Inspection Reports for Divine Living Home
3828 COMLUMBIA AVENUE,, MOUNTVILLE, PA, 17554
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
29.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
532% worse than Pennsylvania average
Pennsylvania average: 4.7 deficiencies/yearDeficiencies per year
32
24
16
8
0
Census
Latest occupancy rate
77% occupied
Based on a August 2024 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Renewal
Census: 30
Capacity: 39
Deficiencies: 32
Aug 27, 2024
Visit Reason
The inspection was conducted as a renewal, provisional inspection of Divine Living Home to assess compliance with applicable laws and regulations.
Findings
The inspection identified multiple deficiencies including expired licenses posted, boiler inspection overdue, abuse incident, staff training deficiencies, sanitary and safety issues, medication management problems, and documentation errors. Plans of correction were accepted and implemented with follow-up scheduled.
Deficiencies (32)
| Description |
|---|
| The home did not have a current license and license inspection summary posted in a conspicuous and public place. |
| Gas boiler inspection was last done on 03/03/23 and certificate expired 01/30/24. |
| Resident #2 hit Resident #1 with a lamp causing injury and fear. |
| Staff Member C worked alone without First Aid and CPR certification during multiple shifts. |
| Administrator had only 8 hours of required annual training in 2023. |
| Staff Member B and Staff Member F did not receive required fire safety and emergency preparedness orientation. |
| Staff Member B and Staff Member F did not receive required 40 hours orientation on resident rights, emergency medical plan, abuse reporting, and incident reporting. |
| Direct Care Staff Member E received only 10 hours of required 12 hours annual training in 2023. |
| Staff Member E did not receive training on medication self-administration, dementia care, infection control, personal care needs, safe management, and mental illness care. |
| Floors, walls, ceilings, windows, doors and other surfaces were not clean or in good repair; bedbug feces and open drain hazard observed. |
| First aid kits lacked eye coverings. |
| Insufficient chairs in resident bedrooms. |
| Pillows had blood stains or missing pillowcases. |
| Residents #6 and #7 lacked operable lamps at bedside. |
| Bedroom ceiling showed water damage, brown staining, and exposed wires. |
| No emergency water supply for 30 residents; water agreement outdated and incomplete. |
| Written emergency procedures last updated and submitted in 2022. |
| Two unlocked plastic kerosene jugs stored near garage and smoking area. |
| Last fire safety inspection and drill by expert conducted 03/31/23. |
| Fire drills exceeded maximum evacuation time; no current maximum safe evacuation time established. |
| Fire drill during sleeping hours not held every 6 months as required. |
| Fire drills during sleeping hours routinely held with only one staff present, contrary to requirements. |
| Resident #8's medical evaluation not current; previous evaluation from 5/17/23. |
| Residents #1, #3, #8, and #9 self-administer medications without documented assessment by qualified medical professional. |
| Unlocked medication boxes found in resident rooms #7 and #9 with medications accessible. |
| Expired OTC medications found in resident room refrigerator. |
| Improper medication disposal methods used by staff. |
| Discrepancies between medication counts on medication cart and electronic narcotic sheets for multiple residents. |
| Medications not administered as prescribed to Resident #8; missed doses documented. |
| Resident #9's preadmission screening form incomplete regarding ability to meet resident needs. |
| Correction fluid used on Resident #1's medical evaluation form in critical sections. |
| Resident #3 and #8 records missing information on religion, hair color, and eye color. |
Report Facts
Residents served: 30
License capacity: 39
Staffing hours: 30
Waking staff: 23
Residents served: 33
License capacity: 39
Staffing hours: 33
Waking staff: 25
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Juliet Marsala | Deputy Secretary | Signed correspondence regarding plan of correction implementation |
Inspection Report
Renewal
Census: 30
Capacity: 39
Deficiencies: 30
Aug 27, 2024
Visit Reason
The inspection was conducted as a renewal and provisional review of Divine Living Home to assess compliance with applicable regulations and licensing requirements.
Findings
The inspection identified multiple deficiencies including expired licenses posted, boiler inspection lapses, abuse incidents, staff training deficiencies, sanitary and safety issues, medication management problems, and documentation errors. Plans of correction were accepted and implemented for all findings.
Deficiencies (30)
| Description |
|---|
| The home did not have a current license and license inspection summary posted in a conspicuous and public place. |
| Gas boiler inspection was outdated and certificate expired. |
| Resident #2 physically abused Resident #1 by hitting with a lamp. |
| Staff Member C worked alone without First Aid and CPR certification during multiple shifts. |
| Administrator did not complete required annual training hours. |
| Staff Members B and F did not receive required fire safety orientation and rights/abuse training within required timeframes. |
| Direct care staff did not meet required annual training hours and missed required training topics. |
| Sanitary conditions were not maintained; soiled undergarments and evidence of feces found in resident rooms and common areas. |
| Floors, walls, ceilings, and other surfaces were not clean or in good repair; bedbug feces and open drain hazard observed. |
| First aid kits lacked eye coverings. |
| Insufficient chairs in resident bedrooms. |
| Pillows and pillowcases were stained or missing in resident bedrooms. |
| Residents #6 and #7 did not have operable lamps or lighting at bedside. |
| Bedroom ceilings showed water damage and exposed wires. |
| No emergency water supply for residents; water agreement outdated and incomplete. |
| Emergency procedures were not updated and submitted annually to local emergency management agency. |
| Combustible materials stored unlocked and accessible near heat sources. |
| Fire safety inspection and fire drills were overdue; evacuation times exceeded mandated limits. |
| Fire drills during sleeping hours were not conducted semi-annually as required. |
| Resident medical evaluations were not completed annually as required. |
| Residents self-administering medications were not assessed by qualified medical personnel. |
| Medications and syringes were not kept locked in resident rooms; unlocked medications observed. |
| Expired OTC medications were found in resident rooms. |
| Discontinued and expired medications were not destroyed according to regulations. |
| Medication storage procedures were inadequate; discrepancies in medication counts and documentation. |
| Medications were not administered or documented according to prescriber's orders. |
| Resident preadmission screening forms were incomplete or missing. |
| Resident support plans did not reflect medical, dental, vision, hearing, mental health or behavioral care services as required. |
| Resident record entries were not permanent, legible, dated or signed; correction fluid used on medical evaluation. |
| Resident records lacked required content including religion, hair color, and eye color. |
Report Facts
License Capacity: 39
Residents Served: 30
Staffing Hours: 30
Waking Staff: 23
Residents Served: 33
Staffing Hours: 33
Waking Staff: 25
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Juliet Marsala | Deputy Secretary | Signed letter regarding plan of correction implementation |
Inspection Report
Census: 30
Capacity: 39
Deficiencies: 0
Jun 27, 2024
Visit Reason
The inspection was an unannounced partial licensing inspection conducted as an interim visit on 06/27/2024.
Findings
No regulatory citations or deficiencies were identified during this inspection.
Report Facts
Total Daily Staff: 30
Waking Staff: 23
Residents Receiving Supplemental Security Income: 19
Residents 60 Years of Age or Older: 22
Residents Diagnosed with Mental Illness: 16
Residents Diagnosed with Intellectual Disability: 4
Residents with Mobility Need: 0
Residents with Physical Disability: 0
Inspection Report
Complaint Investigation
Census: 32
Capacity: 39
Deficiencies: 6
May 3, 2024
Visit Reason
The inspection was conducted as a complaint investigation with unannounced partial on-site and off-site reviews on 05/03/2024, 05/06/2024, and 05/08/2024 to assess compliance with state regulations and the submitted plan of correction.
Findings
The inspection found multiple deficiencies including failure to provide adequate supervision for a resident, unauthorized audio/video monitoring, bedbug infestation with blood-stained bedding, incomplete resident medical evaluations, and overdue resident assessments. The facility submitted plans of correction which were determined to be fully implemented as of the last review.
Complaint Details
The inspection was complaint-driven, with the reason explicitly stated as 'Complaint' and a follow-up type of POC (Plan of Correction) Submission scheduled.
Deficiencies (6)
| Description |
|---|
| Failure to provide assistance with Instrumental Activities of Daily Living (IADLs) as indicated in the resident’s assessment, resulting in a resident frequently leaving the property unsupervised. |
| Unauthorized audio/video monitoring with cameras recording audio in the office, kitchen, and dining room areas, violating resident privacy rights. |
| Sanitary conditions compromised by a bedbug infestation causing blood-stained bedding and rusted electric baseboards with stained box springs in resident bedrooms. |
| Evidence of live bedbugs and infestation throughout the home including bathrooms and bedrooms, noted as a repeated violation. |
| Resident medical evaluations lacking required documentation of body positioning and movement stimulation, noted as a repeated violation. |
| Resident assessments not completed annually as required, with previous assessments overdue. |
Report Facts
License Capacity: 39
Residents Served: 32
Staffing Hours: 32
Waking Staff: 24
Residents Receiving Supplemental Security Income: 21
Residents Age 60 or Older: 21
Residents Diagnosed with Mental Illness: 18
Residents Diagnosed with Intellectual Disability: 4
Inspection Report
Renewal
Census: 33
Capacity: 39
Deficiencies: 9
Oct 17, 2023
Visit Reason
The inspection was conducted as a renewal and complaint investigation of Divine Living Home to assess compliance with 55 Pa. Code Chapter 2600 relating to Personal Care Homes.
Findings
The inspection found multiple violations including staffing shortages, infestation issues, medication administration errors, incomplete medical evaluations, and improper storage of medications and combustible materials. A provisional license was issued due to these violations with plans of correction required.
Complaint Details
The inspection included a complaint investigation component as indicated by the reason for visit and findings related to staffing and medication administration issues.
Deficiencies (9)
| Description |
|---|
| Staff Persons A and B had criminal background checks without completion dates, making it unclear if checks were timely. |
| Direct care staff hours were insufficient to meet the minimum required hours per resident on multiple dates. |
| Evidence of bedbug infestation was found in multiple resident rooms including live bedbugs and feces. |
| Refrigerator and freezer temperatures exceeded required limits, risking food safety. |
| Combustible materials (oxygen canisters) were accessible to residents in multiple rooms. |
| Medical evaluations for residents were incomplete or not timely, missing required information or conducted outside required timeframes. |
| Medications were not administered as prescribed, including refusals not reported and missing documentation. |
| Medication storage procedures were inadequate, including missing medications and lack of proper documentation. |
| Initial resident assessments were not completed within 15 days of admission for some residents. |
Report Facts
License Capacity: 39
Residents Served: 33
Total Daily Staff: 33
Waking Staff: 25
Direct Care Hours Provided: 20
Direct Care Hours Provided: 18
Direct Care Hours Provided: 20
Direct Care Hours Provided: 24
Direct Care Hours Provided During Waking Hours: 11.5
Direct Care Hours Provided During Waking Hours: 19.5
Inspection Report
Enforcement
Census: 33
Capacity: 39
Deficiencies: 12
Oct 17, 2023
Visit Reason
The inspection was conducted due to a renewal and complaint investigation of Divine Living Home on October 17-18, 2023 and February 8, 2024.
Findings
Multiple violations were found including staffing shortages, infestation of bedbugs, improper medication administration and documentation, refrigeration temperature issues, combustible material accessibility, and incomplete resident assessments. The facility was issued a provisional license due to these violations and has submitted plans of correction.
Complaint Details
The inspection included a complaint investigation component, with violations substantiated as detailed in the Licensing Inspection Summary.
Deficiencies (12)
| Description |
|---|
| Staff Persons A and B had criminal background checks without completion dates, making it unclear if checks were timely. |
| Direct care staff hours were insufficient to meet the minimum required hours for residents on multiple dates. |
| Evidence of bedbug infestation found in multiple resident rooms including live bedbugs and feces. |
| Refrigerator and freezer temperatures exceeded required limits, with food stored above safe temperatures. |
| Combustible materials such as oxygen canisters were accessible to residents in unlocked rooms. |
| Resident medical evaluations were not completed within required timeframes or lacked required information. |
| Medications were not administered as prescribed, including missing documentation and unavailable medications. |
| Medication refusals were not properly documented or reported to prescribers within required timeframes. |
| Staff member lacked required medication administration training and worked shifts alone without medication administration capability. |
| Resident preadmission screening form was completed more than 30 days prior to admission. |
| Medication records documented administration of medications not available in the home. |
| Weekly menus were not posted in a conspicuous and public place as required. |
Report Facts
License Capacity: 39
Residents Served: 33
Residents Served: 32
Direct Care Staffing Hours Provided: 20
Direct Care Staffing Hours Provided: 18
Direct Care Staffing Hours Provided: 20
Direct Care Staffing Hours Provided: 24
Direct Care Staffing Hours Provided During Waking Hours: 11.5
Direct Care Staffing Hours Provided During Waking Hours: 19.5
License Capacity: 39
Residents Served: 32
Inspection Report
Plan of Correction
Deficiencies: 0
Sep 15, 2022
Visit Reason
The document reports on the Pennsylvania Department of Human Services, Bureau of Human Service Licensing review conducted on 09/15/2022 regarding the submitted plan of correction for Divine Living Home.
Findings
The submitted plan of correction was determined to be fully implemented and the facility is required to maintain continued compliance.
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