Deficiencies (last 5 years)
Deficiencies (over 5 years)
29.4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
526% worse than Pennsylvania average
Pennsylvania average: 4.7 deficiencies/yearDeficiencies per year
20
15
10
5
0
Census
Latest occupancy rate
45% 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
Complaint Investigation
Deficiencies: 2
Date: Oct 23, 2025
Visit Reason
The inspection was conducted to investigate complaints regarding the facility's failure to develop a comprehensive care plan for dementia care and to provide adequate activities to meet residents' needs.
Complaint Details
The visit was complaint-related, focusing on deficiencies in care planning for dementia and activity programming. Substantiation status is not explicitly stated.
Findings
The facility failed to develop a person-centered comprehensive care plan related to dementia care for one resident and failed to provide an ongoing program of activities to support the physical, mental, and psychosocial well-being of residents on two nursing units. Observations and staff interviews confirmed lack of individualized activities and insufficient staffing to conduct one-on-one visits.
Deficiencies (2)
Failed to develop a person-centered comprehensive care plan related to dementia care and/or activities for one of 35 residents reviewed.
Failed to provide an ongoing program of activities to meet the interests of and support the physical, mental, and psychosocial well-being of each resident for two of eight nursing units.
Report Facts
Residents reviewed: 35
Residents affected: 1
Residents affected: 2
Residents on dining room: 16
Fidget items available: 3
Nursing units: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee E2 | Director of Nursing | Confirmed no care plan was developed for Resident R55 related to Dementia Care and/or activities |
| Employee E13 | Nursing Assistant | Reported lack of activities and engagement for Resident R55 |
| Employee E15 | Director of Activities | Reported one-on-one room visits were not taking place due to staffing issues |
| Employee E16 | Assistant Activities Director | Reported one-on-one room visits were not taking place due to staffing issues |
| Employee E17 | Activity Aide / Nursing Aide | Reported lack of activities and insufficient fidget items for residents |
Inspection Report
Annual Inspection
Deficiencies: 11
Date: Oct 23, 2025
Visit Reason
The inspection was conducted to assess compliance with state and federal regulations related to nursing home operations, resident care, safety, and facility management.
Findings
The facility was found deficient in multiple areas including maintaining a clean and homelike environment, accurate resident assessments, timely development of baseline care plans, comprehensive care planning especially for dementia care, assistance with activities of daily living, provision of resident activities, fall prevention and supervision, catheter care, physician oversight for significant weight loss, and medication administration accuracy. Several residents were affected with minimal to actual harm noted.
Deficiencies (11)
Failed to maintain the facility in a clean and homelike condition in one of eight nursing units (Dementia Unit 2nd floor) with strong urine odor detected and mattress replacement needed.
Failed to ensure that MDS (Minimum Data Set) resident assessment was completed accurately for one of thirty-five residents reviewed.
Failed to ensure that a baseline care plan was developed within 48 hours of a resident's admission for one of thirty-five residents observed.
Failed to develop a person-centered comprehensive care plan related to dementia care and/or activities for one of 35 residents reviewed.
Failed to provide necessary assistance with activities of daily living (ADLs) to maintain proper grooming for one of four residents reviewed.
Failed to provide an ongoing program of activities to meet the interests and support the physical, mental, and psychosocial well-being of residents on two nursing units.
Failed to ensure all interventions to prevent fall incidents were in place after a resident was transferred into bed, resulting in actual harm (fractured jaw) for one of three residents reviewed for falls.
Failed to ensure urinary drainage systems were properly positioned and maintained to prevent urine backflow and urinary tract infection for one of ten residents observed with urinary catheter.
Failed to ensure a physician assessment was completed related to unplanned weight loss for one of six residents reviewed.
Failed to ensure medication error rates were below 5 percent; medication error rate of 5.88% was identified for one of three residents observed during medication administration.
Failed to submit complete and accurate information to the State Survey Agency regarding a resident fall for one of three residents reviewed for facility reported incidents.
Report Facts
Residents reviewed: 35
Residents reviewed: 4
Residents reviewed: 10
Residents reviewed: 6
Residents observed: 3
Medication error rate: 5.88
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee E10 | Unit Manager | Confirmed urine odor and mattress replacement in dementia unit |
| Employee E8 | Licensed Nurse | Confirmed strong urine odor near resident rooms |
| Employee E9 | Housekeeping Staff Member | Confirmed urine odor and cleaning issues |
| Employee E11 | Certified Nursing Assistant | Reported resident change in room with urine odor |
| Employee E5 | Director of Social Worker | Confirmed erroneous MDS assessment coding |
| Employee E6 | Social Worker Assistant | Completed erroneous MDS section B0200 |
| Employee E7 | Charge Nurse | Confirmed resident nephrostomy and care plan absence |
| Employee E2 | Director of Nursing | Confirmed multiple care plan and care deficiencies |
| Employee E13 | Assistant Director of Nursing | Confirmed fall incident and lack of fall mats |
| Employee E12 | Nurse Aide | Failed to provide scheduled shower to resident |
| Employee E15 | Director of Activities | Reported staffing issues affecting resident activities |
| Employee E16 | Assistant Activities Director | Reported staffing issues affecting resident activities |
| Employee E17 | Activity Aide | Reported limited activity resources and resident engagement |
| Employee E19 | Agency Nurse Aide | Involved in resident fall incident without fall mats in place |
| Employee E4 | Licensed Nurse | Administered medications resulting in medication error |
| Employee E14 | Dietitian | Reported notification of physician regarding resident weight loss |
Inspection Report
Follow-Up
Census: 82
Capacity: 182
Deficiencies: 6
Date: 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)
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
Deficiencies: 1
Date: Jul 14, 2025
Visit Reason
The inspection was conducted to assess compliance with professional standards regarding the maintenance of clinical records and safeguarding resident-identifiable information.
Findings
The facility failed to maintain clinical records in accordance with professional standards for one of three clinical records reviewed, specifically for Resident R2. Vital signs were not documented during the night shift on June 14, 2025, and a licensed nurse documented identical vital signs for both evening and night shifts.
Deficiencies (1)
Failure to maintain clinical records in accordance with professional standards, including lack of documentation of vital signs during the night shift and duplicate documentation of vital signs for evening and night shifts.
Report Facts
Residents affected: 3
Residents affected: Few
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee E3 | Licensed nurse | Named in relation to failure to document vital signs properly |
Inspection Report
Follow-Up
Census: 63
Capacity: 182
Deficiencies: 4
Date: 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)
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
Date: 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)
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
Date: 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)
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
Date: 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.
Complaint Details
The inspection was complaint-related as indicated by the reason for inspection being '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.
Deficiencies (2)
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
Routine
Deficiencies: 1
Date: Apr 16, 2025
Visit Reason
The inspection was conducted to assess the facility's compliance with infection prevention and control standards, specifically reviewing treatment and services related to intravenous therapy for residents.
Findings
The facility failed to provide necessary treatment and services to prevent infection in one of three residents reviewed for intravenous therapy. Observations included an unchanged PICC line dressing beyond the ordered interval, missing disinfecting cap on the PICC line connector, and a heavily soiled resident room environment.
Deficiencies (1)
Failure to provide and implement an infection prevention and control program, including failure to change PICC line dressing as ordered and maintain cleanliness.
Report Facts
Residents reviewed for Intravenous Therapy: 3
Residents affected: 1
Days between dressing changes as ordered: 5
Date of last documented dressing change: Apr 4, 2025
Date of observation: Apr 16, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse | Confirmed missing Swab Cap on PICC line connector on April 16, 2025 | |
| Director of Nursing | Confirmed heavily soiled floor and IV pole in Resident R1's room on April 16, 2025 |
Inspection Report
Routine
Deficiencies: 1
Date: Mar 10, 2025
Visit Reason
The inspection was conducted to evaluate the facility's pest control program and ensure it effectively prevents and manages mice, insects, and other pests.
Findings
The facility was found not to be maintaining an effective pest control program on one of eight nursing units, with observations and resident interviews confirming the presence of roaches and mice in multiple areas. Pest control reports from the prior two months documented ongoing issues with roaches and mice, and the facility planned a deep spray treatment of 10 rooms at a time.
Deficiencies (1)
Failure to maintain an effective pest control program to prevent/deal with mice, insects, or other pests.
Report Facts
Rooms treated at a time: 10
Number of nursing units: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Unit Manager | Employee E3 confirmed concerns related to pests and was observed killing roaches. | |
| Nursing Home Administrator | Employee E1 confirmed roaches and mice were an issue and described the pest control plan. |
Inspection Report
Renewal
Census: 76
Capacity: 182
Deficiencies: 20
Date: 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.
Complaint Details
The inspection included a complaint investigation related to medication errors, resident safety, and care concerns. Substantiation status is not explicitly stated.
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.
Deficiencies (20)
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
Deficiencies: 1
Date: Dec 30, 2024
Visit Reason
The inspection was conducted to ensure that residents are free from significant medication errors, focusing on medication administration timeliness and compliance with facility policy.
Findings
The facility failed to provide medications in a timely manner, resulting in significant medication errors for one of five residents reviewed. Resident R1 received multiple medications approximately two hours late, which is outside the one-hour timeframe required by facility policy.
Deficiencies (1)
Failure to provide medications timely, resulting in significant medication error for Resident R1.
Report Facts
Medication administration delay: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee E1 | Administrator | Interviewed regarding medication administration delay for Resident R1 |
Inspection Report
Complaint Investigation
Census: 73
Capacity: 182
Deficiencies: 0
Date: Dec 11, 2024
Visit Reason
The inspection was conducted as a complaint investigation during an unannounced partial licensing inspection.
Complaint Details
The inspection was complaint-related, but no deficiencies or regulatory citations were found, indicating no substantiated issues.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
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
Routine
Deficiencies: 10
Date: Nov 22, 2024
Visit Reason
The inspection was a routine survey conducted to assess compliance with regulatory requirements related to resident rights, safety, care, and infection control at Deer Meadows Rehabilitation Center.
Findings
The facility was found deficient in multiple areas including failure to respect residents' rights regarding personal possessions, maintaining safe and comfortable environmental conditions, providing adequate nursing care such as nail care and pressure ulcer management, implementing fall prevention interventions, monitoring nutritional status, administering oxygen therapy as ordered, providing trauma-informed culturally competent care, maintaining infection control practices, and maintaining an effective pest control program.
Deficiencies (10)
Failed to treat residents with respect and dignity related to the right to retain and use personal possessions.
Failed to maintain comfortable and safe temperature levels for one of eight units in the facility.
Failed to provide nail care for a dependent resident.
Failed to provide appropriate pressure ulcer care and prevent new ulcers from developing for four residents.
Failed to implement fall interventions for two residents.
Failed to monitor and modify interventions consistent with the resident's assessed nutritional needs.
Failed to administer oxygen as ordered by the physician for two residents receiving oxygen therapy.
Failed to provide culturally competent, trauma informed care accounting for residents' past experiences and preferences.
Failed to maintain an effective infection control program related to urinary catheters and respiratory care equipment.
Failed to maintain an effective pest control program to keep the facility free of pests and rodents.
Report Facts
Residents reviewed: 35
Residents reviewed: 8
Residents reviewed: 35
Residents reviewed: 6
Residents reviewed: 5
Residents reviewed: 7
Residents reviewed: 4
Weight loss: 9.3
Weight loss: 11.5
Temperature: 86
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee E15 | Unit Manager | Named in findings related to removal of resident's personal possessions, pressure ulcer care, and fall prevention |
| Employee E11 | Licensed Practical Nurse | Named in findings related to temperature control and nail care |
| Employee E12 | Director of Maintenance | Named in findings related to temperature control |
| Employee E13 | Assistant Director of Maintenance | Named in findings related to temperature measurement |
| Employee E14 | Licensed Practical Nurse | Named in findings related to fall prevention |
| Employee E7 | Unit Manager, Registered Nurse | Named in findings related to fall prevention and pest control |
| Employee E17 | Registered Dietitian | Named in findings related to nutritional monitoring and intervention |
| Employee 5 | Nurse Aide | Named in findings related to oxygen therapy administration |
| Employee 6 | Unit Manager | Named in findings related to oxygen therapy administration |
Inspection Report
Monitoring
Census: 73
Capacity: 182
Deficiencies: 3
Date: 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)
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
Deficiencies: 1
Date: Jul 25, 2024
Visit Reason
The inspection was conducted to evaluate the safety and operational condition of essential food service equipment in the facility's kitchen.
Findings
The facility failed to maintain essential food service equipment safely, specifically a main kitchen grill operating without necessary knobs for safe operation. The grill had been used for several weeks without knobs, and replacement knobs were on backorder.
Deficiencies (1)
Main kitchen grill had 3 burners without knobs to operate safely; the oven next to the grill had one missing knob.
Report Facts
Burners without knobs: 3
Burners with missing knob: 3
Days grill operated without knobs: 24
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jul 2, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding a significant medication error where medications prepared for one resident were administered to a different resident.
Complaint Details
The complaint investigation revealed that on June 22, 2024, Licensed nurse Employee E3 administered medications intended for Resident R2 to Resident R1, resulting in Resident R1 receiving multiple medications including Oxycodone ER 80 mg and others. Resident R1 was given Narcan and monitored, but subsequently had low blood pressure and was transferred to the emergency room. Employee E3 had completed medication pass competency for two residents on May 17, 2024.
Findings
The facility failed to ensure residents were free from significant medication errors, specifically a medication administration error by a licensed nurse who gave Resident R1 medications intended for Resident R2. Resident R1 experienced adverse effects requiring emergency room transfer.
Deficiencies (1)
Failure to ensure residents are free from significant medication errors related to administration of medications prepared for a different resident.
Report Facts
Medication doses administered: 8
Blood pressure reading: 85
Blood pressure reading: 82
Medication pass competency date: May 17, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee E3 | Licensed nurse | Named in medication error finding for administering wrong medications to Resident R1. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: May 15, 2024
Visit Reason
The inspection was conducted following a complaint investigation regarding alleged misappropriation of resident property and abuse involving Resident R1 and nursing aide Employee E3 on May 15, 2024.
Complaint Details
The complaint involved allegations that nursing aide Employee E3 misappropriated Resident R1's property by ripping off posters and physically abused Resident R1 by kicking her. The investigation substantiated mental abuse but found no camera or witness evidence of physical abuse. Resident R1 refused psychiatric evaluation and full body assessment. Employee E3 was placed on administrative leave and terminated after the investigation.
Findings
The facility failed to ensure residents were free from misappropriation of property and mental abuse. Employee E3 was found to have torn down Resident R1's posters, escalating a verbal altercation. The investigation substantiated mental abuse but found no evidence of physical abuse. Employee E3 was suspended and later terminated.
Deficiencies (1)
Failure to protect residents from misappropriation of property and mental abuse by staff.
Report Facts
Residents reviewed: 10
Date of incident: May 15, 2024
Date of report: May 31, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee E3 | Certified Nursing Aide | Named in misappropriation and mental abuse findings. |
| Employee E4 | Licensed Nurse | Documented Resident R1's behavior and intervened during incident. |
| Employee E8 | Licensed Nurse Supervisor | Notified on-call nurse practitioner and supervisor during incident. |
Inspection Report
Routine
Deficiencies: 1
Date: Apr 17, 2024
Visit Reason
The inspection was conducted to evaluate the facility's compliance with food service standards, specifically to ensure that food and drink were palatable, attractive, and served at safe and appetizing temperatures.
Findings
The facility failed to serve foods at proper temperatures and palatability standards on one of eight nursing floors (Ground Wing C). Resident complaints and test tray temperature measurements confirmed that hot foods and beverages were often served below the required temperatures.
Deficiencies (1)
Failure to serve foods that were palatable and at proper temperatures on Ground Wing C nursing unit.
Report Facts
Food temperature: 127
Food temperature: 121.6
Food temperature: 133.2
Food temperature: 113.1
Food temperature: 58.1
Food temperature: 57.1
Food temperature: 80
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Staff | Employee E4 confirmed that the test tray food temperature did not meet facility standards |
Inspection Report
Renewal
Census: 66
Capacity: 182
Deficiencies: 18
Date: 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.
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.
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.
Deficiencies (18)
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
Routine
Deficiencies: 13
Date: Feb 16, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, care planning, nursing services, food safety, respiratory care, and COVID-19 vaccination among others at Deer Meadows Rehabilitation Center.
Findings
The facility was found deficient in multiple areas including failure to uphold resident dignity, inadequate accommodation of resident needs, failure to maintain a safe and clean environment, inaccurate resident assessments, incomplete care plans, failure to follow physician orders, inadequate supervision to prevent aspiration, improper food preparation and storage, failure to administer oxygen as ordered, and delayed COVID-19 vaccination for a resident.
Deficiencies (13)
Failure to uphold the dignity of residents including verbal abuse by staff.
Failure to accommodate residents' needs related to bariatric bed and bedside chair.
Failure to provide a safe, clean, comfortable and homelike environment on one nursing unit.
Failure to ensure accurate Minimum Data Set assessments reflecting residents' cognitive status.
Failure to develop comprehensive person-centered care plans related to supervision needs.
Failure to revise care plan for participation in restorative therapy when resident no longer participated.
Failure to ensure physician's orders were followed for wound care and medication administration.
Failure to provide appropriate supervision to prevent aspiration for a resident.
Failure to provide food prepared in a form designed to meet individual needs for a resident on a mechanically altered diet.
Failure to administer oxygen as ordered by the physician for a resident.
Failure to ensure foods were stored in accordance with food safety standards in a nursing unit pantry.
Failure to timely provide COVID-19 vaccine to a resident who consented.
Failure to ensure a safe, sanitary and functional environment for residents including wheelchair maintenance and leaking toilet.
Report Facts
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 3
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee E9 | Nurse Aide | Named in verbal abuse finding and terminated |
| Employee E1 | Nursing Home Administrator | Interviewed regarding abuse investigation and care needs |
| Employee E12 | Unit Manager | Confirmed resident clothing and environmental findings |
| Employee E4 | Licensed Nurse Unit Manager | Interviewed regarding bariatric chair and wound care supplies |
| Employee E7 | Rehabilitation Director | Interviewed regarding bariatric bed and chair |
| Employee E10 | Registered Nurse Assessment Coordinator | Interviewed regarding inaccurate MDS assessments |
| Employee E17 | Licensed Nurse | Observed and interviewed regarding supervision and medication administration |
| Employee E13 | Speech Therapist | Interviewed regarding diet and supervision orders |
| Employee E16 | Occupational Therapist | Interviewed regarding aspiration risk and care plan |
| Employee E2 | Director of Nursing | Confirmed medication administration issues |
| Employee E15 | Licensed Wound Nurse | Confirmed wound care orders |
| Employee E14 | Regional Food Service Manager | Confirmed pantry food safety observations |
| Employee E20 | Nursing Assistant | Interviewed regarding leaking toilet |
| Assistant Director of Nursing | Assistant Director of Nursing | Interviewed regarding COVID-19 vaccination delay |
Inspection Report
Follow-Up
Census: 66
Capacity: 182
Deficiencies: 5
Date: 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)
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
Complaint Investigation
Deficiencies: 3
Date: Mar 8, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to secure housekeeping carts and hazardous chemical products, which led to a resident accessing and ingesting a hazardous chemical.
Complaint Details
The complaint investigation revealed that Resident R1 accessed and ingested a hazardous chemical disinfectant left unsecured on a housekeeping cart. The resident experienced multiple vomiting episodes and was found unresponsive later, resulting in death. The facility failed to secure chemicals, follow physician orders, and properly document events. Immediate Jeopardy was identified and later lifted after corrective actions.
Findings
The facility failed to secure housekeeping carts and hazardous chemicals, allowing Resident R1 to access and ingest a disinfectant, resulting in vomiting episodes and ultimately death. The facility did not follow physician orders for monitoring, failed to document critical events, and left hazardous chemicals accessible to residents, creating an Immediate Jeopardy situation.
Deficiencies (3)
Failure to notify the resident's physician of a resident's medical condition and failure to follow physician orders for vital signs and assessment every 15 to 30 minutes.
Failure to secure housekeeping cart and hazardous chemical products, allowing residents access to hazardous chemicals, resulting in Immediate Jeopardy to resident health or safety.
Failure of Nursing Home Administrator and Director of Nursing to effectively manage the facility to ensure proper procedures were followed related to securing housekeeping carts and hazardous chemicals.
Report Facts
Residents with dementia on affected units: 27
Residents ambulatory with dementia: 5
Plan of correction audits frequency: 1
Plan of correction audits frequency: 4
Plan of correction audits frequency: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee E4 | Nursing Assistant | Observed Resident R1 drinking disinfectant and intervened to remove the bottle. |
| Employee E5 | Nursing Assistant | Witnessed Resident R1 vomiting episodes and change in voice. |
| Employee E6 | Licensed Nurse | Took vital signs of Resident R1 after ingestion and found them normal. |
| Employee E7 | Nursing Assistant | Observed janitor room door left open and cart in hallway. |
| Employee E8 | Housekeeping Staff | Observed housekeeping carts with unsecured chemicals and unlocked janitor closets. |
| Employee E9 | Housekeeping Staff | Reported previous shift left cart in hallway unsecured. |
| Employee E10 | Housekeeping Director | Conducted audit of housekeeping carts, confirmed broken cart door, and improper storage. |
| Employee E11 | Housekeeping Staff | Left housekeeping cart in hallway to clean flood, contributing to unsecured chemicals. |
| Employee E11 | Physician | Ordered monitoring of Resident R1 after ingestion and assessed resident stable at 9:00 a.m. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Feb 8, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to ensure proper resident care equipment was used to transfer one resident.
Complaint Details
The complaint investigation found that Resident R10 was roughly tossed into bed by a nursing assistant, causing intense pain and requiring hospital admission. The complaint was substantiated based on clinical records, interviews, and care plan review.
Findings
The facility failed to use the proper equipment and procedures to transfer Resident R10, who required assistance of two staff members and a mechanical lift. Resident R10 was reportedly roughly handled during transfer, resulting in severe back pain and hospitalization.
Deficiencies (1)
Failure to ensure that the proper resident care equipment was used to transfer one resident, resulting in potential harm.
Report Facts
Medication dosage: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee E8 | Nursing Assistant | Named in rough handling of Resident R10 during transfer |
| Employee E9 | Registered Nurse | Assessed Resident R10 and administered pain medication |
| Employee E7 | Licensed Nurse | Confirmed proper transfer procedures for Resident R10 |
Inspection Report
Renewal
Census: 53
Capacity: 182
Deficiencies: 15
Date: 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)
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
Date: 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
Date: 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
Date: Oct 19, 2021
Visit Reason
The inspection was conducted as a complaint investigation following a complaint received by the Pennsylvania Department of Human Services.
Complaint Details
The visit was complaint-related as indicated by the inspection reason and was a partial unannounced inspection conducted on 10/19/2021.
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.
Deficiencies (7)
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
Date: May 25, 2021
Visit Reason
The inspection was conducted as a complaint investigation at Deer Meadows Residences on 05/25/2021.
Complaint Details
The inspection was complaint-related, but no deficiencies or citations were substantiated.
Findings
No regulatory citations or deficiencies were identified during this inspection.
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
Date: 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)
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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