Inspection Reports for Crescent Fields
2507 Philmont Ave. Huntingdon Valley, PA 19006, PA, 19006
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Inspection Report
Complaint Investigation
Census: 62
Capacity: 149
Deficiencies: 2
Mar 4, 2025
Visit Reason
The inspection was conducted as a complaint investigation to review the facility's compliance with regulations and to verify the submitted plan of correction.
Findings
The facility was found to have deficiencies related to medication labeling and storage procedures, including faded pharmacy labels and missing medications. The submitted plan of correction was fully implemented and compliance was maintained.
Complaint Details
The inspection was complaint-driven, as indicated by the reason for the inspection. The plan of correction submitted by the facility was accepted and fully implemented.
Deficiencies (2)
| Description |
|---|
| Pharmacy label on resident's insulin lispro medication was scraped or faded, rendering several letters and digits illegible, including the unit maximum. |
| Medications prescribed for residents, including topical and oral medications, were not available in the home at the time of inspection. Documentation errors were also noted in blood glucose readings. |
Report Facts
Residents Served: 62
License Capacity: 149
Secured Dementia Care Unit Capacity: 19
Secured Dementia Care Unit Residents Served: 17
Hospice Current Residents: 6
Residents Age 60 or Older: 60
Residents Diagnosed with Mental Illness: 10
Residents with Mobility Need: 38
Residents with Physical Disability: 7
Inspection Report
Monitoring
Census: 62
Capacity: 149
Deficiencies: 1
Dec 9, 2024
Visit Reason
The visit was conducted as a monitoring review by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing to verify compliance and implementation of a previously submitted plan of correction.
Findings
The inspection found that the submitted plan of correction related to medication storage deficiencies was fully implemented and compliance was maintained. The specific deficiency involved punctured blister packs exposing medications to contamination, which was corrected onsite during the inspection.
Deficiencies (1)
| Description |
|---|
| Medication cards were observed to have punctured blister foil with medication still present, exposing it to contamination or improper sanitation. |
Report Facts
License Capacity: 149
Residents Served: 62
Secured Dementia Care Unit Capacity: 19
Secured Dementia Care Unit Residents Served: 16
Hospice Current Residents: 3
Residents Diagnosed with Mental Illness: 10
Residents Age 60 or Older: 62
Residents with Mobility Need: 18
Residents with Physical Disability: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Healthcare Director | Named in medication storage deficiency correction and plan of correction implementation | |
| Resident Care Coordinator | Performed Memory Care medication cart audit related to deficiency | |
| Administrator | Involved in ongoing compliance monitoring as part of plan of correction |
Inspection Report
Renewal
Census: 55
Capacity: 149
Deficiencies: 32
Sep 30, 2024
Visit Reason
The inspection was conducted as a renewal visit to review compliance with licensing regulations and verify the submitted plan of correction was fully implemented.
Findings
The inspection identified multiple deficiencies related to resident confidentiality, medication management, resident assessments, support plans, and safety procedures. The facility submitted plans of correction for all deficiencies, which were accepted and implemented or scheduled for ongoing compliance monitoring.
Deficiencies (32)
| Description |
|---|
| Resident records confidentiality breached by leaving medication cart, laptop, and narcotics book unlocked and unattended. |
| Refund for deceased resident was not issued within required timeframe. |
| Resident bed enabler was not secured properly and posed safety risk. |
| Poisonous materials were unlocked and accessible to residents not assessed as safe to use them. |
| First aid kit in Memory Care Unit lacked thermometer, scissors, and tweezers. |
| Resident bed linens and pillowcases were not clean and in good repair. |
| Residents lacked operable lamps or bedside lighting. |
| Emergency procedures were not submitted annually to local emergency management agency. |
| Egress routes were obstructed by furniture blocking exit. |
| Resident medical evaluation lacked required medical diagnosis and emergency information. |
| Medications stored unlocked and unattended in resident rooms. |
| Resident medication record did not include current list of medications. |
| Medication administration errors including unattended medications and inaccurate documentation. |
| Medications and CAM not stored under proper conditions of sanitation, temperature, moisture, and light. |
| Discontinued medications not properly destroyed or removed from medication carts. |
| Medications and glucometers not properly labeled with resident information. |
| Medication administration records did not reflect accurate glucometer readings and medication use. |
| Medications prescribed as needed were not available in the home when required. |
| Medication records lacked required details including resident name, drug allergies, dosage, route, and administration times. |
| Medication refusals were not documented or communicated to prescriber or family. |
| Prescriber’s directions for medication administration were not consistently followed. |
| Medication errors were not immediately reported to resident, designated person, or prescriber. |
| Documentation of medication errors and prescriber responses were incomplete or missing. |
| Staff person administered medications without completing Department-approved medication administration course. |
| Prohibited use of chemical restraint (Lorazepam) to control behaviors without proper orders. |
| Resident initial assessment was not completed within 15 days of admission. |
| Resident annual assessments were not current or complete. |
| Resident support plan was not developed within 30 days of admission or lacked required content. |
| Resident support plan did not document medical, dental, vision, hearing, mental health or behavioral care services. |
| Resident refused to sign support plan but no notation of refusal was documented. |
| Resident cognitive preadmission screening lacked date of cognitive evaluation. |
| Resident records did not include the most current version of the annual assessment. |
Report Facts
Residents served: 55
License capacity: 149
Memory Care Capacity: 19
Memory Care Residents Served: 15
Current Hospice Residents: 5
Residents 60 years or older: 59
Residents with mobility needs: 38
Residents with physical disability: 19
Total Daily Staff: 93
Waking Staff: 70
Inspection Report
Follow-Up
Census: 60
Capacity: 149
Deficiencies: 13
Jul 24, 2024
Visit Reason
The inspection was a partial, unannounced follow-up visit triggered by a complaint and incident to review the submitted plan of correction and verify compliance.
Findings
The facility was found to have multiple deficiencies related to contract signatures, abuse, staff qualifications, orientation, training, medication administration, and preadmission screening. The submitted plan of correction was fully implemented and compliance was maintained as of the follow-up dates.
Complaint Details
The inspection was complaint-related, triggered by a complaint and incident involving resident abuse and neglect. The complaint was substantiated as evidenced by the detailed abuse incident and subsequent findings.
Deficiencies (13)
| Description |
|---|
| Resident-home contract was not signed by the resident at move-in. |
| Incident of resident striking staff and subsequent inadequate response leading to resident injury and death. |
| Direct care staff person did not have required high school diploma, GED, or active nurse aide registry status. |
| Staff persons A, B, and C did not receive required fire safety orientation on first day of work. |
| Staff persons A, B, and C did not complete required orientation training on resident rights, emergency medical plan, and mandatory reporting within 40 scheduled hours. |
| Direct care staff person A received zero hours of annual training in 2023. |
| Direct care staff persons A, B, and C did not receive training in required topics including care for residents with mental illness or intellectual disability, safe management techniques, personal care needs, dementia care, medication administration, infection control, and others during 2023. |
| Staff persons A, B, and C did not receive fire safety training by a fire safety expert during 2023-2024. |
| Training records for Staff persons A, B, and C were missing at time of inspection. |
| Staff person A administered medications without successfully completing Department-approved medication administration course. |
| Resident's preadmission screening form was missing the date of prescreen. |
| Resident admitted to Secure Dementia Care Unit without completed written cognitive preadmission screening. |
| Direct care staff persons A, B, and C working in Secure Dementia Care Unit had zero hours of dementia-related training during 2023-2024. |
Report Facts
License Capacity: 149
Residents Served: 60
Capacity of Secured Dementia Care Unit: 19
Residents Served in Secured Dementia Care Unit: 12
Current Hospice Residents: 6
Residents 60 Years or Older: 60
Residents with Mobility Need: 39
Staff Total Daily: 99
Staff Waking: 74
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff Person A | Named in abuse incident, training deficiencies, medication administration violation, and orientation/training deficiencies. | |
| Staff Person B | Named in abuse incident, training deficiencies, orientation/training deficiencies, and employment termination. | |
| Staff Person C | Named in orientation and training deficiencies. | |
| Regional Director of Operations | Educated staff and management on regulations and compliance monitoring. | |
| Administrator | Involved in auditing, training, and compliance monitoring. | |
| Business Office Manager | Audited files, received education, and responsible for compliance monitoring. | |
| Healthcare Director | Provided training and education on healthcare regulations and staff training. | |
| Maintenance Director | Fire Safety Expert | Provided fire safety training to staff. |
Inspection Report
Renewal
Census: 28
Capacity: 196
Deficiencies: 24
Sep 27, 2023
Visit Reason
The inspection was conducted as a full, unannounced visit for renewal, complaint, and new reasons on 09/27/2023.
Findings
The inspection identified multiple deficiencies including lack of proper staff orientation and training, unsecured poisonous materials accessible to residents, missing or incomplete documentation in resident records, food safety violations, missing emergency procedures information, and vehicle documentation issues. Plans of correction were accepted and implemented with follow-up dates scheduled.
Deficiencies (24)
| Description |
|---|
| Staff persons did not receive orientation on fire safety and emergency preparedness topics on their first day of work. |
| Staff members did not complete required training within 40 scheduled work hours on resident rights and emergency medical plan. |
| The home's staff training plan did not include the dates, times, and locations of scheduled training for each staff member for the upcoming year. |
| Poisonous materials were unlocked and accessible to residents not assessed as capable of safely using or avoiding them. |
| Trash outside the home was not properly stored; approximately 9 wood pallets and a piece of metal were behind dumpsters. |
| The first aid kit in the facility bus was missing eye coverings, tweezers, and a thermometer. |
| Elevator #3 lacked a certificate of operation from the Department of Labor and Industry or local authority. |
| Residents 4, 5, and 6 did not have access to a source of light that can be turned on or off at the bedside. |
| Unlabeled and undated food items were found in refrigerators and freezers. |
| No thermometer was present in the freezer in the Memory Care Unit kitchenette. |
| The home's written emergency procedures did not include contact information for each resident’s designated person. |
| The home did not maintain at least a 3-day supply of nonperishable food and drinking water for residents. |
| No inspection tags were on the fire extinguisher on the facility bus. |
| An unannounced fire drill was not held during July for the entire facility and not held during August in the personal care unit. |
| Resident 7's medical evaluation did not include medical information pertinent to diagnosis and treatment in case of an emergency. |
| The home's menu for the current week was not posted in a public and conspicuous place throughout the facility. |
| The home did not have a copy of the driver's license in good standing for the person who operated the vehicle used to transport residents. |
| Medication blister cards for residents 8 and 9 had ripped open foil on pills. |
| Glucometer readings for resident 7 did not match the MAR log on multiple occasions. |
| Resident 3's preadmission screening form was not completed prior to admission. |
| Resident 3 participated in the development of the support plan but did not sign the support plan. |
| Resident 3 admitted to the Secure Dementia Care Unit did not have a written cognitive pre-admission screening. |
| Resident 3 admitted to the Secure Dementia Care Unit had no documentation that the resident and designated person did not object to admission. |
| Resident 3's record did not include eye color or hair color; Resident 7's record lacked eye color, hair color, race, and a recent photograph. |
Report Facts
Residents served: 28
License capacity: 196
Memory Care Unit capacity: 18
Memory Care Unit residents served: 3
Number of wood pallets: 9
Emergency drinking water required: 84
Emergency drinking water available: 66
Inspection Report
Renewal
Census: 28
Capacity: 196
Deficiencies: 23
Sep 27, 2023
Visit Reason
The inspection was conducted as a full, unannounced visit for renewal, complaint, and new reasons on 09/27/2023.
Findings
The inspection identified multiple deficiencies including lack of staff orientation on fire safety and resident rights, unsecured poisonous materials accessible to residents, missing items in first aid kits, elevator certificate issues, inadequate lighting in resident bedrooms, improper food labeling and storage, missing emergency procedures information, insufficient emergency water supply, missing fire extinguisher inspection tags, missed monthly fire drills, incomplete resident medical evaluations, missing menus, incomplete vehicle documentation, medication storage issues, incomplete preadmission screening and support plan signatures, and incomplete resident record content.
Deficiencies (23)
| Description |
|---|
| Staff persons did not receive orientation on fire safety and emergency preparedness topics on their first day of work. |
| Staff members did not complete training on resident rights and emergency medical plan within 40 scheduled working hours. |
| The home's staff training plan did not include the dates, times, and locations of scheduled training for each staff member for the upcoming year. |
| Poisonous materials were unlocked, unattended, and accessible to residents not assessed as capable of safely using or avoiding poisons. |
| Trash outside the home was not properly stored; approximately 9 wood pallets and a piece of metal were behind dumpsters. |
| The first aid kit in the facility bus was missing eye coverings, tweezers, and a thermometer. |
| Elevator #3 did not have a certificate of operation from the Department of Labor and Industry or appropriate local authority. |
| Residents did not have access to a source of light that can be turned on or off at the bedside. |
| Unlabeled and undated food items were found in refrigerators and freezers. |
| No thermometer was present in the freezer in the Memory Care Unit kitchenette. |
| The home's written emergency procedures did not include contact information for each resident’s designated person. |
| The home did not maintain at least a 3-day supply of nonperishable food and drinking water for residents. |
| No inspection tags were on the fire extinguisher on the facility bus. |
| An unannounced fire drill was not held during July for the entire facility and not held during August in the personal care unit. |
| Resident medical evaluation did not include medical information pertinent to diagnosis and treatment in case of an emergency. |
| The home's menu for the current week was not posted in a public and conspicuous place throughout the facility. |
| The home did not have a copy of the driver's license in good standing for the person who operated the vehicle used to transport residents. |
| Prescription medications for residents were found in blister cards with ripped open foil on the back of pills. |
| Medication administration records (MAR) logs were incomplete or inaccurate for multiple residents. |
| Resident’s preadmission screening form was not completed within 30 days prior to admission. |
| Resident participated in the development of support plan but did not sign the support plan. |
| Resident admitted to Secure Dementia Care Unit did not have a written cognitive pre-admission screening. |
| Resident record did not include eye color or hair color, and lacked a recent photograph. |
Report Facts
License Capacity: 196
Residents Served: 28
Memory Care Unit Capacity: 18
Memory Care Residents Served: 3
Residents 60 Years or Older: 28
Residents with Supplemental Security Income: 0
Residents Diagnosed with Intellectual Disability: 0
Residents with Physical Disability: 0
Residents with Mobility Need: 1
Number of Wood Pallets: 9
Emergency Drinking Water Required: 84
Emergency Drinking Water Available: 66
Inspection Report
Original Licensing
Capacity: 149
Deficiencies: 3
Jun 1, 2023
Visit Reason
The inspection was conducted as a licensing inspection for a new personal care home facility that is not yet serving four or more residents, to assess compliance with 55 Pa. Code Ch. 2600.
Findings
The facility was found to be in substantial compliance with regulations but the licensing inspector was unable to complete a full inspection due to the facility being new and not yet serving four or more residents. Several citations related to fire safety approval, evacuation procedures, and key-locking devices were noted and plans of correction were submitted and accepted.
Deficiencies (3)
| Description |
|---|
| The home does not have a permanent certificate of occupancy. |
| The home does not have a maximum safe evacuation time specified in writing within the past year by a fire safety expert; evacuation time exceeded 2 minutes 30 seconds during a fire drill. |
| Directions for operating the home's locking mechanism are not conspicuously posted near any of the doors to and from the Secure Dementia Care Unit (SDCU). |
Report Facts
License Capacity: 149
Secure Dementia Care Unit Capacity: 19
Evacuation time: 150
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