Inspection Report
Follow-Up
Census: 82
Capacity: 182
Deficiencies: 6
Sep 4, 2025
Visit Reason
The inspection visit was conducted as a partial, unannounced follow-up to review the submitted plan of correction related to an incident.
Findings
The report details multiple deficiencies identified during the inspection, including unlocked confidential records, unlocked poisonous materials accessible to residents, stained ceiling tiles, lint accumulation in the dryer, incomplete resident assessments, and missing signage for key-locking devices. All deficiencies had plans of correction accepted and were implemented by October 27, 2025.
Deficiencies (6)
| Description |
|---|
| Resident records were unlocked, unattended, and accessible in the conference room, violating confidentiality requirements. |
| Micro-kill bleach wipes labeled as poisonous were unlocked and accessible to residents in the activity room cabinet on the 5th floor Bair unit. |
| Three stained ceiling tiles were found on the 5th floor hallway near a room, with an empty bucket and caution wet floor sign nearby. |
| Approximately 1 inch accumulation of lint was found in the lint trap of the commercial dryer. |
| Resident's most recent assessment did not reflect the need for a walker despite medical documentation indicating such need. |
| Directions for operating the home's locking mechanism were not conspicuously posted near the 5th floor fire door in the Secure Dementia Care Unit. |
Report Facts
Residents Served: 82
License Capacity: 182
Capacity: 39
Residents Served: 20
Current Residents: 4
Residents Age 60 or Older: 82
Residents with Mobility Need: 22
Total Daily Staff: 104
Waking Staff: 78
Inspection Report
Follow-Up
Census: 63
Capacity: 182
Deficiencies: 4
Jun 30, 2025
Visit Reason
The inspection visit was conducted as a follow-up to review the 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. Specific deficiencies related to bathroom ventilation, unlocked electrical breaker panels, unattended push pins, and missing menus in the memory care unit were corrected and verified through audits and staff education.
Deficiencies (4)
| Description |
|---|
| Bathroom in room did not have an operable window or ventilation fan; exhaust fan was inoperable. |
| Three electrical breaker panels in the memory care unit were unlocked and unattended, accessible to residents. |
| Approximately 5 push pins were left unattended in an unlocked cabinet accessible to residents in the memory care unit. |
| The home did not have a menu posted in the memory care unit. |
Report Facts
License Capacity: 182
Residents Served: 63
Secured Dementia Care Unit Capacity: 39
Secured Dementia Care Unit Residents Served: 24
Current Hospice Residents: 5
Residents Age 60 or Older: 87
Residents with Mobility Need: 24
Total Daily Staff: 87
Waking Staff: 65
Inspection Report
Monitoring
Census: 61
Capacity: 182
Deficiencies: 2
May 20, 2025
Visit Reason
The visit was an unannounced partial inspection conducted for monitoring purposes to review the facility's compliance and plan of correction implementation.
Findings
The inspection found deficiencies related to medication administration documentation, including missing blood sugar readings and missing staff initials on medication administration records. The facility submitted a plan of correction which was accepted and determined to be fully implemented.
Deficiencies (2)
| Description |
|---|
| Blood sugar reading not documented in resident's medication administration record and medication not signed out on controlled substance inventory log. |
| Medication administration record missing initials of staff who administered medications on multiple dates and times. |
Report Facts
Residents Served: 61
License Capacity: 182
Secured Dementia Care Unit Capacity: 39
Secured Dementia Care Unit Residents Served: 20
Hospice Current Residents: 7
Residents Age 60 or Older: 61
Residents with Mobility Need: 24
Total Daily Staff: 85
Waking Staff: 64
Inspection Report
Monitoring
Census: 60
Capacity: 182
Deficiencies: 10
May 13, 2025
Visit Reason
The visit was an unannounced partial inspection conducted as a monitoring review of Deer Meadows Residences to verify compliance with regulatory requirements and the submitted plan of correction.
Findings
The inspection identified multiple deficiencies related to training records, locking poisonous materials, sanitary conditions, surfaces, water pressure, windows, toilet paper availability, unobstructed egress, and numerous medication management issues including prescription accuracy, storage, labeling, administration, and documentation. All deficiencies had plans of correction accepted and were implemented by July 22, 2025.
Deficiencies (10)
| Description |
|---|
| The home's record of direct care staff training did not include the length or source of training. |
| An open closet containing poisonous materials was unlocked and accessible to residents in the secure dementia care unit. |
| Strong odor of urine and feces found in a resident's bathroom; used glove and face mask found on steps in fire tower #3. |
| Peeling paint, missing baseboards, and stained/missing ceiling tiles found in fire towers 4, 5, and 7. |
| Insufficient hot water pressure in the 5th floor bathroom near the dining area in the secure dementia care unit. |
| Broken window on the 2nd floor landing in fire tower #4 with top windowpane unable to properly close. |
| No toilet paper available for a toilet in a resident's bathroom. |
| Resident moved bedside table blocking exit from room, obstructing egress. |
| Medication cart contained discontinued medications and medications without current orders; improper medication storage and labeling. |
| Medication administration errors including administering wrong medication, missing documentation of administration times and initials, and failure to follow prescriber's orders. |
Report Facts
License Capacity: 182
Residents Served: 60
Residents Served in Secured Dementia Care Unit: 24
Current Hospice Residents: 6
Staffing Hours - Total Daily Staff: 89
Staffing Hours - Waking Staff: 67
Inspection Report
Follow-Up
Census: 64
Capacity: 182
Deficiencies: 2
May 5, 2025
Visit Reason
The inspection visit was conducted as a follow-up to review the submitted plan of correction for prior deficiencies at Deer Meadows Residences, triggered by a complaint.
Findings
The facility was found to have previously unlocked and unattended resident records and poisonous materials accessible in the nurses office on the secured dementia care unit. The plan of correction was accepted and fully implemented, including securing doors, staff training, and daily audits to ensure ongoing compliance.
Complaint Details
The inspection was complaint-related as indicated by the reason for inspection being 'Complaint'.
Deficiencies (2)
| Description |
|---|
| Resident records were unlocked, unattended, and accessible in the nurses office in the 3rd floor secured dementia care unit. |
| Poisonous materials including Aloe Vesta Daily Moisturizer, Biotene Fluoride Toothpaste, and We Care Vitamins A&D Ointment were unlocked, unattended, and accessible to residents in the nurses office in the 3rd floor secured dementia care unit. |
Report Facts
License Capacity: 182
Residents Served: 64
Secured Dementia Care Unit Capacity: 39
Secured Dementia Care Unit Residents Served: 25
Hospice Current Residents: 6
Staff Total Daily: 92
Staff Waking: 69
Residents Age 60 or Older: 64
Residents with Mobility Need: 28
Inspection Report
Renewal
Census: 76
Capacity: 182
Deficiencies: 20
Feb 11, 2025
Visit Reason
The inspection was conducted as a renewal and complaint investigation of Deer Meadows Residences to assess compliance with licensing requirements and address complaints.
Findings
Multiple deficiencies were identified including privacy violations, safeguarding resident money, medication management errors, sanitary conditions, safety hazards, and inadequate activity programming. Plans of correction were submitted and partially implemented with ongoing audits and staff training planned.
Complaint Details
The inspection included a complaint investigation related to medication errors, resident safety, and care concerns. Substantiation status is not explicitly stated.
Deficiencies (20)
| Description |
|---|
| Resident #1 did not have a shower curtain in bathroom. |
| No safeguard addendum in resident #2's file prior to 12/2/2024. |
| Staff person A's first aid training not certified by recognized health care organization. |
| Resident #1's dentures were observed on soap dispenser without container. |
| Dumpster was uncovered and gray cabinet outside dumpster. |
| Peeling paint on stairwell walls and caulk pulling away on resident #2's bathroom sink. |
| Resident #3's record did not include current medication list; discrepancies in medication dosages. |
| A bottle of medication was unlocked and accessible in resident #4's bathroom. |
| Damaged medications observed on medication cart for multiple residents. |
| Resident #12 was not administered prescribed Senna Oral tablet due to medication unavailability. |
| Resident #2 was administered an extra dose of trazodone without physician's PRN order. |
| Resident #2 exhibited behaviors without positive interventions until admission to secured dementia care unit. |
| Activities program did not include social, physical, intellectual, and recreational activities as scheduled. |
| Resident #1 did not have additional assessments despite signs of confusion. |
| Resident #1's support plan did not address behavioral needs of agitation and aggression. |
| No objection statement for resident #13's admission to secured dementia care unit. |
| Directions for operating locking mechanism not posted near Secure Dementia Care Unit door. |
| Resident #1 and #2 did not have operable lamp or source of light at bedside. |
| Resident #1 did not have roller to hold toilet paper in bathroom. |
| Insufficient hot water pressure in resident #3's kitchen sink. |
Report Facts
License Capacity: 182
Residents Served: 76
Residents Served in Secured Dementia Care Unit: 28
Hospice Residents: 7
Total Daily Staff: 109
Waking Staff: 82
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Residential Social Worker | Corrected safeguard violation for resident #2. | |
| Residential Administrator | Took immediate actions on multiple violations including privacy, sanitary conditions, and medication errors. | |
| Director of Environmental Services | Replaced shower curtain and repaired peeling paint. | |
| Residential Health Care Center Coordinator (RHCCC) | Addressed medication record errors and medication storage violations. | |
| Director of Plant Operations | Repaired water pressure issues, replaced toilet paper roller, and fixed locking mechanism signage. | |
| Activity Director | Addressed deficiencies in activity programming. |
Inspection Report
Complaint Investigation
Census: 73
Capacity: 182
Deficiencies: 0
Dec 11, 2024
Visit Reason
The inspection was conducted as a complaint investigation during an unannounced partial licensing inspection.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Complaint Details
The inspection was complaint-related, but no deficiencies or regulatory citations were found, indicating no substantiated issues.
Report Facts
Resident Census: 73
Total Licensed Capacity: 182
Secured Dementia Care Unit Capacity: 39
Secured Dementia Care Unit Residents Served: 27
Hospice Current Residents: 7
Resident Support Staff: 0
Total Daily Staff: 105
Waking Staff: 79
Inspection Report
Monitoring
Census: 73
Capacity: 182
Deficiencies: 3
Nov 18, 2024
Visit Reason
The visit was an unannounced partial inspection conducted as a monitoring review of Deer Meadows Residences to verify compliance with regulatory requirements and the submitted plan of correction.
Findings
The inspection found repeat violations related to resident personal equipment, additional assessments, and support plan documentation. The facility had issues with uncovered bedside mobility devices, incomplete assessments for residents receiving mobility devices, and insufficient detail in support plans regarding transfer assistance. The facility submitted and implemented a plan of correction by 12/16/2024.
Deficiencies (3)
| Description |
|---|
| Resident has a bedside mobility device that is uncovered and not attached to the bed frame, with an open space measuring 4 inches by 20 inches long. |
| The home did not complete an assessment for a resident when the bedside mobility device was received, despite signed consent. |
| The resident's support plan did not document how the need for transfer assistance would be met. |
Report Facts
Residents Served: 73
License Capacity: 182
Secured Dementia Care Unit Capacity: 39
Secured Dementia Care Unit Residents Served: 29
Hospice Current Residents: 4
Residents Age 60 or Older: 73
Residents with Mobility Need: 37
Total Daily Staff: 110
Waking Staff: 83
Inspection Report
Renewal
Census: 66
Capacity: 182
Deficiencies: 18
Mar 11, 2024
Visit Reason
The inspection was conducted as a renewal and complaint investigation to review compliance with licensing requirements and to verify the implementation of the submitted plan of correction.
Findings
Multiple deficiencies were identified including issues with record confidentiality, contract signatures, staff qualifications, resident personal equipment safety, sanitary conditions, food labeling and storage, medical evaluations, medication storage and labeling, support plans, and preadmission screening. Plans of correction were accepted and implemented by the facility with ongoing audits and staff education.
Complaint Details
The inspection included a complaint investigation component as indicated by the reason for visit: Renewal, Complaint. Specific complaint details or substantiation status are not explicitly stated.
Deficiencies (18)
| Description |
|---|
| Resident records were unlocked, unattended, and accessible to a non-staff laboratory worker. |
| Resident-home contract for Resident 1 was not signed by the resident. |
| Direct care staff persons A and B did not have a high school diploma, GED, or active registry status initially. |
| Uncovered bedside mobility devices in residents' beds posed a hazardous condition. |
| Staff person used bare, ungloved fingers during medication pass; another staff observed without shoes in dining room. |
| Five unlabeled, undated leftover sandwiches found in memory care kitchen fridge. |
| Unlabeled and undated cold cut turkey, ham, cheese, beef bologna, and icing found in kitchen storage. |
| Resident 3's medical evaluation did not include immunization history and mobility needs assessment. |
| Resident 1’s most recent medical evaluation was overdue. |
| Menus posted but lunch served did not follow the posted menu on two days. |
| Medications in memory care and personal care medication carts lacked open date labeling and were past discard dates. |
| Resident 4's medication container lacked a complete pharmacy label. |
| Medication administration and documentation errors including missing blood glucose readings and narcotics log discrepancies. |
| Resident 7 and 8’s preadmission screening forms lacked determination that the resident's needs can be met by the home. |
| Resident 3’s additional assessment was overdue. |
| Resident 1’s support plan did not initially indicate need for bedside mobility device; Resident 9’s support plan had clerical error regarding medication self-administration. |
| Resident 7 participated in support plan development but did not sign the plan. |
| Resident 3’s written cognitive preadmission screening date was unknown. |
Report Facts
License Capacity: 182
Residents Served: 66
Secured Dementia Care Unit Capacity: 20
Secured Dementia Care Unit Residents Served: 19
Current Hospice Residents: 7
Residents Age 60 or Older: 66
Residents with Mobility Need: 30
Staff Resident Support: 96
Total Daily Staff: 192
Waking Staff: 144
Inspection Report
Follow-Up
Census: 66
Capacity: 182
Deficiencies: 5
Feb 8, 2024
Visit Reason
The inspection was a partial, unannounced follow-up visit to review the submitted plan of correction for the facility.
Findings
The submitted plan of correction was determined to be fully implemented with continued compliance required. Several deficiencies were identified and corrected, including removal of a hazardous retractable gate, adjustment of hot water temperature, installation of a working landline telephone, posting of emergency telephone numbers, and replacement of a missing thermometer in the first aid kit.
Deficiencies (5)
| Description |
|---|
| A retractable gate in the resident dining room of the proposed new Secured Dementia Care Unit presented hazards such as climbing or appendage entrapment. |
| Hot water temperature at the bathroom sink of a resident room measured 125.7°F, exceeding the maximum allowed 120°F. |
| The home did not have a working, non-coin-operated landline telephone in the proposed new Secured Dementia Care Unit. |
| No emergency telephone numbers, including nearest hospital and fire department, were posted in the proposed new Secured Dementia Care Unit. |
| The first aid kit in the nursing station did not include a thermometer. |
Report Facts
License Capacity: 182
Residents Served: 66
Secured Dementia Care Unit Capacity: 20
Secured Dementia Care Unit Residents Served: 19
Hot Water Temperature: 125.7
Hot Water Temperature: 110.1
Staffing Hours - Total Daily Staff: 96
Staffing Hours - Waking Staff: 72
Residents with Mobility Need: 30
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Plant Operations | Named in relation to making adjustments to the boiler and installing the physical phone. | |
| Administrator | Named in relation to immediate corrective actions including phone installation and staff education. |
Inspection Report
Renewal
Census: 53
Capacity: 182
Deficiencies: 15
Sep 7, 2022
Visit Reason
The inspection was conducted as a full, unannounced visit for renewal and complaint reasons, with an exit conference on 09/08/2022.
Findings
The inspection identified multiple deficiencies including failure to post current license inspection summaries, unsigned resident contracts, incomplete medical evaluations, medication administration training deficiencies, storage and labeling issues, obstructed egress, incorrect exit signage, and uncovered trash receptacles. Plans of correction were accepted and implemented for all violations.
Deficiencies (15)
| Description |
|---|
| The home's most recent License Inspection Summaries were not posted in a conspicuous and public place. |
| Resident-home contract for resident #1 was not signed by the resident. |
| Resident #1's record did not contain a signed statement acknowledging receipt of resident rights and complaint procedures. |
| Resident #2 did not have access to a source of light that can be turned on/off at bedside. |
| Outdated or undated food items found in dry storage area. |
| Three large bags of sand blocked egress from the home's fire tower #5 exit. |
| Exit sign on the 4th floor near Fire Tower 8 was pointing in the wrong direction. |
| Resident #1's medical evaluation missing height, weight, and immunization history; Resident #3's evaluation missing general physical exam, immunization history, ability to self-administer, and health status; Resident #4's evaluation missing height, weight, immunization history, allergies, body positioning, and ability to self-administer. |
| Staff person A administered medications without completing required medication administration training. |
| Glucometer readings for Resident #5 did not match recorded blood glucose readings on Medication Administration Record. |
| Resident #1 was not educated on the right to refuse medication if a medication error is suspected. |
| Resident #5's preadmission screening form was outdated; Resident #6's preadmission screening form lacked determination that resident's needs can be met. |
| Resident #3's current assessment was completed late; previous assessment was also late. |
| Residents #3 and #4 participated in support plan development but did not sign the support plan. |
| Uncovered, unattended trash can in the main kitchen. |
Report Facts
License Capacity: 182
Residents Served: 53
Staffing Hours: 71
Waking Staff: 53
Secured Dementia Care Unit Capacity: 20
Secured Dementia Care Unit Residents Served: 16
Hospice Current Residents: 19
Residents 60 Years or Older: 53
Residents with Mobility Need: 18
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff Person A | Named in medication administration training deficiency and medication administration violations. | |
| Administrator | Named in multiple findings related to plan of correction implementation and resident contract issues. | |
| Maintenance Director | Named in findings related to removal of sand bags blocking egress and correction of exit signage. | |
| Dietary Director | Named in findings related to food storage and audit. | |
| Residential Health Center Coordinator | Named in findings related to medical evaluation audits and glucometer audits. | |
| Admissions Coordinator | Named in findings related to contract audits and admission procedures. | |
| Social Worker | Named in findings related to support plan audits. |
Inspection Report
Census: 44
Capacity: 182
Deficiencies: 0
Dec 9, 2021
Visit Reason
The inspection was conducted as a licensing inspection triggered by an incident at the facility.
Findings
No regulatory citations or deficiencies were identified during this unannounced partial inspection.
Report Facts
Total Daily Staff: 58
Waking Staff: 44
Residents Served: 44
License Capacity: 182
Residents with Mobility Need: 14
Residents 60 Years or Older: 44
Inspection Report
Renewal
Capacity: 182
Deficiencies: 0
Dec 1, 2021
Visit Reason
The document is related to the renewal of the license for Deer Meadows Residences, a Personal Care Home, following receipt of the renewal application dated August 17, 2021. The Department advises that an onsite inspection will be conducted within the next twelve months as required by regulation.
Findings
The Department issued a regular license in response to the renewal application. The certificate of compliance is valid from December 1, 2021, to December 1, 2022. No findings of noncompliance or deficiencies are stated in the documents provided.
Report Facts
Maximum licensed capacity: 182
Secure Dementia Care Unit capacity: 20
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sarah Hutchins | Administrator | Named as legal entity representative on renewal application |
| Jamie L. Buchenauer | Deputy Secretary, Office of Long-term Living | Signed renewal license letter |
Inspection Report
Complaint Investigation
Census: 49
Capacity: 182
Deficiencies: 7
Oct 19, 2021
Visit Reason
The inspection was conducted as a complaint investigation following a complaint received by the Pennsylvania Department of Human Services.
Findings
The inspection found multiple deficiencies related to resident care including failure to provide assistance with personal hygiene and dressing, unlocked medication storage, incomplete medication records, and inadequate documentation in resident support plans. Plans of correction were accepted and implemented with staff education and procedural improvements.
Complaint Details
The visit was complaint-related as indicated by the inspection reason and was a partial unannounced inspection conducted on 10/19/2021.
Deficiencies (7)
| Description |
|---|
| Resident #1 did not receive required assistance with personal hygiene on 09/28/21. |
| Resident #1 did not receive required assistance with dressing, undressing, and care of clothes on 09/30/21. |
| Medication cart was unlocked, unattended, and accessible inside the medication room on 10/19/21 at 2:30 pm. |
| Narcotic log sheet for resident #2 showed unexplained discrepancy in pill count on 09/17/21. |
| Resident #1's medication administration record did not indicate diagnosis or purpose for medications including PRN. |
| Resident #2 and #3's medication administration records lacked initials of staff administering medications on multiple dates in October 2021. |
| Resident #1's support plan did not document how dementia care needs would be met. |
Report Facts
License Capacity: 182
Residents Served: 49
Residents Served in Secured Dementia Care Unit: 17
Hospice Current Residents: 21
Residents with Mobility Need: 18
Total Daily Staff: 67
Waking Staff: 50
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Deer Meadows Administrator | Named in multiple findings related to education and implementation of plans of correction. | |
| Deer Meadows Educator | Named in multiple findings related to education and implementation of plans of correction. |
Inspection Report
Complaint Investigation
Census: 50
Capacity: 182
Deficiencies: 0
May 25, 2021
Visit Reason
The inspection was conducted as a complaint investigation at Deer Meadows Residences on 05/25/2021.
Findings
No regulatory citations or deficiencies were identified during this inspection.
Complaint Details
The inspection was complaint-related, but no deficiencies or citations were substantiated.
Report Facts
Residents Served: 50
License Capacity: 182
Secured Dementia Care Unit Capacity: 20
Residents Served in Dementia Care Unit: 17
Hospice Current Resident Count: 19
Residents Age 60 or Older: 50
Residents with Mobility Need: 20
Inspection Report
Follow-Up
Census: 50
Capacity: 182
Deficiencies: 7
May 17, 2021
Visit Reason
The inspection was conducted as a follow-up to verify the implementation of a previously submitted plan of correction for Deer Meadows Residences.
Findings
The facility was found to have corrected all cited deficiencies, including sanitary conditions, trash receptacle coverage, water pressure, menu posting, and medication management. The plan of correction was fully implemented and compliance was maintained.
Deficiencies (7)
| Description |
|---|
| Living room carpet was stained and bathroom shower curtain was dirty and stained. |
| Trash cans in public bathrooms and dining room bathroom were uncovered and lacked lids. |
| Hot water and water pressure were insufficient in a bedroom and a bathroom. |
| Weekly menu posted outside dining room was not current. |
| Discontinued medications were still on the medication cart for resident #1. |
| An Albuterol package on the med cart was not labeled with the resident's name. |
| Medication label directions did not match prescriber's orders for residents #1, #2, and #4. |
Report Facts
License Capacity: 182
Residents Served: 50
Secured Dementia Care Unit Capacity: 20
Secured Dementia Care Unit Residents Served: 17
Current Hospice Residents: 19
Residents Age 60 or Older: 50
Residents with Mobility Need: 20
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Shawn Parker | Signed the letter confirming the plan of correction was fully implemented | |
| Director of Environmental Services | Responsible for correcting sanitary conditions and trash receptacle deficiencies | |
| Director of Plant Operations | Responsible for correcting water pressure deficiencies | |
| Director of Dinning Services | Responsible for correcting menu posting deficiency | |
| Interim Personal Care Administrator | Completed medication cart audits and educated staff on medication regulations | |
| Resident Health Center Coordinator | Responsible for ongoing medication cart audits |
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