Inspection Reports for Columbia Cottage Hanover, LLC
2288 GRANDVIEW ROAD, HANOVER, PA, 17331
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
1.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
74% better than Pennsylvania average
Pennsylvania average: 4.7 deficiencies/yearDeficiencies per year
4
3
2
1
0
Census
Latest occupancy rate
77% occupied
Based on a May 2025 inspection.
Census over time
Inspection Report
Follow-Up
Census: 37
Capacity: 48
Deficiencies: 1
Date: May 7, 2025
Visit Reason
The inspection was a partial, unannounced follow-up visit conducted due to an incident involving a resident fall and potential neglect.
Findings
The facility was found to have failed to properly assess a resident for suspected fractures following a fall, resulting in a delayed diagnosis of a right hip fracture requiring surgery. The facility updated its post-fall protocols, educated staff, and implemented ongoing audits to ensure compliance.
Deficiencies (1)
Failure to assess resident for suspected fractures as required per the home's post-fall policy after an unwitnessed fall.
Report Facts
License Capacity: 48
Residents Served: 37
Total Daily Staff: 58
Waking Staff: 44
Inspection Report
Renewal
Census: 42
Capacity: 48
Deficiencies: 1
Date: Sep 24, 2024
Visit Reason
The inspection was conducted as a renewal review of the facility's license on 09/24/2024 and 09/25/2024 to determine compliance with regulatory requirements.
Findings
The submitted plan of correction was found to be fully implemented. A violation was identified where a non-licensed staff member administered injectable medication, but immediate corrective actions were taken and policies updated to prevent recurrence.
Deficiencies (1)
Staff Person A, who is not a licensed medical professional, administered prescribed injectable medication to Resident #1, violating medication administration requirements.
Report Facts
License Capacity: 48
Residents Served: 42
Total Daily Staff: 60
Waking Staff: 45
Current Residents in Hospice: 1
Residents Age 60 or Older: 42
Residents with Mobility Need: 18
Residents with Physical Disability: 1
Inspection Report
Renewal
Census: 44
Capacity: 48
Deficiencies: 0
Date: Jun 14, 2023
Visit Reason
The inspection was conducted as a renewal licensing inspection of the facility.
Findings
No regulatory citations or deficiencies were identified during this licensing inspection.
Report Facts
Residents Served: 44
License Capacity: 48
Current Residents in Hospice: 4
Residents Age 60 or Older: 43
Residents Diagnosed with Intellectual Disability: 3
Residents with Mobility Need: 10
Residents with Physical Disability: 1
Inspection Report
Renewal
Census: 36
Capacity: 48
Deficiencies: 4
Date: May 24, 2022
Visit Reason
The inspection was conducted as a renewal visit with an incident review on 05/24/2022 at Columbia Cottage Hanover, LLC.
Findings
The inspection identified several deficiencies including combustible materials stored near heat sources, unlocked medications accessible to residents not assessed for self-administration, inaccurate glucometer readings not matching the Medication Administration Record (MAR), and failure to follow prescriber’s orders for insulin administration. Plans of correction were accepted and implemented with follow-up audits and staff re-education.
Deficiencies (4)
Combustible materials were stored near the furnace and hot water heater in the mechanical room.
A prescribed OTC medication was found unlocked and accessible in a resident's medicine cabinet despite the resident not being assessed to self-administer medications.
Two glucometer readings for Resident #2 did not match the readings reported on the Medication Administration Record (MAR).
Resident #2 did not receive insulin as prescribed according to the sliding scale instructions based on glucometer readings.
Report Facts
License Capacity: 48
Residents Served: 36
Staffing: 56
Waking Staff: 42
Glucometer Reading: 207
Glucometer Reading: 191
Glucometer Reading: 317
Glucometer Reading: 371
Insulin Units Given: 8
Insulin Units Recommended: 6
Inspection Report
Routine
Deficiencies: 0
Date: Jan 5, 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.
Notice
Capacity: 48
Deficiencies: 0
Date: Jan 29, 2021
Visit Reason
This document serves as a renewal notice and certificate of compliance for Columbia Cottage Hanover LLC to operate an assisted living facility. It informs the facility of the license renewal, the requirement for annual inspections, and the fee payment needed to maintain the certificate.
Findings
No inspection findings are reported. The document confirms issuance of a regular license and outlines the requirement for an onsite inspection within the next twelve months to ensure compliance with applicable regulations.
Report Facts
Licensed capacity: 48
License fee per bed: 35
Total license fee: 1680
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Deena Brant | Managing Director | Named as legal entity representative and recipient of correspondence |
| Jamie L. Buchenauer | Deputy Secretary, Office of Long-term Living | Signed renewal letter dated January 29, 2021 |
| Linnette Bidelspach | Acting Director Licensing Administration | Signed letter regarding license fee payment dated January 18, 2021 |
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