Deficiencies (last 5 years)
Deficiencies (over 5 years)
4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
15% better than Pennsylvania average
Pennsylvania average: 4.7 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
80% occupied
Based on a September 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Renewal
Census: 36
Capacity: 45
Deficiencies: 9
Sep 8, 2025
Visit Reason
The inspection was conducted as a renewal inspection of Cornwall Manor, a personal care home, to assess compliance with licensing requirements.
Findings
The inspection identified multiple deficiencies including unlocked controlled substance books, unsafe resident equipment posing entrapment risks, lack of refrigerator/freezer thermometers, outdated food items, incomplete medical evaluations, discontinued medications still present, damaged medication packaging, incomplete resident assessments, and incomplete support plans. Plans of correction were accepted and implemented with follow-up audits and staff education scheduled.
Deficiencies (9)
| Description |
|---|
| Two control substance books containing residents' medication information were unlocked, unattended, and accessible on medication carts. |
| Resident #2's enabler bar for transferring and repositioning in bed was uncovered with a large opening and not securely fastened, posing an entrapment risk. |
| No thermometer was present in the refrigerator or freezer in the second-floor kitchenette. |
| Dented cans of Campbell's chicken noodle soup and pineapple chunks were found in the home's kitchen. |
| Resident #3's initial medical evaluation was not completed within the required timeframe. |
| Discontinued medication Cefdinir 300mg for resident #2 was found in the medication cart. |
| Resident #4's Lorazepam 0.5mg bubble pack contained a tear with the pill still inside, covered with scotch tape. |
| Resident #3 and #5 had incomplete or outdated additional assessments. |
| Resident #2's support plan did not include required details about the enabler bar device used for transferring and repositioning. |
Report Facts
License Capacity: 45
Residents Served: 36
Current Hospice Residents: 1
Total Daily Staff: 36
Waking Staff: 27
Inspection Report
Renewal
Census: 35
Capacity: 45
Deficiencies: 8
Sep 11, 2024
Visit Reason
The inspection was conducted as a full, unannounced visit for renewal and complaint reasons on 09/11/2024.
Findings
The inspection identified multiple deficiencies related to staff training hours and topics, fire drill compliance, medical evaluations, medication storage and administration, and following prescriber's orders. Plans of correction were accepted and some were implemented by mid to late October 2024.
Deficiencies (8)
| Description |
|---|
| Direct Care Staff Members A and B received only 8.5 hours of annual training in training year 2023, less than the required 12 hours. |
| Direct Care Staff Members A and B did not receive required training topics during 2023 including medication self-administration, meeting resident needs, dementia care, personal care service needs, and safe management techniques. |
| Direct Care Staff Members A and B did not receive training in resident rights, Older Adult Protective Services Act, and falls and accident prevention during 2023. |
| A fire drill during sleeping hours was not conducted within the required 6-month interval. |
| During multiple fire drills, not all residents evacuated to a designated meeting place away from the building or within the fire-safe area. |
| Resident #1's most recent medical evaluation was incomplete; Resident #2's previous medical evaluation was outdated. |
| Resident #3's prescribed medication was not available in the home and thus not administered as ordered. |
| Resident #1 and Resident #3 did not receive prescribed medications on specified dates. |
Report Facts
License Capacity: 45
Residents Served: 35
Total Daily Staff: 35
Waking Staff: 26
Resident with Physical Disability: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Personal Care Administrator | Reviewed training plans, fire drill logs, and medication procedures; responsible for staff training audits and compliance. | |
| Manager of Nursing | Responsible for reviewing and signing off monthly fire drill documents and medication audits; provided education on fire drill requirements. | |
| LPN | Re-ordered medication for Resident #2 and involved in medication reconciliation and audits. |
Inspection Report
Renewal
Census: 36
Capacity: 45
Deficiencies: 2
May 11, 2023
Visit Reason
The inspection was conducted as a renewal inspection of the facility's license.
Findings
The submitted plan of correction was determined to be fully implemented. Two deficiencies were noted related to emergency management agency submission and medication storage procedures, both of which had corrective actions accepted and implemented.
Deficiencies (2)
| Description |
|---|
| The home's written emergency procedures were not submitted annually to the local emergency management agency as required. |
| A prescribed medication for Resident #1 was not available in the home on the day of inspection. |
Report Facts
Licensed Capacity: 45
Census: 36
Total Daily Staff: 36
Waking Staff: 27
Inspection Report
Renewal
Census: 26
Capacity: 45
Deficiencies: 1
Apr 21, 2022
Visit Reason
The inspection was conducted as a renewal inspection of the facility's license.
Findings
The submitted plan of correction was found to be fully implemented, with the emergency procedures now posted in a conspicuous and public place as required.
Deficiencies (1)
| Description |
|---|
| The home’s emergency procedures are not posted in a conspicuous and public place in the home. |
Report Facts
License Capacity: 45
Residents Served: 26
Total Daily Staff: 26
Waking Staff: 20
Notice
Capacity: 35
Deficiencies: 0
Oct 20, 2021
Visit Reason
The document serves as a renewal notification and license issuance for Cornwall Manor Personal Care Home, confirming receipt of the renewal application and advising of the requirement for an annual onsite inspection within the next twelve months.
Findings
No inspection findings are reported in this document; it is an administrative notice confirming license renewal and outlining future inspection requirements.
Report Facts
Maximum capacity: 35
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary, Office of Long-term Living | Signed the renewal notification letter |
Notice
Deficiencies: 0
Apr 15, 2021
Visit Reason
The document serves to notify Cornwall Manor that their request to waive the requirement for the personal care home Department-approved competency-based training test for an administrator candidate has been granted under specified conditions.
Findings
The waiver is granted with conditions including documentation requirements and a specified expiration date of April 30, 2021. The Department will review compliance with these conditions during the annual inspection.
Report Facts
Waiver expiration date: Apr 30, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jeanne Parisi | Bureau Director, Human Services Licensing | Signed the waiver approval letter. |
Loading inspection reports...
