Inspection Reports for
Concordia at Rebecca Residence
3746 CEDAR RIDGE ROAD,, ALLISON PARK, PA, 15101
Back to Facility Profile40 Reports
Inspection Report — Jun 30, 2026
Follow-Up
Date: Jun 30, 2026
Visit Reason
The inspection was a partial, unannounced follow-up visit triggered by a complaint and incident to verify the implementation of a previously submitted plan of correction.
Complaint Details
The inspection was complaint-related and incident-driven, focusing on abuse and assessment deficiencies. The plan of correction was accepted and fully implemented.
Findings
The facility was found to have fully implemented the submitted plan of correction related to abuse and additional resident assessments. Continued compliance is required.
Citations (2)
42b - Abuse: A resident was neglected and verbally abused during a wandering incident, resulting in distress. Staff responded immediately, and corrective actions including reeducation and increased monitoring were implemented.
225c - Additional Assessment: A resident's most recent assessment was incomplete under the behavioral/cognitive need section, missing key behavioral/cognitive needs information. The issue was corrected promptly and audits were planned to ensure compliance.
Report Facts
Residents Served: 50
Hospice Current Residents: 11
Residents Age 60 or Older: 59
Residents Diagnosed with Mental Illness: 1
Residents with Mobility Need: 8
Inspection Report — May 11, 2026
Complaint Investigation
Date: May 11, 2026
Visit Reason
The inspection was conducted as a complaint investigation following an allegation of sexual abuse by a direct care staff member against a resident.
Complaint Details
The complaint involved an allegation of sexual abuse by a direct care staff person against a resident. The allegation was substantiated by the Bureau of Human Service Licensing, which found failures in timely reporting, suspension, and notification procedures.
Findings
The facility failed to immediately report suspected abuse to the local Area Agency on Aging, delayed suspension of the alleged perpetrator, and delayed notification to the resident's designated person. Additionally, medication carts were found unlocked and unattended, posing a safety risk.
Citations (4)
2600.15a: The residence failed to immediately report suspected sexual abuse to the local Area Agency on Aging, delaying the report until approximately 12 hours after the allegation.
2600.15b: The home did not immediately suspend or implement a supervision plan for the staff person involved in the abuse allegation, allowing continued unsupervised work until late evening.
2600.15d: The home failed to immediately notify the resident and the resident’s designated person of the abuse allegation, delaying notification until late evening.
2600.183b: Prescription and over-the-counter medication carts were found unlocked, unattended, and accessible, risking resident safety.
Report Facts
Residents Served: 57
Current Hospice Residents: 12
Resident Support Staff: 0
Total Daily Staff: 70
Waking Staff: 53
Notice — Oct 17, 2025
Date: Oct 17, 2025
Visit Reason
The document serves to notify the facility that a waiver request to waive the requirement for direct care staff to have a high school diploma, GED, or active registry status was granted due to the staff member's education obtained outside the United States.
Findings
The waiver is granted under specific conditions including documentation of the staff member's educational qualifications and training to be maintained by the facility and made available upon request. The Department will review this waiver annually during inspections to ensure compliance.
Inspection Report — Sep 19, 2025
Renewal
Date: Sep 19, 2025
Visit Reason
The inspection was conducted as a renewal review of the facility's license to ensure continued compliance with regulatory requirements.
Findings
The inspection found deficiencies related to refrigerator/freezer temperature monitoring and incomplete resident medical evaluations. Plans of correction were submitted and fully implemented by the facility.
Citations (2)
No thermometer in the freezer portion of the first-floor country kitchen’s LG refrigerator and freezer; Traulsen four-door cooler measured 45.6°F exceeding required temperature; no thermometer in the home’s main kitchen Traulsen two-door freezer.
Resident annual medical evaluations did not have any of the boxes checked in block #4 designated for 'Special Health or Dietary Needs.'
Report Facts
Residents Served: 59
Current Residents in Hospice: 13
Residents Age 60 or Older: 59
Residents Diagnosed with Mental Illness: 1
Residents with Mobility Need: 12
Residents with Physical Disability: 1
Total Daily Staff: 71
Waking Staff: 53
Notice — Jun 3, 2025
Date: Jun 3, 2025
Visit Reason
The document serves to notify the facility that a waiver request to 55 Pa.Code § 2600.54(a)(2) regarding direct care staff qualifications has been granted.
Findings
The waiver is granted under specific conditions including documentation of educational qualifications and training to be maintained by the facility and subject to annual review during inspections.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Theresa Hartman | Bureau Director, Human Services Licensing | Signed the waiver approval letter. |
Notice — Jun 2, 2025
Date: Jun 2, 2025
Visit Reason
The document serves to notify the facility that a waiver request to waive the requirement for direct care staff to have a high school diploma, GED, or active registry status was granted due to education obtained outside the United States.
Findings
The waiver is granted with conditions including documentation of training and educational qualifications to be kept on file and subject to annual review during inspections. Noncompliance with conditions may result in termination of the waiver or other licensing actions.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Theresa Hartman | Bureau Director, Human Services Licensing | Signed the waiver approval letter |
Inspection Report — May 20, 2025
Date: May 20, 2025
Visit Reason
The inspection was conducted as a licensing inspection due to an incident, with an unannounced partial inspection type.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Resident Support Staff: 69
Waking Staff: 52
Residents Served: 58
Current Hospice Residents: 10
Residents Age 60 or Older: 58
Residents Diagnosed with Mental Illness: 1
Residents with Mobility Need: 11
Residents with Physical Disability: 1
Residents Receiving Supplemental Security Income: 0
Residents Diagnosed with Intellectual Disability: 0
Inspection Report — Mar 3, 2025
Complaint Investigation
Date: Mar 3, 2025
Visit Reason
The inspection was conducted as a complaint and incident investigation, as indicated by the reason stated in the inspection information section.
Complaint Details
The complaint investigation found that direct care staff discovered a suspicious liquid in a resident's room during a seizure-like event but the incident was not reported to the Department within 24 hours as required. The administrator did not report the incident timely due to the belief the liquid was salad dressing.
Findings
The facility failed to report a suspected abuse incident within the required 24-hour timeframe to the Department’s personal care home regional office or complaint hotline. The administrator concluded the suspicious liquid was salad dressing and did not report it timely, which was a violation of reporting requirements.
Citations (1)
Failure to report a suspected abuse incident within 24 hours to the Department as required.
Report Facts
Residents Served: 58
Current Residents in Hospice: 13
Residents Age 60 or Older: 58
Residents Diagnosed with Mental Illness: 1
Residents with Mobility Need: 15
Residents with Physical Disability: 2
Total Daily Staff: 73
Waking Staff: 55
Inspection Report — Aug 22, 2024
Renewal
Date: Aug 22, 2024
Visit Reason
The inspection visit on 08/22/2024 was conducted for renewal, complaint, and incident reasons as part of the facility's regulatory oversight.
Findings
The submitted plan of correction related to a medication discrepancy was fully implemented and compliance was maintained. A discontinued medication was found in the medication cart but was promptly removed and staff were re-educated on medication reconciliation policies.
Citations (1)
A bottle of Atorvastatin 10 mg tablets prescribed for resident #1 was found in the medication cart despite being discontinued.
Report Facts
Residents Served: 55
Current Hospice Residents: 6
Residents Diagnosed with Mental Illness: 2
Residents with Mobility Need: 16
Residents with Physical Disability: 1
Total Daily Staff: 71
Waking Staff: 53
Inspection Report — Mar 8, 2024
Date: Mar 8, 2024
Visit Reason
The inspection was a partial, unannounced visit conducted due to an incident at the facility on 03/08/2024.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Residents Served: 59
Current Hospice Residents: 8
Residents 60 Years or Older: 59
Residents Diagnosed with Mental Illness: 1
Residents with Mobility Need: 13
Residents with Physical Disability: 1
Total Daily Staff: 72
Waking Staff: 54
Inspection Report — Jan 31, 2024
Date: Jan 31, 2024
Visit Reason
The inspection was a partial, unannounced licensing inspection conducted due to an incident at the facility.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Total Daily Staff: 74
Waking Staff: 56
Resident Support Staff: 0
Residents Served: 59
Current Hospice Residents: 7
Residents Age 60 or Older: 59
Residents Diagnosed with Mental Illness: 2
Residents with Mobility Need: 15
Inspection Report — Oct 30, 2023
Complaint Investigation
Date: Oct 30, 2023
Visit Reason
The inspection was conducted as a complaint investigation to review compliance with resident care requirements.
Complaint Details
The visit was complaint-related as indicated by the inspection reason. The plan of correction was accepted and fully implemented.
Findings
The submitted plan of correction was found to be fully implemented. A deficiency was identified related to inadequate assistance with activities of daily living, specifically incontinence care for a resident who required total physical assistance.
Citations (1)
Resident #1 did not receive incontinence care checks and changes every 2 hours as required, resulting in saturated clothing and bed linens.
Report Facts
Residents Served: 57
Residents Age 60 or Older: 57
Residents Diagnosed with Mental Illness: 1
Residents with Mobility Need: 16
Residents with Physical Disability: 1
Total Daily Staff: 73
Waking Staff: 55
Notice — Oct 11, 2023
Date: Oct 11, 2023
Visit Reason
The document serves to grant a waiver for a direct care staff person at Concordia at Rebecca Residence to obtain additional time to complete her GED, as required by 55 Pa.Code § 2600.54(a)(2).
Findings
The waiver is granted with conditions including that the staff member may not administer medication until GED completion, documentation must be maintained, and the waiver is effective until December 11, 2023. The Department will review compliance annually during inspections.
Report Facts
Waiver effective until: Dec 11, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Theresa Hartman | Bureau Director, Human Services Licensing | Signed the waiver approval letter. |
Notice — Jun 30, 2023
Date: Jun 30, 2023
Visit Reason
The document serves to grant a waiver for a direct care staff person at Concordia at Rebecca Residence to obtain her GED by October 4, 2023, with conditions on medication administration and documentation.
Findings
The waiver is granted under specified conditions including the staff member not administering medication until GED completion, documentation requirements, and a defined effective period from July 4, 2023 to October 4, 2023.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Thersa Hartman | Bureau Director, Human Services Licensing | Signed the waiver approval letter. |
Inspection Report — Apr 10, 2023
Follow-Up
Date: Apr 10, 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 related to medication administration violations.
Findings
The facility was found to have fully implemented the plan of correction regarding medication administration violations, including leaving medications unattended and unlocked, and inaccurate documentation of medication administration. Continued compliance must be maintained.
Citations (4)
Medication administration violation where staff left numerous morning medications unattended on resident #1's nightstand and did not administer them as ordered.
Prescription medications and syringes were not kept locked and were accessible on resident #1's nightstand despite resident #1 being unable to self-administer medications.
Medication administration times were not recorded accurately; medications were documented as administered though they were left unattended and not given.
Failure to follow prescriber's orders by not administering medications as directed and leaving them unattended.
Report Facts
Staffing: 66
Staffing: 50
Residents with mobility need: 11
Residents age 60 or older: 55
Residents diagnosed with mental illness: 1
Notice — Jan 4, 2023
Date: Jan 4, 2023
Visit Reason
The document serves as a formal notice granting a waiver to a direct care staff person at Concordia at Rebecca Residence to obtain a GED by July 4, 2023, with conditions on medication administration and documentation.
Findings
The waiver is granted under specific conditions including the staff member not administering medication until GED completion and documentation requirements. The waiver is effective from January 4, 2023 to July 4, 2023 and will be reviewed annually during inspections.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jeanne Parisi | Director | Signed the waiver approval letter. |
Inspection Report — Dec 14, 2022
Renewal
Date: Dec 14, 2022
Visit Reason
The inspection was conducted as a renewal and complaint investigation of Concordia at Rebecca Residence, including unannounced full inspections on 12/14/2022, 12/15/2022, and 12/16/2022.
Findings
The facility was found to have multiple deficiencies including unqualified direct care staff, unsanitary conditions in the kitchen microwave, damaged ceiling tiles, lack of operable bedside lamps for residents, incomplete fire safety inspection documentation, and outdated annual medical evaluations for residents. Plans of correction were accepted and implemented by January 30, 2023.
Citations (6)
Direct care staff person provided unsupervised care without a high school diploma, GED, or active registry status on the Pennsylvania nurse aide registry.
Unidentifiable yellow substance splattered on every interior surface of the Garden Unit country kitchen microwave and brown residue underneath the rotating glass dish.
Drop ceiling tile in the first floor country kitchen was dry but water damaged and stained brownish yellow in an area measuring approximately 5 inches by 2.5 inches.
Lamp on the bedside table was out of reach from bedside in resident room belonging to resident #1.
Fire safety inspection conducted by a fire safety expert did not designate specific fire safe areas or areas of refuge in writing and only indicated 'Behind fire doors' on the fire safety inspection letter dated 7/12/22.
Resident #2's current medical evaluation was dated after the inspection, and the previous medical evaluation was completed on 2/18/21, indicating an outdated annual medical evaluation.
Report Facts
Residents Served: 55
Current Residents in Hospice: 11
Total Daily Staff: 66
Waking Staff: 50
Inspection Report — May 4, 2022
Complaint Investigation
Date: May 4, 2022
Visit Reason
The inspection was conducted as a complaint investigation following allegations of abuse and inappropriate behaviors involving residents and staff at Concordia at Rebecca Residence.
Complaint Details
The complaint involved an allegation of sexual assault by staff person A against resident #1, which was investigated and found unsubstantiated. Multiple staff reported inappropriate behaviors by resident #2, including inappropriate touching and statements. The facility was educated on suspension protocols and updated resident assessments.
Findings
The investigation found an allegation of sexual assault by a staff member which was ultimately unsubstantiated after internal and DHS/APS investigations. Additionally, multiple incidents involving inappropriate behaviors and statements by resident #2 were documented, requiring updated assessments and staff training.
Citations (2)
Failure to immediately develop and implement a plan of supervision or suspend a staff person involved in an alleged abuse incident.
Resident #2's assessment was not initially updated to reflect behavioral needs and incidents of inappropriate sexual behaviors were reported.
Report Facts
Residents Served: 53
Current Residents in Hospice: 6
Resident Age 60 or Older: 53
Residents with Mobility Need: 8
Notice — Mar 8, 2022
Date: Mar 8, 2022
Visit Reason
The document serves to notify Concordia at Rebecca Residence that their request to waive certain Pennsylvania Code regulations regarding preadmission screening and medical evaluation forms has been granted.
Findings
The waiver allows the facility to use preadmission screening and medical evaluation forms from Point, Click, Care instead of the Department’s specified forms. The Department will review compliance with this waiver during the annual inspection and may terminate the waiver or take licensing action if conditions are not met.
Inspection Report — Feb 28, 2022
Complaint Investigation
Date: Feb 28, 2022
Visit Reason
The inspection was conducted as a complaint and incident investigation at the facility.
Complaint Details
The inspection was complaint-related, but no deficiencies were found and the follow-up was not required.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Residents Served: 56
Current Hospice Residents: 6
Residents Age 60 or Older: 56
Residents Diagnosed with Mental Illness: 1
Residents with Mobility Need: 15
Residents with Physical Disability: 2
Total Daily Staff: 71
Waking Staff: 53
Inspection Report — Jan 6, 2022
Complaint Investigation
Date: Jan 6, 2022
Visit Reason
The inspection was conducted as a complaint investigation to review the facility's compliance with regulatory requirements.
Complaint Details
The visit was complaint-related. The deficiency involved failure to update a resident's support plan as required. The plan of correction was initially not accepted but later accepted after resident discharge and document submission.
Findings
The facility was found to have a deficiency related to the failure to update a resident's support plan to reflect changes in cognitive behaviors, supervision needs, and incontinence care. The submitted plan of correction was reviewed and determined to be fully implemented.
Citations (1)
Resident #1's support plan had not been updated to include changes in cognitive behaviors, supervision/wandering needs, and increased incontinence care.
Report Facts
Residents Served: 57
Current Residents in Hospice: 6
Residents Age 60 or Older: 57
Residents with Mobility Need: 15
Residents with Physical Disability: 1
Inspection Report — Sep 15, 2021
Renewal
Date: Sep 15, 2021
Visit Reason
The inspection was conducted as a renewal and complaint investigation of Concordia at Rebecca Residence.
Findings
The inspection identified multiple deficiencies including unsigned resident contracts, staff lacking required qualifications, inadequate staffing during certain hours, incomplete or unsigned medical evaluations and support plans, sanitary issues, and medication documentation errors. Plans of correction were submitted and determined to be fully implemented by the follow-up dates.
Citations (14)
Resident #3's resident-home contract was not signed by the resident until after admission.
Direct care staff person C did not have a high school diploma, GED or active registry status on the Pennsylvania nurse aide registry at hire.
Inadequate staffing during night shifts on multiple dates, with only one staff present when two were needed for safe evacuation and resident transfers.
Direct care staff persons A, B, and C did not complete or pass the Department-approved direct care training and competency test within required timeframes.
Multiple areas of dried egg yolk were found on the bottom of the refrigerator in the PC North Pantry.
No emergency telephone numbers were posted on or near the telephone in resident #3's bedroom.
Two cement slabs of the sidewalk in the PC North courtyard were raised approximately 1.5 inches, posing a tripping hazard.
Resident #1, #2, #8, and #10 had medical evaluations not signed by the physician or missing evaluation dates.
Incorrect blood glucose readings were documented on residents' medication administration records.
Resident #1 received incorrect insulin dosage based on sliding scale; resident #4's blood glucose was not taken as required.
Resident #2's preadmission screening form did not include a determination that the home can meet the resident's needs.
Resident #6's most recent assessment was not completed timely.
Residents #7, #8, #9, and #10's support plans did not indicate need for 2-person assistance with transfers or use of Broda chair.
Residents #1, #7, #8, and #10's support plans were not signed by the resident or assessor, and did not indicate if resident was unable or refused to sign.
Report Facts
Residents Served: 59
Residents with Mobility Needs: 14
Residents Requiring 2 Staff Assistance: 9
Current Hospice Residents: 9
Raised Cement Slabs: 2
Insulin Sliding Scale Units: 14
Notice — Feb 5, 2021
Date: Feb 5, 2021
Visit Reason
The document serves as a certificate of compliance and notification of license renewal for Concordia at Rebecca Residence, a Personal Care Home. It also informs the facility administrator about the requirement for an annual onsite inspection within the next twelve months.
Findings
The Department has issued a regular license in response to the renewal application and advises that an annual inspection will be conducted within the next twelve months. No findings or deficiencies are reported in this document.
Report Facts
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Melanie Stewart | Administrator | Facility administrator addressed in the renewal notification letter. |
| Jamie L. Buchenauer | Deputy Secretary, Office of Long-term Living | Signed the renewal notification letter. |
Inspection Report — Nov 25, 2019
Renewal
Date: Nov 25, 2019
Visit Reason
The inspection was an unannounced renewal inspection conducted by the Pennsylvania Department of Human Services, Bureau of Human Services Licensing on November 25, 2019.
Findings
The inspection found several violations including unsecured resident records, incomplete fee schedules in contracts, and discrepancies in fire drill records. Plans of correction were submitted and fully implemented by February 7, 2020.
Citations (4)
Resident records were found unsecured on the medication cart with prescription information visible on a laptop screen for approximately ten minutes.
The home charged specified amounts for personal needs services but did not include a fee schedule listing allowable charges in the resident's admission contract.
Fire drill records showed discrepancies between the number of residents evacuated and the number recorded, including one drill with zero residents evacuated despite 59 present.
Direct care staff administered insulin to a resident without direct supervision and had not completed a Department-approved diabetes patient education program within the past 12 months.
Report Facts
Residents Served: 62
Current Hospice Residents: 3
Staffing Hours - Total Daily Staff: 73
Staffing Hours - Waking Staff: 55
Residents Evacuated - Fire Drills: 56
Residents Evacuated - Fire Drills: 60
Residents Evacuated - Fire Drills: 59
Residents Evacuated - Fire Drills: 55
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Melanie Stewart | LPN/PCHA | Named in multiple findings and plans of correction including record confidentiality, fee schedule correction, fire drill documentation, and diabetes training oversight. |
| Michael Kaufman | Executive Director | Involved in plan of correction for fire door security and safety mechanisms. |
Inspection Report — Nov 21, 2019
Renewal
Date: Nov 21, 2019
Visit Reason
This document is a renewal application and license issuance for Concordia at Rebecca Residence, a Personal Care Home, confirming the facility's authorization to operate with a maximum capacity of 65 residents.
Findings
The Department of Human Services has received the renewal application and is issuing a regular license. The Department will conduct an onsite annual inspection within the next twelve months as required by regulation.
Inspection Report — Apr 24, 2019
Routine
Date: Apr 24, 2019
Visit Reason
The Department’s Bureau of Human Services Licensing conducted an inspection of Concordia at Rebecca Residence to assess compliance with 55 Pa. Code Ch. 2600 relating to Personal Care Homes.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Inspection Report — Jan 11, 2019
Complaint Investigation
Date: Jan 11, 2019
Visit Reason
The inspection was conducted as a complaint investigation following allegations of abuse reported to the local police department involving a resident at the facility.
Complaint Details
The complaint involved an allegation received from the local police department that a staff person sexually harassed a resident on 12/20/18. The allegation was not reported to the local Area Agency on Aging until 1/23/19, and the facility failed to submit a timely incident report to the Department.
Findings
The facility failed to immediately report suspected abuse of a resident to the local Area Agency on Aging and the Department as required by regulations. A specific incident of alleged sexual harassment was not reported timely, and corrective actions were initiated.
Citations (2)
55 Pa.Code §2600.15(a) requires immediate reporting of suspected abuse of a resident. The facility failed to report an allegation of sexual harassment by a staff person against a resident on 12/20/18 until 1/23/19.
55 Pa.Code §2600.16(c) requires reporting incidents to the Department within 24 hours. The facility did not submit an incident report to the Department until 1/23/19 following the 12/20/18 incident.
Report Facts
Number of Residents Served: 61
Number of Deficiencies: 2
Inspection Report — Nov 19, 2018
Renewal
Date: Nov 19, 2018
Visit Reason
The document is a renewal application and license issuance for Concordia at Rebecca Residence, a Personal Care Home, with a requirement for an onsite inspection within the next twelve months as part of the renewal process.
Findings
No inspection findings are reported in this document. It confirms the issuance of a regular license and outlines the Department's obligation to conduct an onsite inspection within twelve months.
Inspection Report — Oct 25, 2018
Annual Inspection
Date: Oct 25, 2018
Visit Reason
Annual inspection conducted by the Department’s Bureau of Human Services Licensing to assess compliance with 55 Pa. Code Chapter 2600 for Personal Care Homes.
Findings
Multiple violations were found related to emergency procedures, medical evaluations missing license numbers, and medication refusal documentation. Plans of correction were submitted and approved with implementation dates in May 2019.
Citations (4)
55 Pa.Code §2600.107(b) - Emergency procedures did not include telephone numbers for the Pennsylvania Emergency Management Agency (PEMA).
55 Pa.Code §2600.141(a)(1) - Initial medical evaluations for several residents did not include the medical professional's license number and one evaluation had illegible special needs information.
55 Pa.Code §2600.141(b)(1) - Annual medical evaluation for Resident 15 did not include the medical professional's license number.
55 Pa.Code §2600.187(c) - Resident #P refused prescribed medication on 10/14/18 and the refusal was not reported to the prescriber within 24 hours as required.
Report Facts
Total Daily Staff: 77
Waking Staff: 58
Number of Hospice Residents: 3
Number of Residents Served: 61
Inspection Report — Aug 9, 2018
Complaint Investigation
Date: Aug 9, 2018
Visit Reason
The inspection was conducted due to an incident reported at the facility involving a resident choking on food.
Complaint Details
The complaint was substantiated. The facility failed to timely report an incident where resident #1 choked on a piece of hamburger and was hospitalized for aspiration.
Findings
The facility failed to report a choking incident involving a resident to the Department within the required 24-hour timeframe. The resident was transported to the hospital for aspiration, but the incident was reported late.
Citations (1)
Regulation 55 Pa.Code §2600 2600.16(c) requires the home to report incidents to the Department within 24 hours. The facility did not report the choking incident involving resident #1 until four days later.
Report Facts
Number of Residents Served: 61
Total Daily Staff: 78
Waking Staff: 59
Number of Current Hospice Residents: 4
Number of Hospice Residents in past year: 15
Number of Residents 60 Years or Older: 61
Number of Residents with Mobility Need: 17
Number of Residents with Physical Disability: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ashlee Mayuric | Administrator | Named as facility administrator and signed plan of correction |
| Karen Georgoulis | Department representative conducting inspection | |
| Lauren Spagna | Department representative conducting inspection |
Inspection Report — Aug 6, 2018
Complaint Investigation
Date: Aug 6, 2018
Visit Reason
The inspection was conducted as a complaint investigation to assess compliance with 55 Pa. Code Ch. 2600 relating to Personal Care Homes.
Complaint Details
The inspection was triggered by a complaint. The report does not explicitly state the substantiation status of the complaint.
Findings
Violations of the Personal Care Homes regulations were found during the inspection. The facility was required to correct all violations by specified dates and maintain continued compliance.
Citations (2)
Resident #1's assessment indicated inconsistent assistance needs for transfers, with the plan stating verbal cues would be provided but the mobility section indicating minimal mobility. The facility updated the assessment and planned to monitor with each new Resident Assessment Service Plan (RASP).
Staff failed to use proper communication devices during an emergency, resulting in delayed assistance for a resident who fell. The facility planned to educate all staff on communication policies and use of cordless phones and switchboard operators.
Report Facts
Number of Residents Served: 63
Number of Current Hospice Residents: 4
Number of Hospice Residents in past year: 15
Residents Age 60 or Older: 62
Residents with Mobility Need: 15
Residents with Physical Disability: 2
Inspection Report — Nov 29, 2017
Renewal
Date: Nov 29, 2017
Visit Reason
The document is a renewal license issued in response to a renewal application for Concordia at Rebecca Residence, a Personal Care Home. The Department advises 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 serves as a license renewal notice and outlines the Department's requirement to conduct an annual inspection within the next year.
Inspection Report — Oct 3, 2017
Renewal
Date: Oct 3, 2017
Visit Reason
The inspection was conducted as a result of the Department of Human Services' annual licensing inspection and included renewal and complaint reasons.
Findings
The inspection found violations related to confidentiality of resident records, fire safety signage, and incomplete resident assessments. Plans of correction were submitted addressing these issues with partial or full implementation status noted.
Citations (3)
55 Pa.Code §2600.17 - Resident records were found unlocked, accessible, and unattended in a drawer inside the north country kitchen containing confidential care documentation for residents #1, #2, and #3.
55 Pa.Code §2600.121(a) - There was no sign indicating that the courtyard door in the 1st floor living room is not an exit.
55 Pa.Code §2600.225(a) - The assessment for resident #4 dated 8/17/17 was blank under the section 'Long-term Memory.'
Report Facts
Number of Residents Served: 61
Number of Current Hospice Residents: 4
Number of Hospice Residents In Past Year: 13
Notice — Apr 27, 2017
Date: Apr 27, 2017
Visit Reason
The document serves as a waiver approval for a direct care staff person at Rebecca Residence to have additional time to complete the Pennsylvania Nurse Aide National Assessment Program written examination while working at the licensed personal care home.
Findings
The waiver is granted under specific conditions including passing the exam by a scheduled date and maintaining documentation. The Department will review compliance with these conditions during inspections and may take licensing action if conditions are not met.
Report Facts
Waiver expiration date: Jun 6, 2017
Inspection Report — Dec 20, 2016
Routine
Date: Dec 20, 2016
Visit Reason
The Department of Human Services licensing representatives conducted an inspection of the facility on December 20, 2016.
Findings
No regulatory violations were identified as a result of this inspection.
Inspection Report — Dec 12, 2016
Routine
Date: Dec 12, 2016
Visit Reason
The Department of Human Services licensing representatives conducted an inspection of the facility on December 12, 2016.
Findings
No regulatory violations were identified as a result of this inspection.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Susie Pollock | Regional Licensing Director | Signed the inspection report letter. |
Notice — Nov 23, 2016
Date: Nov 23, 2016
Visit Reason
Notification of receipt of renewal application and information about the requirement for an annual onsite inspection within the next twelve months.
Findings
No inspection findings are reported. The document confirms issuance of a regular license and outlines the Department's obligation to conduct an annual inspection.
Inspection Report — Aug 25, 2016
Annual Inspection
Date: Aug 25, 2016
Visit Reason
The inspection was an annual licensing inspection conducted on August 25, 2016, including renewal and complaint reasons.
Findings
Multiple violations of 55 Pa.Code Chapter 2600 were found related to staff training deficiencies, furniture and equipment disrepair, and building hazards. Plans of correction were submitted with partial or full implementation status.
Citations (4)
55 Pa.Code 2600.65(f) - Staff person A did not receive training on medication self-administration, dementia care, infection control, and hygiene during the 2015 training year.
55 Pa.Code 2600.65(g) - Staff person A did not receive training on resident rights or the Older Adult Protective Services Act during the 2015 training year.
55 Pa.Code 2600.95 - Several north courtyard exterior ground lighting fixtures were in disrepair, including broken bases, missing and broken shades, and missing or broken light bulbs.
55 Pa.Code 2600.100(a) - A piece of lumber with exposed nails broke off from a raised wooden garden box and was laying on the sidewalk, posing a laceration hazard to residents.
Report Facts
Number of Residents Served: 60
Number of Current Hospice Residents: 4
Number of Residents Age 60 or Older: 60
Number of Residents with Mobility Need: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ashlee Mayuric | Administrator | Named as facility administrator and signed plans of correction. |
Notice — Aug 18, 2016
Date: Aug 18, 2016
Visit Reason
This letter responds to a request for a waiver of Pennsylvania Code Chapter 2600 related to personal care homes, specifically regarding resident medical evaluation and health care documentation requirements.
Findings
The letter requests additional information to support the waiver request, including a medical evaluation form with a date field and special diet-check options for 'low cholesterol' and 'no concentrated sweets'.
Report Facts
Waiver request code reference: 55
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tara Pride | Director of Regulatory Implementation | Signed the letter regarding waiver request |
| Jill Kachmar | Regulatory Implementation Manager | Contact for returning requested documentation |
Report — August 2, 2016
August 2, 2016
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