Inspection Report
Follow-Up
Census: 127
Capacity: 190
Deficiencies: 4
Jul 10, 2024
Visit Reason
The inspection visit on 07/10/2024 was a partial, unannounced follow-up inspection triggered by a complaint and incident to verify the implementation of a submitted plan of correction.
Findings
The facility was found to have fully implemented the submitted plan of correction addressing prior deficiencies related to resident abuse, medication labeling, medication administration documentation, and additional resident assessments. Continued compliance is required.
Complaint Details
The inspection was complaint-related, triggered by allegations of resident abuse and incidents involving maladaptive behaviors requiring 1:1 staffing. The complaint was substantiated as deficiencies were identified and addressed.
Deficiencies (4)
| Description |
|---|
| Resident-to-resident abuse incidents in the secured dementia care unit were observed, including verbal and physical altercations, with inadequate staff intervention prior to the incident. |
| Pharmacy label for Resident #3's medication did not include current administration instructions, differing from physician's orders. |
| Medication Administration Record did not include initials of staff who administered a non-medicated cream to Resident #3 on 7/6/2024 at 8:00 PM. |
| Resident #1 and Resident #4's assessments and support plans did not reflect significant behavioral changes and did not address how behavioral needs would be met through staff supports. |
Report Facts
License Capacity: 190
Residents Served: 127
Secured Dementia Care Unit Capacity: 44
Secured Dementia Care Unit Residents Served: 32
Current Hospice Residents: 6
Residents Age 60 or Older: 126
Residents with Mobility Need: 33
Inspection Report
Renewal
Census: 137
Capacity: 190
Deficiencies: 7
Apr 4, 2023
Visit Reason
The inspection was conducted as a renewal and incident review of the facility on 04/04/2023, 04/05/2023, 04/06/2023, and 04/07/2023.
Findings
The inspection found multiple deficiencies including insufficient CPR-trained staff during night shifts, inoperable bathroom exhaust fans, unsealed food storage, unlocked medications accessible to residents, loose pills in medication carts, missing medications, and incomplete medication administration documentation. Plans of correction were accepted and implemented by May 2023.
Deficiencies (7)
| Description |
|---|
| Insufficient number of staff trained in CPR and first aid during night shifts on 3/25/23 and 3/26/23. |
| Bathrooms in bedrooms 213 and 214 lacked operable exhaust fans for ventilation. |
| Two large trays of meat sauce in the walk-in cooler were opened and unsealed. |
| Prescription medications, OTC medications, CAM and syringes were unlocked and accessible in Resident 1's bedroom. |
| Two loose pills were observed in the Connections medication cart. |
| Resident 2's prescribed medication was not available in the home on 4/5/23. |
| Resident 2's medication administration record did not include the initials of the staff person who administered medication on a specified date and time. |
Report Facts
License Capacity: 190
Residents Served: 137
Secured Dementia Care Unit Capacity: 44
Secured Dementia Care Unit Residents Served: 34
Current Hospice Residents: 11
Residents Age 60 or Older: 136
Residents with Mobility Need: 49
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Responsible for ensuring CPR training compliance, medication storage, medication audits, and overall compliance with regulations. | |
| Assistant Director of Nursing | Assisted in training nightshift coworkers in CPR. | |
| Executive Director | Responsible for completing random audits to ensure CPR trained coworkers on nightshift. | |
| Director of Maintenance | Responsible for fixing bathroom exhaust fans and conducting audits to ensure operational status. | |
| Chef Manager | Covered meat sauce immediately upon discovery of unsealed food. | |
| Director of Dining Services | Responsible for educating culinary associates on proper food storage and conducting audits. | |
| Associate Executive Director | Locked apartment door immediately upon discovery of unlocked medications. | |
| Director of Nursing | Responsible for medication storage, medication audits, reordering medications, and ensuring documentation of medication administration. |
Inspection Report
Follow-Up
Census: 155
Capacity: 190
Deficiencies: 2
Feb 8, 2023
Visit Reason
The inspection was conducted as a follow-up review of a previously submitted plan of correction related to an incident at the facility.
Findings
The facility was found to have fully implemented the submitted plan of correction regarding an unreported resident incident and a confidentiality breach involving resident records. Continued compliance was required.
Deficiencies (2)
| Description |
|---|
| Failure to report an incident where resident #1 punched resident #2 to the Department within 24 hours. |
| A laptop computer containing personally identifiable information for 16 residents was found unlocked and unsupervised on a medication cart in a hallway. |
Report Facts
Residents Served: 155
License Capacity: 190
Secured Dementia Care Unit Capacity: 44
Secured Dementia Care Unit Residents Served: 36
Current Hospice Residents: 11
Residents Age 60 or Older: 154
Residents with Mobility Need: 48
Residents with Physical Disability: 1
Residents with Supplemental Security Income: 0
Residents Diagnosed with Mental Illness: 0
Residents Diagnosed with Intellectual Disability: 0
Inspection Report
Follow-Up
Census: 128
Capacity: 190
Deficiencies: 1
Jun 28, 2022
Visit Reason
The inspection was conducted as a follow-up to verify the implementation of a previously submitted plan of correction related to facility compliance, including renewal, complaint, and incident reasons.
Findings
The submitted plan of correction was found to be fully implemented, specifically addressing the issue of outdated signage for key-locking devices in the Secure Dementia Care Unit. The signage was updated and verified acceptable on the day of inspection.
Deficiencies (1)
| Description |
|---|
| The directions posted by the keypads in the Secure Dementia Care Unit for operating the home's locking mechanism were not current when observed on 6/28/22, as the code had been changed on 6/24/22. |
Report Facts
License Capacity: 190
Residents Served: 128
Secured Dementia Care Unit Capacity: 44
Secured Dementia Care Unit Residents Served: 31
Hospice Current Residents: 11
Residents 60 Years or Older: 127
Residents with Mobility Need: 32
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Associate Executive Director | Named in training related to plan of correction implementation | |
| Maintenance Director | Named in training and responsible for changing entry codes and signage | |
| Connections Manager | Named in training related to plan of correction implementation |
Inspection Report
Routine
Deficiencies: 0
Oct 14, 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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