Inspection Reports for Eagleview Landing
650 Stockton Dr, Exton, PA 19341, PA, 19341
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Inspection Report
Complaint Investigation
Census: 70
Capacity: 121
Deficiencies: 5
Jul 31, 2025
Visit Reason
The inspection was conducted as a complaint and incident investigation at Eagleview Landing to review allegations of resident mistreatment and compliance with regulatory requirements.
Findings
The investigation found multiple violations including abuse and rough treatment of residents by staff member A, improper denial of resident requests, unqualified direct care staff, lint accumulation in dryers posing fire hazards, and incomplete support plan signatures. Corrective actions including staff termination, education, audits, and ongoing monitoring were implemented.
Complaint Details
The visit was complaint-related due to allegations of resident mistreatment by staff member A, which were substantiated leading to the employee's termination and reporting to the Department of Human Services and Area on Aging.
Deficiencies (5)
| Description |
|---|
| Resident was roughly handled by staff member A causing pain and bruising, constituting abuse. |
| Resident was denied permission to attend a community event and put to bed early by staff member A. |
| Direct care staff person A lacked required high school diploma, GED, or active nurse aide registry status. |
| Significant accumulation of lint in lint traps of dryers on 2nd and 4th floors, creating fire hazard. |
| Resident participated in support plan development but did not sign the plan. |
Report Facts
Residents served: 70
License capacity: 121
Residents served in secured dementia care unit: 25
Capacity of secured dementia care unit: 46
Current hospice residents: 7
Residents age 60 or older: 70
Residents with mobility need: 27
Total daily staff: 97
Waking staff: 73
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee A | Named in multiple abuse and mistreatment findings; placed on administrative leave and terminated | |
| Staff nurse E | Nurse | Observed bruising on resident after abuse incident |
| Staff C | Notified nurse of resident pain and bruising after abuse incident |
Inspection Report
Follow-Up
Census: 63
Capacity: 121
Deficiencies: 7
Jul 2, 2025
Visit Reason
The inspection visit on 07/02/2025 was a partial, unannounced follow-up inspection triggered by a complaint and incident to verify the implementation of a previously submitted plan of correction.
Findings
The facility was found to have fully implemented the submitted plan of correction. Several deficiencies were identified related to locking poisonous materials, medication administration documentation, following prescriber's orders, additional resident assessments, support plan signatures, admission support plans, and legibility of record entries. All deficiencies were addressed with corrective actions, training, and ongoing monitoring plans.
Complaint Details
The inspection was complaint-related as indicated by the reason for visit and was conducted to verify correction of prior deficiencies.
Deficiencies (7)
| Description |
|---|
| Lockbox for resident personal hygiene items containing poisonous materials was open and accessible to residents not assessed capable of safely using or avoiding poisons. |
| Medication administration record did not include initials of staff who administered medication at specified times. |
| Resident was administered medication four times due to pharmacy delay in discontinuing previous order, not following prescriber's orders. |
| Resident did not have a new assessment completed after transfer to secured dementia care unit despite significant condition change. |
| Resident assessment and support plan was not signed by the assessor. |
| Resident's initial support plan was not completed within 72 hours of admission to secured dementia care unit. |
| Entries in resident's record were illegible, including a crossed out inventory log entry without proper notation and overwritten dates and times. |
Report Facts
License Capacity: 121
Residents Served: 63
Secured Dementia Care Unit Capacity: 45
Secured Dementia Care Unit Residents Served: 22
Hospice Current Residents: 7
Resident with Mobility Need: 25
Resident Age 60 or Older: 63
Total Daily Staff: 88
Waking Staff: 66
Inspection Report
Renewal
Census: 69
Capacity: 121
Deficiencies: 12
Jun 11, 2025
Visit Reason
The inspection was conducted as a renewal and complaint investigation to assess compliance with licensing regulations and to review the submitted plan of correction.
Findings
Multiple deficiencies were identified including breaches in record confidentiality, inadequate staff orientation on fire safety, sanitary condition issues, missing thermometers in refrigerators, outdated food labeling, lack of emergency management submission, incomplete fire drills during sleeping hours, and medication storage and documentation violations. The facility submitted and implemented plans of correction for all deficiencies.
Complaint Details
The inspection included a complaint investigation component as indicated by the reason for visit: Renewal, Complaint.
Deficiencies (12)
| Description |
|---|
| Resident Task book for Memory care unit residents was unlocked, unattended, and accessible on top of the memory care medication cart. |
| Staff persons A and B did not receive required orientation on fire safety and emergency preparedness topics on their first day of work. |
| Staff person B did not complete required training within 40 scheduled working hours on resident rights, emergency medical plan, mandatory reporting of abuse and neglect, and reporting of reportable incidents. |
| Brown substance frozen on the bottom of the freezer in the first-floor memory care unit. |
| No thermometer in the two second floor bistro refrigerators. |
| Unlabeled, undated food containers and water bottle found in the second-floor memory care unit refrigerator. |
| Written emergency procedures not submitted to the local emergency management agency; no documentation provided. |
| Fire drills not conducted during sleeping hours as required; last drill during sleeping hours was on 10/29/2024. |
| Unlocked, unattended medications including Lorazepam .5 mg tablet found in resident 1's bedroom; bedroom door was not locked. |
| Resident 1's medication record did not include a current list of medications; some medications were missing from the record and from the resident's possession. |
| Blister packs for residents 2, 3, and 4 had punctures in medication packaging. |
| Resident 5 and 6 had undocumented insulin administration on multiple dates and times. |
Report Facts
License Capacity: 121
Residents Served: 69
Secured Dementia Care Unit Capacity: 45
Residents Served in Dementia Unit: 25
Current Hospice Residents: 7
Total Daily Staff: 95
Waking Staff: 71
Residents with Mobility Need: 26
Residents 60 Years or Older: 69
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Named in multiple findings related to record confidentiality, medication storage, and staff training. |
| Executive Director | Executive Director | Named in findings related to emergency management submission, fire drill compliance, medication record corrections, and staff training. |
| Maintenance Director | Maintenance Director | Named in findings related to placement of thermometers and fire drill education. |
| Regional Director of Clinical Services | Regional Director of Clinical Services | Named in training related to medication record compliance. |
| Assistant Director of Nursing | Assistant Director of Nursing | Named in findings related to medication audits and staff training. |
Inspection Report
Complaint Investigation
Census: 70
Capacity: 121
Deficiencies: 9
Feb 19, 2025
Visit Reason
The inspection was conducted as a complaint investigation during an unannounced partial inspection on 02/19/2025.
Findings
Multiple deficiencies were identified including delays in assistance with activities of daily living leading to incontinence incidents, direct care staff providing unsupervised services without completing required training, lack of annual training for several staff members, missing medications, failure to follow prescriber's medication orders, missing documentation for secured dementia care unit admissions, and insufficient dementia care training for staff.
Complaint Details
The inspection was complaint-driven as indicated by the reason for inspection and the unannounced partial inspection type.
Deficiencies (9)
| Description |
|---|
| Resident experienced long wait times for assistance with toileting, resulting in episodes of bladder and bowel incontinence. |
| Direct care staff person provided unsupervised ADL services without completing required Department-approved training and competency test. |
| Direct care staff persons A, B, and D received zero hours of annual training in 2024. |
| Direct care staff persons A, B, and D did not receive required training in medication self-administration, dementia care, infection control, and other specified topics during 2024. |
| Direct care staff persons A, B, and D did not receive required annual training in fire safety, emergency preparedness, resident rights, and other mandated areas during 2024. |
| As needed (PRN) medications prescribed to a resident were not available in the home at the time of inspection. |
| Resident was not administered prescribed medications on multiple dates and times, constituting a repeat violation. |
| No documentation that resident and designated person did not object to admission to the secured dementia care unit. |
| Direct care staff person working in the secured dementia care unit had zero hours of required dementia care training during 2024. |
Report Facts
Residents Served: 70
License Capacity: 121
Residents Served in Secured Dementia Care Unit: 25
Capacity of Secured Dementia Care Unit: 45
Current Hospice Residents: 5
Residents Age 60 or Older: 70
Residents with Mobility Needs: 29
Direct Care Staff Total Daily Staff: 99
Waking Staff: 74
Deficiencies Cited: 9
Inspection Report
Complaint Investigation
Census: 65
Capacity: 121
Deficiencies: 11
Jan 13, 2025
Visit Reason
The inspection was conducted as a complaint and incident investigation with multiple on-site and off-site review dates in January 2025 to determine compliance with regulations and the submitted plan of correction.
Findings
The inspection found multiple violations including failure to timely report incidents, breaches of resident confidentiality, improper treatment of residents, incomplete staff lists, uncertified CPR training, medication storage and administration issues, use of manual restraints, incomplete support plans, refusal to document resident signatures, and illegible record entries. Plans of correction were accepted or directed with completion dates mostly by March 2025.
Complaint Details
The visit was complaint-related with substantiation implied by multiple violations found and plans of correction required.
Deficiencies (11)
| Description |
|---|
| Failure to report incident to Department within 24 hours as required. |
| Resident records confidentiality breach by posting medication information on wall. |
| Staff person yelled at resident during combative incident, violating dignity and respect. |
| Staff list incomplete, missing some staff and substitute personnel. |
| CPR and first aid training provided by uncertified trainers. |
| Medication prescribed as needed was not available in the home. |
| Resident observed without prescribed elasticated support bandages. |
| Use of manual restraint by staff crossing resident's arms and pulling wheelchair. |
| Support plan did not document how resident's hearing and vision needs would be met. |
| No notation made regarding resident's refusal to sign support plan. |
| Narcotic control record entries were illegible and improperly crossed out. |
Report Facts
Inspection dates: 4
Residents served: 65
License capacity: 121
Secured dementia care unit capacity: 45
Current hospice residents: 5
Residents age 60 or older: 65
Residents with mobility need: 23
Deficiencies cited: 11
Inspection Report
Follow-Up
Census: 77
Capacity: 121
Deficiencies: 3
Sep 30, 2024
Visit Reason
The inspection visit on 09/30/2024 was a partial, unannounced follow-up review related to an incident.
Findings
The submitted plan of correction was found to be fully implemented. Deficiencies involved treatment of residents, following prescriber's orders, and support plan documentation for medical/dental care, all of which were addressed with corrective actions and staff training.
Deficiencies (3)
| Description |
|---|
| Agency staff yelled and cursed at a secured dementia care unit resident and threw blankets on the resident while they were lying on the bed. |
| Resident was prescribed an X-ray which was not completed on time due to isolation and order misplacement. |
| Resident verbally expressed suicidal ideation which was not noted in the most recent support plan. |
Report Facts
License Capacity: 121
Residents Served: 77
Secured Dementia Care Unit Capacity: 46
Secured Dementia Care Unit Residents Served: 24
Hospice Current Residents: 5
Inspection Report
Complaint Investigation
Census: 85
Capacity: 121
Deficiencies: 1
Aug 8, 2024
Visit Reason
The inspection visit on 08/08/2024 was conducted as a complaint investigation at Eagleview Landing.
Findings
The inspection found that the certificates of operation for the facility's four elevators had expired as of 07/31/2024. A plan of correction was submitted and fully implemented by 09/20/2024, including scheduling annual elevator inspections and submitting documentation to the Pennsylvania Department of Labor and Industry.
Complaint Details
The visit was complaint-related as indicated by the inspection information section stating 'Reason: Complaint'.
Deficiencies (1)
| Description |
|---|
| The certificate of operation from the Department of Labor and Industry for the home's four elevators had an expiration date of 07/31/24. |
Report Facts
License Capacity: 121
Residents Served: 85
Secured Dementia Care Unit Capacity: 46
Secured Dementia Care Unit Residents Served: 24
Hospice Current Residents: 5
Residents Diagnosed with Mental Illness: 45
Residents Aged 60 or Older: 85
Residents with Mobility Need: 18
Residents with Physical Disability: 38
Elevators: 4
Inspection Report
Renewal
Census: 80
Capacity: 121
Deficiencies: 9
Jul 9, 2024
Visit Reason
The inspection was a licensing inspection conducted on July 9, 2024, to determine compliance with 55 Pa. Code Ch. 2600 relating to Personal Care Homes, resulting in the issuance of a regular license.
Findings
The facility was found to be in compliance overall, but several deficiencies were identified including missing resident contract signatures, abuse allegations, incomplete staff training on resident rights and abuse reporting, uncovered trash receptacles, improper food labeling, outdated menus, and medication administration errors. Plans of correction were accepted and implemented with proposed completion dates in August 2024.
Deficiencies (9)
| Description |
|---|
| Resident-home contracts for residents #1 and #2 were not signed by the resident or did not indicate why the resident did not sign. |
| Resident #1 reported physical abuse by staff causing bruising to the wrist. |
| Multiple staff did not complete required training on resident rights, emergency medical plan, and mandatory abuse reporting within 40 scheduled working hours. |
| Uncovered, unattended trash can found in the kitchen on the second floor of Memory Care. |
| Food items in the kitchen were observed closed but undated, unsealed, or unlabeled. |
| The home's menu posted was outdated and did not reflect the current two-week menu. |
| Resident #2 did not receive insulin as prescribed according to blood sugar readings on two occasions. |
| Resident #3 was administered medication daily instead of every other day as prescribed. |
| Resident #4 missed multiple medication doses due to not being marked active in the medication administration system during a leave of absence. |
Report Facts
License Capacity: 121
Residents Served: 80
Secured Dementia Care Unit Capacity: 45
Residents Served in Secure Dementia Care Unit: 31
Hospice Residents: 6
Staffing Hours - Resident Support Staff: 58
Staffing Hours - Total Daily Staff: 171
Staffing Hours - Waking Staff: 128
Inspection Report
Complaint Investigation
Census: 79
Capacity: 121
Deficiencies: 0
May 21, 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; however, no deficiencies were found and no follow-up was required.
Report Facts
License Capacity: 121
Residents Served: 79
Secured Dementia Care Unit Capacity: 46
Secured Dementia Care Unit Residents Served: 30
Hospice Residents: 6
Resident Support Staff: 99
Waking Staff: 74
Inspection Report
Complaint Investigation
Census: 79
Capacity: 121
Deficiencies: 6
May 16, 2024
Visit Reason
The inspection was an unannounced partial complaint investigation with a provisional reason, conducted on 05/16/2024 to review compliance and follow-up on a previously submitted plan of correction.
Findings
The inspection identified multiple deficiencies including breaches in record confidentiality, privacy violations due to unauthorized electronic devices, lack of annual staff training in fire safety and emergency preparedness, unsanitary conditions related to trash disposal, lack of accessible drinking water in the memory care area, and incomplete medication administration documentation.
Complaint Details
The inspection was complaint-related with a provisional status. The submitted plan of correction was reviewed and found fully implemented as of 07/22/2024.
Deficiencies (6)
| Description |
|---|
| Task sheets outlining residents' shower and toileting schedules were found unlocked, unattended, and accessible to unauthorized persons. |
| An electronic device resembling a camera and a voice-activated device were found in a resident's apartment without proper signage indicating recording. |
| Staff person did not receive required annual training in fire safety, emergency preparedness, Older Adult Protective Services Act, and falls and accident prevention during the 2023 training year. |
| A trash can without a lid, containing used adult briefs and unsanitary waste, was found outside a resident's apartment. |
| Residents had no access to drinking water in the memory care area due to absence of a hydration station during the inspection period. |
| Medication administration record did not include the initials of the staff person who administered medication to a resident at 7 pm. |
Report Facts
License Capacity: 121
Residents Served: 79
Memory Care Capacity: 46
Memory Care Residents Served: 30
Current Hospice Residents: 6
Total Daily Staff: 99
Waking Staff: 74
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Regional Director Health Services | Regional Director Health Services | Conducted in-service training on confidentiality and narcotic audits; involved in investigation and corrective actions. |
| Garden House Director | Garden House Director | Responsible for conducting rounds to ensure compliance with confidentiality, privacy signage, hydration, and narcotic audits. |
| Guest Relations Director | Guest Relations Director | Conducting audit on residents with cameras to ensure signage compliance. |
| Business Office Director | Business Office Director | Conducted audit of all staff trainings for 2023 and 2024. |
| Health Services Director | Health Services Director | Conducted education on trash removal protocol and in-service on narcotic audits. |
Inspection Report
Complaint Investigation
Census: 83
Capacity: 121
Deficiencies: 14
Mar 11, 2024
Visit Reason
The inspection was conducted as a complaint and incident investigation with an unannounced partial review on 03/11/2024 and 03/12/2024.
Findings
Multiple deficiencies were identified including failure to report incidents timely, improper treatment of residents, inadequate staff orientation and training, medication administration errors, incomplete medical evaluations, support plan deficiencies, and incomplete resident records. The submitted plan of correction was fully implemented by 05/17/2024.
Complaint Details
The inspection was complaint-driven, triggered by complaints and incidents as noted in the inspection information section. The exit conference was held on 03/12/2024.
Deficiencies (14)
| Description |
|---|
| Failure to report an incident of a resident found injured to the Department within 24 hours. |
| Resident was not treated with dignity and respect by agency staff member. |
| Staff person did not receive required orientation on fire safety and emergency preparedness topics on first day of work. |
| Staff person did not complete required orientation on resident rights, emergency medical plan, and mandatory abuse reporting within 40 scheduled work hours. |
| Unlabeled and undated leftover food items found in facility kitchen. |
| Resident medical evaluations did not include medical information pertinent to diagnosis and treatment in case of emergency. |
| Medication administration error: staff left residents unattended during medication administration and failed to place medication as ordered. |
| Improper storage of medications: medication was resealed with tape after being punched. |
| Failure to follow prescriber's orders regarding medication administration and supply usage. |
| Preadmission screening form was completed after resident admission date. |
| Support plan did not specify how resident's dietary needs would be met. |
| Support plans and assessments missing descriptions and plans for meeting residents' needs in areas such as laundry, shopping, finances, memory, and ambulation. |
| Resident participated in support plan development but did not sign the plan, and no notation of refusal or inability to sign was documented. |
| Resident records missing color of hair, color of eyes, race, and record of incident reports. |
Report Facts
License Capacity: 121
Residents Served: 83
Secured Dementia Care Unit Capacity: 46
Residents Served in Dementia Unit: 32
Current Hospice Residents: 7
Total Daily Staff: 117
Waking Staff: 88
Residents Diagnosed with Mental Illness: 51
Residents with Mobility Need: 34
Residents with Physical Disability: 41
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff person B | Agency Nurse | Named in findings related to medication administration errors, incomplete orientation, and was placed on Do Not Return status. |
Inspection Report
Renewal
Census: 94
Capacity: 121
Deficiencies: 18
Oct 11, 2023
Visit Reason
The inspection was conducted as a complaint, provisional, and monitoring visit to assess compliance with 55 Pa. Code Chapter 2600 relating to Personal Care Homes.
Findings
Multiple deficiencies were identified including lack of staff certified in CPR during overnight shifts, unsecured poisonous materials, unsanitary conditions, medication storage and administration issues, incomplete medical evaluations, and resident abuse incidents. Plans of correction were proposed for all deficiencies with some not yet implemented as of the report date.
Complaint Details
The inspection included complaint investigations related to resident abuse, medication errors, and failure to report incidents timely. Some allegations of resident abuse were not reported to the local area agency on aging. Staff failed to report medication errors and incidents to the Department within required timeframes.
Deficiencies (18)
| Description |
|---|
| No staff person certified in First Aid or CPR was present during overnight shifts when 94 residents were present. |
| Poisonous materials were unlocked and accessible to residents not assessed as capable of safe use. |
| Feces were found around toilet bowls in resident bathrooms. |
| Unlabeled and undated leftover food was found in the memory care kitchen refrigerator. |
| Medical evaluations for some residents were not completed within required timeframes. |
| Medications and syringes were not locked and accessible to residents. |
| Medications not current or properly labeled were found in the facility. |
| Medication administration records lacked required documentation including staff initials and times. |
| Resident abuse incidents were reported late or not reported to appropriate agencies. |
| Staff failed to report medication errors to residents, designated persons, and prescribers. |
| Staff orientation and training records were incomplete or missing required content. |
| Facility failed to maintain sanitary conditions in resident areas and kitchens. |
| Trash receptacles in kitchens and bathrooms were uncovered, allowing penetration of insects and rodents. |
| Emergency food and water supplies were insufficient for the number of residents. |
| Emergency procedures were not submitted annually to the local emergency management agency. |
| Obstructions and inoperable automatic doors were found on egress routes. |
| Support plans and medical evaluations lacked required signatures and documentation of resident needs. |
| Locking mechanisms on secured dementia care unit doors lacked manufacturer statements and posted operating instructions. |
Report Facts
License Capacity: 121
Residents Served: 94
Residents Served in Secured Dementia Care Unit: 40
Staffing Hours: 135
Waking Staff: 101
Fine Amount: 1680
Correction Dates: 15
Correction Dates: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jason Childers | Executive Vice President | Named in relation to licensing and inspection correspondence. |
| Juliet Marsala | Deputy Secretary, Office of Long-term Living | Signed official letters regarding licensing and enforcement. |
Inspection Report
Renewal
Census: 94
Capacity: 121
Deficiencies: 14
Oct 11, 2023
Visit Reason
The inspection was conducted as a complaint, provisional, and monitoring visit to assess compliance with 55 Pa. Code Chapter 2600 relating to Personal Care Homes.
Findings
Multiple deficiencies were found including medication management issues, unsafe storage of poisonous materials, sanitary condition violations, incomplete medical evaluations, and resident abuse incidents. The facility was issued a second provisional license with required plans of correction and enforcement actions including fines.
Complaint Details
The inspection was complaint-related with substantiated findings including resident abuse, medication errors, and failure to report incidents timely.
Deficiencies (14)
| Description |
|---|
| No staff person certified in First Aid or CPR was present during overnight shifts with 94 residents. |
| Poisonous materials were unlocked and accessible to residents not assessed as safe to use them. |
| Sanitary conditions were not maintained; feces found around toilets in resident bathrooms. |
| Food safety violation: unlabeled and undated leftover food found in memory care kitchen. |
| Medical evaluations for some residents were not completed within required timeframes. |
| Medications and syringes were not always locked or properly stored; unlocked medications accessible in resident rooms. |
| Prescription medications not current or properly labeled; medication administration records missing required information. |
| Medication administration errors including missed doses, improper documentation, and failure to follow prescriber's orders. |
| Resident abuse incidents including elopement and physical aggression were not properly reported or addressed. |
| Staff criminal background checks and training records were incomplete or missing. |
| Fire safety and emergency preparedness orientation and training were incomplete for some staff. |
| Facility maintenance issues including unsecured trash receptacles, delayed locking of secure unit doors, and missing emergency supplies. |
| Support plans and assessments were incomplete or not updated to reflect resident needs and changes. |
| Locking mechanisms lacked manufacturer statements and operating instructions were not posted. |
Report Facts
License Capacity: 121
Residents Served: 94
Secure Dementia Care Unit Capacity: 46
Residents Served in SDCU: 40
Total Daily Staff: 135
Waking Staff: 101
Fine Amount: 240
Fine Amount: 400
Number of Deficiencies: 48
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff Member B | Named in relation to failure to complete criminal background check and involvement in medication diversion investigation. | |
| Staff Person C | Named in relation to medication administration errors and narcotic count violations. | |
| Staff Person D | Named in relation to medication administration errors and resident privacy violation. | |
| Staff Person E | Named in relation to medication administration errors and narcotic count violations. | |
| Staff Person F | Named in relation to incomplete orientation and training. | |
| Staff Person G | Named in relation to incomplete orientation and training. | |
| Staff Person H | Named in relation to incomplete ancillary staff orientation and annual training. | |
| Administrator | Named in relation to education on reporting suspected abuse and contract signature audits. | |
| General Manager | Named in relation to oversight of audits, training, and compliance with plans of correction. | |
| Health Service Director | Named in relation to training, audits, and oversight of medication administration and resident care. | |
| Executive Chef | Named in relation to food safety and sanitary condition compliance. | |
| Wellness Nurse | Named in relation to medication storage and resident care. | |
| Garden House Director | Named in relation to resident care and compliance with support plans. |
Inspection Report
Renewal
Census: 94
Capacity: 121
Deficiencies: 19
Oct 11, 2023
Visit Reason
The inspection was conducted as a complaint, provisional, and monitoring visit to assess compliance with 55 Pa. Code Chapter 2600 relating to Personal Care Homes.
Findings
Multiple deficiencies were found including lack of staff certified in CPR during overnight shifts, unsecured poisonous materials accessible to residents, unsanitary conditions in resident bathrooms, unlabeled and undated food items, incomplete medical evaluations, medication storage and administration issues, resident abuse incidents, and incomplete staff training and documentation.
Deficiencies (19)
| Description |
|---|
| No staff person certified in First Aid or CPR was present during overnight shifts with 94 residents present. |
| Poisonous materials such as Calazime Zinc Oxide paste were unlocked and accessible to residents not assessed capable of safe use. |
| Feces were found around toilet bowls in resident bathrooms. |
| Unlabeled and undated leftover food was found in the memory care kitchen refrigerator. |
| Medical evaluations for some residents were incomplete or not timely. |
| Medications and syringes were not always locked or properly labeled; some medications were not current or missing. |
| Medication administration records lacked initials of administering staff and documentation of refusals. |
| Resident abuse incidents were reported late or not reported to appropriate agencies; staff failed to respond to alarms indicating resident elopement. |
| Criminal background checks and staff training were incomplete or not documented for some employees. |
| Support plans and assessments were incomplete or not updated to reflect resident needs and changes. |
| Fire safety orientation and emergency preparedness training were incomplete for some staff. |
| Trash receptacles were uncovered and unattended in kitchen areas. |
| Medication storage conditions did not always meet sanitation and manufacturer requirements. |
| Emergency food and water supplies were insufficient for the number of residents. |
| Exit doors and locking mechanisms did not lock immediately and lacked proper manufacturer statements and posted instructions. |
| Resident rights to privacy and medication refusal were not consistently respected or documented. |
| First aid kits in transport vehicles lacked required items such as breathing shields and eye coverings. |
| Staff schedules did not always provide required 1:1 supervision for residents with behavioral needs. |
| Medication errors were not always reported immediately to residents, designated persons, and prescribers. |
Report Facts
License Capacity: 121
Residents Served: 94
Residents Served in Secure Dementia Care Unit: 40
Staffing Hours: 135
Waking Staff: 101
Fine Amount: 240
Fine Amount: 400
Inspection Dates: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jason Childers | Executive Vice President | Named in letter regarding licensing and inspection results. |
| Juliet Marsala | Deputy Secretary, Office of Long-term Living | Signed licensing letters and notices. |
Inspection Report
Follow-Up
Census: 102
Capacity: 121
Deficiencies: 16
Aug 24, 2023
Visit Reason
The inspection was a follow-up review to assess the implementation of the plan of correction submitted for violations identified during the August 24, 25, 28, and 29, 2023 inspection.
Findings
The facility was found to have multiple deficiencies including medication errors, failure to report suspected abuse, incomplete criminal background checks, improper storage of poisonous materials, and failure to follow prescriber's orders. Several plans of correction were directed with completion dates mostly by October 31, 2023, but many were noted as not implemented as of November 9, 2023.
Deficiencies (16)
| Description |
|---|
| Delayed provision of staff records for staff under 18 working in dining and activities. |
| Medication error involving Lorazepam not offered or administered to Resident #1 for the entire month of August except 8/24/23. |
| Failure to report missing 36 tablets of Lorazepam prescribed to Resident #1 to the Department of Aging. |
| Work permit for minor staff member issued late and not signed by the minor. |
| Criminal background checks not completed timely for several staff members. |
| Staff members under age 16 employed, violating age restrictions for certain tasks. |
| Staff member did not receive required annual training in falls and accident prevention. |
| Poisonous materials (boxes of wine) found unlocked and accessible in memory care unit. |
| Unlabeled and undated leftover food (white dip) found in refrigerator. |
| Combustible materials stored near heat source in memory care unit. |
| Failure to conduct resident evacuation drills as required. |
| Expired medication (Centrum Multi Gummy) administered to Resident #1. |
| Damaged blister packs and missing medications for multiple residents. |
| Failure to maintain accurate medication administration and control logs for multiple residents. |
| Medication refusal by Resident #1 not reported to prescriber within required timeframe. |
| Resident #1 was not offered prescribed Lorazepam as ordered for most of August. |
Report Facts
License Capacity: 121
Residents Served: 102
Staffing: 145
Waking Staff: 109
Missing Lorazepam Tablets: 36
Medication Expired Date: Jul 31, 2023
Medication Administration Dates: 8
Inspection Report
Complaint Investigation
Census: 94
Capacity: 121
Deficiencies: 18
Jun 29, 2023
Visit Reason
The inspection was conducted as a partial, unannounced complaint and incident investigation with multiple on-site and off-site visits on 06/29/2023, 07/10/2023, and 07/11/2023.
Findings
Multiple deficiencies were identified including failure to provide immediate access to requested records, breaches of resident record confidentiality, privacy violations during medication administration, unqualified direct care staff, incomplete staff orientation and training, unsanitary conditions, improper medication storage and labeling, expired medications, failure to follow prescriber's orders, incomplete preadmission screening, and inadequate documentation of residents' ability to self-administer medications.
Complaint Details
The inspection was complaint-related, triggered by complaints and incidents as noted in the inspection information section. The report includes multiple findings related to complaint investigation.
Deficiencies (18)
| Description |
|---|
| Failure to provide immediate access to Medication Administration training binder as requested by Department agent. |
| Resident records were unlocked, unattended, and accessible, violating confidentiality requirements. |
| Medication administered to resident in dining room without privacy, with other residents present. |
| Direct care staff person did not have a high school diploma, GED, or active registry status on the Pennsylvania nurse aide registry. |
| Direct care staff persons did not complete required orientation and training within required timeframes. |
| Direct care staff person did not complete and pass Department-approved direct care training and competency test. |
| Medication administered without proper hand washing or sanitizing; bathroom lacked hand drying supplies. |
| Food uncovered and unattended in private dining room. |
| Resident's most recent medical evaluation was not completed within required timeframe. |
| Medications and syringes were left unlocked, unattended, and accessible on medication carts. |
| Several expired medications were found on medication carts throughout the home. |
| Medications were not stored in an organized manner under proper conditions of sanitation, temperature, moisture, and light. |
| Prescription medications lacked pharmacy labels on original containers. |
| Medication sensors and controlled medications were not properly labeled or counted at every shift. |
| Resident's prescribed medications were not available in the home as required. |
| Failure to follow prescriber's orders regarding medication availability and administration. |
| Resident's preadmission screening form did not include determination that resident's needs can be met by the home. |
| Resident's support plan did not accurately document ability to self-administer medications or need for assistance. |
Report Facts
License Capacity: 121
Residents Served: 94
Secured Dementia Care Unit Capacity: 43
Secured Dementia Care Unit Residents Served: 33
Current Hospice Residents: 4
Staffing Hours - Total Daily Staff: 133
Staffing Hours - Waking Staff: 100
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff person A | Named in finding related to removal of Medication Administration training binder. | |
| Staff person B | Named in finding related to removal of Medication Administration training binder and absence from work. | |
| Staff person C | Named in finding related to leaving resident with another resident's MAR and unlocked computer screen. | |
| Staff person D | Named in findings related to privacy violation during medication administration and failure to wash hands. | |
| Staff person E | Named in findings related to lack of high school diploma/GED or active registry and incomplete orientation/training. | |
| Staff person F | Named in findings related to incomplete orientation/training. | |
| Staff person G | Named in findings related to incomplete orientation/training and failure to complete direct care training and competency test. | |
| Chanelle Newton | Wellness Nurse | Responsible for observing staff taking blood sugar results and providing training. |
Inspection Report
Follow-Up
Census: 93
Capacity: 121
Deficiencies: 4
Apr 26, 2023
Visit Reason
The inspection visit on 04/26/2023 was a partial, unannounced follow-up review triggered by a complaint and incident.
Findings
The report found multiple deficiencies including failure to notify a resident's designated person of a fall, incomplete medical evaluation within required timeframes, improper medication storage and administration procedures, and medication record errors involving administration documentation after a resident's death. The submitted plan of correction was accepted and fully implemented by 06/22/2023.
Complaint Details
The visit was complaint-related and incident-driven, with the final report validating the occurrence of a fall affecting resident 1 and medication administration errors related to resident 2's death.
Deficiencies (4)
| Description |
|---|
| Failure to notify resident or designated person immediately after a validated fall incident. |
| Medical evaluation not completed within 60 days prior to admission or within 30 days after admission. |
| Failure to develop and implement procedures for safe storage, access, security, distribution, and use of medications and medical equipment. |
| Medication record errors including administration documented after resident was deceased. |
Report Facts
License Capacity: 121
Residents Served: 93
Secured Dementia Care Unit Capacity: 46
Residents Served in Dementia Unit: 29
Hospice Current Residents: 5
Residents Age 60 or Older: 93
Residents with Mental Illness: 1
Residents with Mobility Need: 32
Inspection Report
Monitoring
Census: 94
Capacity: 121
Deficiencies: 6
Apr 13, 2023
Visit Reason
The visit was an unannounced partial inspection conducted for monitoring purposes to review compliance with licensing requirements.
Findings
The inspection found multiple deficiencies including incomplete criminal background checks for staff, missing body positioning/movement information in a resident's medical evaluation, improper storage and dating of medications, and presence of discontinued or expired medications in medication carts. Plans of correction were accepted and implemented by mid-May 2023.
Deficiencies (6)
| Description |
|---|
| Criminal background check for a staff member was not completed prior to employment. |
| Resident 1's medical evaluation did not include body positioning/movement section. |
| Medications for residents 2, 3, and 4 were opened and on the medication cart without indicating the date opened, contrary to manufacturer instructions requiring discard after 42 days. |
| Resident 5's inhaler was opened and on the medication cart without an open date; inhaler must be discarded after 30 days. |
| Resident 5's medication was opened and was to be discarded after 30 days but remained in the cart. |
| Resident 6's discontinued medication remained in the cart past its expiration date. |
Report Facts
Residents Served: 94
License Capacity: 121
Secured Dementia Care Unit Capacity: 45
Secured Dementia Care Unit Residents Served: 30
Hospice Current Residents: 7
Residents Age 60 or Older: 94
Residents with Mental Illness: 1
Residents with Mobility Need: 33
Total Daily Staff: 127
Waking Staff: 95
Inspection Report
Complaint Investigation
Census: 71
Capacity: 121
Deficiencies: 0
May 26, 2022
Visit Reason
The inspection was conducted as a complaint investigation with unannounced partial inspections on 05/26/2022, 06/16/2022, and 07/06/2022.
Findings
No regulatory citations or deficiencies were identified as a result of the inspections conducted on the stated dates.
Complaint Details
The visit was complaint-related, but no deficiencies or citations were found, and the follow-up type was noted as not required.
Report Facts
Total Daily Staff: 93
Waking Staff: 70
Residents Served: 71
License Capacity: 121
Memory Care Capacity: 46
Memory Care Residents Served: 21
Residents Diagnosed with Mental Illness: 2
Residents with Mobility Need: 22
Residents 60 Years of Age or Older: 71
Inspection Report
Renewal
Census: 43
Capacity: 121
Deficiencies: 13
Oct 18, 2021
Visit Reason
The inspection was an unannounced full renewal inspection conducted on 10/18/2021 to assess compliance with licensing requirements for Eagleview Landing.
Findings
The inspection identified multiple deficiencies including unsigned resident contracts and statements, missing criminal background checks for staff, unsecured poisonous materials accessible to residents, lint accumulation in dryers, incomplete medication records, improper medication storage and administration, lack of resident education on medication refusal rights, unsigned support plans, and incomplete preadmission screening and consent documentation for secured dementia care unit residents. Plans of correction were accepted and implemented with audits, staff training, and documentation improvements.
Deficiencies (13)
| Description |
|---|
| Resident-home contracts for residents #1, #2, and #3 were not signed by the residents. |
| Resident #1, #2, and #3's records did not contain a signed statement acknowledging receipt of resident rights and complaint procedures. |
| Staff person A did not have a criminal history background check completed in accordance with state requirements; FBI check was missing due to out-of-state residency. |
| Two tubes of toothpaste and a box of denture cleaner with poison warnings were unlocked and accessible to residents, including resident #1. |
| Approximate 1/4 inch lint accumulation found in lint traps of dryers on 4th and 1st floors. |
| Resident #4's medication record did not include a current list of medications; list had not been updated since admission. |
| Resident #1 had an opened medication pen without an 'opened on date' recorded, contrary to manufacturer instructions. |
| Resident #1's glucometer reading was inaccurately recorded on the MAR. |
| Resident #1 and #3 were not administered prescribed medications on specified dates due to 'DRUG NOT AVAILABLE'. |
| Residents #1, #2, and #3 were not educated on their right to refuse medication if they believed there was a medication error. |
| Residents #1, #2, and #4 participated in support plan development but did not sign the support plans. |
| Resident #3's written cognitive preadmission screening was not completed within 72 hours prior to admission to the secured dementia care unit. |
| Resident #3's file lacked documentation that the resident and designated person did not object to admission to the secured dementia care unit. |
Report Facts
License Capacity: 121
Residents Served: 43
Secured Dementia Care Unit Capacity: 46
Residents Served in Secured Dementia Care Unit: 15
Hospice Residents: 4
Residents Age 60 or Older: 43
Residents Diagnosed with Mental Illness: 1
Residents with Mobility Need: 17
Total Daily Staff: 60
Waking Staff: 45
Notice
Capacity: 121
Deficiencies: 0
Sep 1, 2021
Visit Reason
The document serves as a renewal notification and license issuance for the Personal Care Home 'Eagleview Landing' following receipt of a renewal application dated July 6, 2021. It also advises that an annual inspection will be conducted within the next twelve months as required by regulation.
Findings
No inspection findings are reported in this document. It confirms issuance of a regular license and states that enforcement action will be taken if non-compliance is found during future inspections.
Report Facts
Maximum licensed capacity: 121
Secure Dementia Care Unit capacity: 46
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary, Office of Long-term Living | Signed the renewal notification letter. |
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