party for corrective actions and education related to medication administration and other deficiencies. | |
| Resident Wellness Coordinator | Responsible party for auditing support plans to ensure compliance with documentation requirements. |
Inspection Report
Complaint Investigation
Census: 36
Capacity: 70
Deficiencies: 0
Apr 17, 2025
Visit Reason
The inspection was conducted as a complaint investigation at the facility on 04/17/2025.
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: 70
Residents Served: 36
Secured Dementia Care Unit Capacity: 11
Secured Dementia Care Unit Residents Served: 10
Current Hospice Residents: 4
Residents Receiving Supplemental Security Income: 1
Residents Age 60 or Older: 36
Residents with Mobility Need: 12
Resident Support Staff: 0
Total Daily Staff: 48
Waking Staff: 36
Inspection Report
Renewal
Census: 37
Capacity: 70
Deficiencies: 3
Nov 14, 2024
Visit Reason
The inspection was conducted as a renewal visit to assess compliance with licensing requirements at Colonial Courtyard at Tyrone.
Findings
The inspection identified deficiencies related to contract signatures, signed statements acknowledging receipt of resident rights, and resident personal equipment safety hazards. The facility submitted and fully implemented a plan of correction to address these issues.
Deficiencies (3)
| Description |
|---|
| The resident-home contract was not signed by the resident as required. |
| Resident record did not contain a statement signed by the resident acknowledging receipt of a copy of the resident rights and complaint procedures. |
| An enabler bar attached to a bed had an uncovered opening measuring 7 ½ inches by 11 ¾ inches, creating a potential entrapment hazard. |
Report Facts
License Capacity: 70
Residents Served: 37
Memory Care Capacity: 11
Memory Care Residents Served: 11
Current Hospice Residents: 4
Residents Age 60 or Older: 37
Residents with Mobility Need: 13
Uncovered Opening Dimensions: 7.5
Uncovered Opening Dimensions: 11.75
Inspection Report
Complaint Investigation
Census: 42
Capacity: 70
Deficiencies: 0
Jun 13, 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 triggered by a complaint and incident, but no deficiencies or citations were found.
Report Facts
Residents Served: 42
License Capacity: 70
Secured Dementia Care Unit Capacity: 11
Secured Dementia Care Unit Residents Served: 8
Hospice Current Residents: 5
Residents Age 60 or Older: 42
Residents with Supplemental Security Income: 1
Residents with Mobility Need: 12
Inspection Report
Renewal
Census: 41
Capacity: 70
Deficiencies: 6
Jan 24, 2024
Visit Reason
The inspection was an unannounced full renewal inspection conducted to review compliance with licensing requirements and verify the submitted plan of correction.
Findings
The inspection identified multiple deficiencies including unsigned resident contracts, incomplete criminal background checks, lack of current first aid/CPR training for staff, improper medication administration, unsecured medications and syringes, and incomplete preadmission screening forms. All deficiencies had plans of correction accepted and were implemented or scheduled for completion.
Deficiencies (6)
| Description |
|---|
| Resident-home contracts for two residents were not signed by the residents. |
| Staff member lacked a Pennsylvania State Police clearance within 1 year prior to hire and within 30 days after hire as required. |
| The home lacked a staff member with current training in first aid and CPR during the inspection period. |
| Staff member observed placing medications beside a resident and walking away without administering them properly. |
| Medications and creams were found unlocked, unattended, and accessible in resident rooms and bathrooms. |
| Resident's preadmission screening form did not include a determination that the resident's needs could be met by the home. |
Report Facts
Residents served: 41
License capacity: 70
Residents in secured dementia care unit: 10
Current hospice residents: 6
Residents with mobility need: 12
Inspection Report
Follow-Up
Census: 42
Capacity: 70
Deficiencies: 2
Nov 2, 2023
Visit Reason
The inspection visit on 11/02/2023 was a partial, unannounced follow-up inspection triggered by an incident to verify the implementation of a previously submitted plan of correction.
Findings
The submitted plan of correction related to additional resident assessments for significant changes was determined to be fully implemented as of the follow-up review. The facility demonstrated compliance with updating Resident Assessment and Support Plans (RASPs) for residents with significant changes.
Deficiencies (2)
| Description |
|---|
| Resident #1's RASP did not update personal care need for supervision and mental health need of wandering after transfer from secured dementia care to senior care. |
| Resident #2's RASP was not updated to reflect initiation of hospice services despite documentation by the home's CRNP. |
Report Facts
License Capacity: 70
Residents Served: 42
Secured Dementia Care Unit Capacity: 11
Secured Dementia Care Unit Residents Served: 9
Hospice Residents: 9
Total Daily Staff: 53
Waking Staff: 40
Inspection Report
Follow-Up
Census: 44
Capacity: 70
Deficiencies: 3
May 16, 2023
Visit Reason
The visit was a follow-up review conducted on 05/16/2023 to determine if the submitted plan of correction for previous deficiencies was fully implemented.
Findings
The submitted plan of correction was found to be fully implemented, with updated documentation and corrective actions taken for medical evaluations, medication labeling, and preadmission screening forms. Continued compliance must be maintained.
Deficiencies (3)
| Description |
|---|
| Resident 1's Documentation of Medical Evaluation (DME) was incomplete, missing health status and mobility needs sections. |
| Resident 1 had discrepancies between medication orders and pharmacy labels regarding dosage instructions. |
| Resident 2's preadmission screening form was missing date of birth and medical, psychological, and behavioral diagnoses. |
Report Facts
License Capacity: 70
Residents Served: 44
Secured Dementia Care Unit Capacity: 11
Secured Dementia Care Unit Residents Served: 10
Resident Supplemental Security Income: 1
Residents Age 60 or Older: 44
Residents with Mobility Need: 19
Inspection Report
Renewal
Census: 36
Capacity: 70
Deficiencies: 12
Mar 9, 2023
Visit Reason
The inspection was conducted as a renewal and complaint investigation to review compliance with licensing requirements and address specific complaints.
Findings
The inspection identified multiple deficiencies including failure to report a medication error incident, improper use of restraints, inadequate staff training on fire safety and abuse reporting, incomplete medical evaluations, medication record inaccuracies, failure to follow prescriber's orders, incomplete preadmission screening, and inconsistent documentation regarding residents' ability to self-administer medications. Plans of correction were accepted and implemented by May 19, 2023.
Complaint Details
The complaint investigation included allegations of improper restraint use and failure to report incidents. The internal investigation and Blair County Adult Protective Services found the restraint allegation unsubstantiated.
Deficiencies (12)
| Description |
|---|
| Failure to report a medication error incident to the Department within 24 hours. |
| Use of restraints by denying assistance to Resident 1 to get out of bed. |
| Staff Member B did not receive required fire safety and emergency preparedness training on the first day. |
| Staff Members A, B, C, and D did not receive required training on mandatory reporting of abuse and neglect. |
| Annual staff training plan for 2023 was not developed. |
| Resident 2’s pet canine had an expired rabies vaccination. |
| Resident 3’s medical evaluation did not include blood pressure, height, weight, pulse rate, and temperature. |
| Medication records for Residents 4 and 5 lacked specific diagnoses for prescribed medications. |
| Failure to follow prescriber's orders for Resident 5’s blood glucose levels and insulin administration. |
| Resident 3's preadmission screening lacked required cognitive screening for secured dementia care unit admission. |
| Resident 3's and Resident 4's preadmission screening forms lacked determinations that residents' needs can be met by the home. |
| Inconsistent documentation regarding Resident 2’s ability to self-administer medications. |
Report Facts
License Capacity: 70
Residents Served: 36
Secured Dementia Care Unit Capacity: 11
Secured Dementia Care Unit Residents Served: 7
Current Hospice Residents: 5
Residents Age 60 or Older: 36
Residents with Mobility Need: 10
Residents Receiving Supplemental Security Income: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Resident Wellness Director | Named in multiple findings related to reeducation and auditing of staff and compliance. | |
| Staff Member A | Involved in medication error incident not reported. | |
| Staff Member B | Did not receive required fire safety training and abuse reporting training. | |
| Staff Member C | Did not receive required abuse reporting training. | |
| Staff Member D | Did not receive required abuse reporting training. | |
| Staff Member E | Confirmed management instructed staff not to assist Resident 1 with getting out of bed. | |
| Administrator | Involved in reeducation and corrective actions for multiple deficiencies. |
Inspection Report
Follow-Up
Census: 43
Capacity: 70
Deficiencies: 3
Jan 26, 2022
Visit Reason
The inspection was an unannounced partial review conducted due to an incident at the facility.
Findings
The submitted plan of correction was determined to be fully implemented. The report details incidents of abuse and aggression involving Resident #1 and outlines corrective actions including staff education and ongoing monitoring.
Deficiencies (3)
| Description |
|---|
| Failure to report incidents of suspected abuse involving Resident #1 on 11/28/21 and 12/4/21. |
| Resident #1 physically abused Resident #2 by pushing and forcing hands down the front of Resident #2's pants on 12/19/21. |
| Support plans did not address behaviors of Resident #1 including agitation and aggression, nor were revisions made to address these behaviors. |
Report Facts
Residents Served: 43
License Capacity: 70
Secured Dementia Care Unit Capacity: 11
Secured Dementia Care Unit Residents Served: 11
Current Hospice Residents: 4
Residents Age 60 or Older: 43
Residents with Supplemental Security Income: 1
Residents with Mobility Need: 13
Notice
Capacity: 70
Deficiencies: 0
Sep 16, 2021
Visit Reason
This document serves as a renewal notification and license issuance for the Personal Care Home 'Colonial Courtyard at Tyrone' following receipt of the renewal application dated September 14, 2021.
Findings
The Department advises that an onsite annual inspection will be conducted within the next twelve months to ensure compliance with Title 55, PA Code, Chapter 2600. No findings or deficiencies are reported in this document.
Report Facts
Maximum licensed capacity: 70
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary | Signed the renewal notification letter |
Inspection Report
Renewal
Deficiencies: 0
Aug 11, 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.
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