Inspection Reports for Elizabethtown Personal Care
141 HEISEY AVENUE,, PA, 17022
Back to Facility ProfileDeficiencies (last 2 years)
Deficiencies (over 2 years)
65.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
1294% worse than Pennsylvania average
Pennsylvania average: 4.7 deficiencies/yearDeficiencies per year
40
30
20
10
0
Census
Latest occupancy rate
72% occupied
Based on a December 2024 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Renewal
Census: 28
Capacity: 39
Deficiencies: 11
Dec 10, 2024
Visit Reason
The inspection was conducted as a renewal, complaint, and provisional review of Elizabethtown Personal Care Home to assess compliance with applicable regulations and verify correction of previous deficiencies.
Findings
The inspection identified multiple deficiencies including failure to report incidents timely, abuse related to allergy management, sanitary condition issues, lack of bedside lighting, incomplete emergency procedure submissions, incomplete evacuation during fire drills, medication storage and labeling issues, incomplete medication records, and failure to follow prescriber's orders. Plans of correction were directed and implemented with ongoing monitoring.
Deficiencies (11)
| Description |
|---|
| Failure to report an incident involving a resident allergic reaction to crab patty to the Department within 24 hours. |
| Resident #2 was served a food allergen causing anaphylaxis; abuse violation due to neglect in allergy management. |
| Strong urine odor and sticky floor around commode in second floor bathroom indicating unsanitary conditions. |
| Residents #1 and #2 did not have operable lamps at bedside for lighting. |
| Written emergency procedures not reviewed, updated, and submitted annually to local emergency management agency. |
| During multiple fire drills, not all residents were evacuated as required. |
| Resident #6's medications were stored insecurely with key left in lockbox and unlabeled bottles present. |
| Medications for residents #4 and #5 were not available in the home at time of inspection. |
| Resident #6's medication box contained unlabeled bottles; medications disposed and self-administration discontinued. |
| Resident #3's medication administration record (MAR) lacked required details and documentation of medication administration was incomplete or inaccurate. |
| Failure to follow prescriber's orders including missed medication administration and improper documentation by staff. |
Report Facts
License Capacity: 39
Residents Served: 28
Staffing Hours: 28
Waking Staff: 21
Current Residents in Hospice: 2
Residents 60 Years or Older: 21
Residents Diagnosed with Mental Illness: 3
Residents Diagnosed with Intellectual Disability: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff Person A | Named in medication administration and documentation violation related to Resident #1. |
Inspection Report
Follow-Up
Census: 25
Capacity: 39
Deficiencies: 7
Sep 11, 2024
Visit Reason
The inspection was a partial, unannounced follow-up visit on 09/11/2024 to verify the implementation of a previously submitted plan of correction related to a fine.
Findings
The facility was found to have fully implemented the submitted plan of correction addressing multiple deficiencies including annual medical evaluations, smoking area guidelines, medication storage and administration, and additional resident assessments. Continued compliance is required.
Deficiencies (7)
| Description |
|---|
| Resident medical evaluations were not completed timely but were completed during the visit. |
| Smoking occurred in a non-designated area without proper fire safety safeguards. |
| Medications and syringes were found unlocked and accessible in resident rooms contrary to policy. |
| Medications prescribed were not available in the home as required. |
| Prescriber's medication orders were not properly followed, including medications left unattended and not administered as ordered. |
| Staff administered medications without completing the required Department-approved medication administration course. |
| Resident assessments were incomplete or outdated but efforts were underway to bring them into compliance. |
Report Facts
License Capacity: 39
Residents Served: 25
Staffing Hours: 26
Waking Staff: 20
Hospice Residents: 2
Residents 60 Years or Older: 21
Residents with Mental Illness: 3
Residents with Intellectual Disability: 3
Residents with Mobility Need: 1
Inspection Report
Renewal
Census: 28
Capacity: 39
Deficiencies: 22
Apr 2, 2024
Visit Reason
The inspection was conducted as a renewal and provisional licensing inspection of Elizabethtown Personal Care to assess compliance with 55 Pa. Code Chapter 2600 relating to Personal Care Homes.
Findings
Multiple violations were identified including failure to post current licensing summary, incomplete criminal background checks, lack of CPR certified staff during night shifts, incomplete staff training and orientation, sanitary issues, medication storage and administration deficiencies, fire safety inspection and drill deficiencies, and resident abuse reporting failures. Plans of correction were accepted or directed with various completion dates.
Deficiencies (22)
| Description |
|---|
| Home's most current licensing summary was not posted in a conspicuous and public place. |
| Criminal background check was not obtained for a staff member prior to hire. |
| No staff certified in CPR/First Aid present during night shifts. |
| New staff member did not receive required fire safety and emergency preparedness orientation on first day. |
| Direct care staff did not have required annual training hours and training topics. |
| Resident bedroom and communal bathroom had strong urine odor and puddle of urine. |
| Resident rooms lacked operable lamps at bedside. |
| Toilet paper was not available in communal bathroom. |
| Dented cans of food found in dry storage area. |
| Emergency procedures were not posted in a conspicuous and public place. |
| Fire safety inspection and fire drill were not conducted annually; last conducted in 2022. |
| Fire drill records lacked required details including exit route, number of residents and staff participating. |
| Home exceeded evacuation time limits during multiple fire drills and lacked written maximum safe evacuation time. |
| Designated smoking area was observed with cigarette butts on the ground. |
| Medications and syringes were unlocked, unattended, and accessible in resident bedrooms for residents who cannot self-administer. |
| Expired medication found in medication cart. |
| Resident's glucometer was incorrectly calibrated and blood glucose readings did not match documentation. |
| Resident's prescribed medication was not available in the home. |
| Medication administration did not follow prescriber's orders. |
| Staff administered medications without completing required Department-approved medication administration course. |
| Residents were not educated on their right to refuse medication if they believe there may be a medication error. |
| Resident support plan lacked resident signature or notation of refusal/inability to sign. |
Report Facts
License Capacity: 39
Residents Served: 28
Staffing Hours: 28
Waking Staff: 21
Fine Amount: 78
Inspection Dates: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff Member A | Named in findings related to criminal background check delay, medication administration without required course, abuse reporting, and medication administration errors. | |
| Staff Member B | Named in findings related to criminal background check delay, medication administration without required course, and incomplete annual training. | |
| Staff Member C | Named in findings related to medication administration course completion without required observations. | |
| Staff Member E | Named in findings related to medication administration course completion without required course. | |
| Staff Member F | Named in findings related to medication administration course completion without required course. | |
| Staff Member G | Named in findings related to medication administration course completion without passing exam. | |
| Staff Member H | Named in findings related to medication administration course completion without required course. | |
| Administrator | Administrator | Named in multiple findings related to education, audits, and corrective actions. |
| Maintenance Director | Maintenance Director | Named in findings related to fire drill scheduling, furniture repair, and lighting audits. |
| Dietary Manager | Dietary Manager | Named in findings related to food storage and dented cans. |
| Human Resources Coordinator | Human Resources Coordinator | Named in findings related to criminal background checks and staff training audits. |
| PCHA | Named in findings related to staff education, incident reporting, and oversight. |
Inspection Report
Renewal
Census: 28
Capacity: 39
Deficiencies: 39
Apr 2, 2024
Visit Reason
The inspection was a renewal and provisional licensing inspection conducted on April 2, 2024, with a follow-up on June 4, 2024, to assess compliance with Pennsylvania Personal Care Homes regulations.
Findings
Multiple violations were found including failure to post current licensing summary, incomplete criminal background checks, inadequate staff training (CPR, medication administration, fire safety), sanitary issues, medication storage and administration errors, incomplete emergency procedures, fire safety deficiencies, and resident abuse reporting failures. Plans of correction were accepted or directed with various completion dates.
Deficiencies (39)
| Description |
|---|
| Home’s most current licensing summary was not posted in a conspicuous and public place. |
| Criminal background check not obtained for Staff Member A until after hire date. |
| No staff certified in CPR/First Aid present during night shifts. |
| Staff Member A did not receive fire safety orientation on first day of work. |
| Staff Member B did not have 12 hours of annual training related to job duties in 2023. |
| Staff Member B did not receive required training on multiple topics including medication self-administration and infection control. |
| Resident bedroom and communal bathroom had strong urine odor and puddle of urine. |
| Resident rooms lacked operable lamps at bedside. |
| Toilet paper was not available in the 2nd floor communal bathroom. |
| Dented cans of food found in dry storage area. |
| Emergency procedures not posted in a conspicuous and public place. |
| Fire safety inspection and fire drill not conducted annually; last done in 2022. |
| Fire drill records incomplete, missing key information. |
| No maximum safe evacuation time specified by fire safety expert; evacuation times exceeded 2 minutes 30 seconds. |
| Designated smoking area was littered with cigarette butts. |
| Medications and syringes unlocked and accessible in resident rooms for residents who cannot self-administer. |
| Expired medication found in medication cart. |
| Resident’s glucometer incorrectly calibrated; blood glucose readings did not match documentation. |
| Medication not available in home for Resident #3 as prescribed. |
| Medication administration not following prescriber’s orders for Ketoconazole shampoo. |
| Staff administered medications without completing required Department-approved medication administration course. |
| Residents not educated on right to refuse medication if medication error suspected. |
| Resident did not sign support plan and no notation of refusal or inability to sign. |
| Resident abuse incidents not reported timely to authorities as required. |
| Criminal background check not obtained for Staff Member B as of inspection date. |
| Administrator not present an average of 20 hours per week during May 2024. |
| Staff not trained in medication administration during overnight shifts, resulting in inability to provide medication administration services. |
| No staff certified in CPR/First Aid present during overnight shifts on specified dates. |
| Broken urinal handle in 1st floor pink common bathroom. |
| Toilet paper not provided in multiple common bathrooms. |
| Emergency procedures not posted in a conspicuous and public place. |
| Fire drill records incomplete and missing required information. |
| No maximum safe evacuation time specified by fire safety expert; evacuation times exceeded limits. |
| Medications unlocked and accessible in resident rooms for residents who cannot self-administer. |
| OTC medications and CAM not labeled with resident’s name. |
| Resident’s glucometer not calibrated correctly; glucose readings not documented properly. |
| Medication administration not following prescriber’s orders for Ketoconazole shampoo. |
| Staff administered medications without completing required Department-approved medication administration course. |
| Resident did not sign support plan and no notation of refusal or inability to sign. |
Report Facts
License Capacity: 39
Residents Served: 28
Residents Served: 26
Staffing Hours: 28
Waking Staff: 21
Staffing Hours: 26
Waking Staff: 20
Fine Per Resident Per Day: 3
Calculated Fine Per Day: 78
Mandated Correction Date: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff Member A | Named in findings related to criminal background check delay, medication administration without required course, abuse reporting, and medication administration errors. | |
| Staff Member B | Named in findings related to criminal background check delay, incomplete annual training, medication administration without required course, and medication administration errors. | |
| Staff Member C | Named in findings related to medication administration course completion without required observations. | |
| Staff Member E | Named in findings related to medication administration course completion without required course. | |
| Staff Member F | Named in findings related to medication administration course completion without required course. | |
| Staff Member G | Named in findings related to medication administration course completion without passing exam. | |
| Staff Member H | Named in findings related to medication administration course completion without required course. | |
| Administrator | Administrator | Named in multiple findings related to education, audits, and corrective actions. |
| Maintenance Director | Maintenance Director | Named in findings related to fire drill scheduling, furniture repair, and lighting. |
| Dietary Manager | Dietary Manager | Named in findings related to food storage and dented cans. |
| Human Resources Coordinator | Human Resources Coordinator | Named in findings related to background checks and staff training. |
| PCHA | Named in findings related to staff education, incident reporting, and oversight. |
Inspection Report
Enforcement
Census: 29
Capacity: 39
Deficiencies: 21
Jul 13, 2023
Visit Reason
The inspection was conducted as an interim licensing inspection due to violations found during previous inspections on July 13-14, 2023 and November 15, 2023, resulting in revocation of the previous certificate and issuance of a provisional license.
Findings
Multiple violations were found related to regulatory compliance including failure to post required documents, incomplete criminal background checks, improper storage of poisonous materials, medication administration errors, incomplete resident medical evaluations and records, and staff training deficiencies. Plans of correction were accepted or directed with specified completion dates.
Deficiencies (21)
| Description |
|---|
| The home's Chapter 2600 regulation book was not posted in a conspicuous and public place in the home. |
| Criminal background checks were not completed prior to date of hire for several staff members. |
| An unlabeled bottle of a corrosive chemical was found in the maintenance room. |
| First Aid kit on second floor was missing tweezers. |
| Refrigerator used for resident food stored at 44°F, freezer at 12°F, exceeding required temperatures. |
| Resident medical evaluations missing key information such as height, body positioning, health status, cognitive function, and mobility assessment. |
| Medication administration records contained errors including incorrect administration times and unlabeled medications. |
| Medication room and refrigerator were found unlocked with medications accessible. |
| Medication narcotic logs were incomplete and lacked documentation of last dose administration. |
| Resident contracts lacked documentation of education on right to refuse medication. |
| Preadmission screening forms were not completed for some residents prior to admission. |
| Resident support plans lacked documentation of medical, dental, vision, hearing, mental health, or behavioral care services. |
| Resident records were missing identifying marks, eye color, hair color, race, and preferred language. |
| Staff did not receive required fire safety orientation on first day of work. |
| Staff did not complete required training on resident rights, emergency medical plan, abuse reporting, and reportable incidents within first 40 hours. |
| Poisonous materials were stored in unlabeled containers. |
| Resident medical evaluation missing blood pressure, height, weight, pulse, temperature, medical diagnoses, emergency medical information, allergies, and medication regimen. |
| Staff administering medications were not current on Department-approved medication administration course or diabetic education. |
| Residents were not educated on their right to refuse medication if they believed there was an error. |
| Resident support plans did not include medical diagnoses or plans to meet medical needs. |
| Resident records lacked religion and height information. |
Report Facts
License Capacity: 39
Residents Served: 29
Staffing Hours: 29
Waking Staff: 22
Current Residents on Hospice: 1
Current Residents on Hospice: 2
Number of Residents 60 or Older: 28
Diagnosed with Mental Illness: 1
Diagnosed with Intellectual Disability: 1
Inspection Report
Enforcement
Census: 29
Capacity: 39
Deficiencies: 23
Jul 13, 2023
Visit Reason
The inspection was conducted due to licensing inspections on July 13-14, 2023 and November 15, 2023, resulting in violations of 55 Pa. Code Chapter 2600 related to Personal Care Homes, leading to revocation of the previous certificate and issuance of a first provisional license based on an acceptable plan of correction.
Findings
Multiple violations were found including failure to post required regulations, incomplete criminal background checks for staff, improper storage of poisonous materials, missing items in first aid kits, refrigerator temperature violations, incomplete medical evaluations, medication administration errors, unlocked medication storage, incomplete resident records, and inadequate staff training and certification. Plans of correction were proposed and some implemented, but enforcement actions remain in place.
Deficiencies (23)
| Description |
|---|
| Chapter 2600 regulation book was not posted in a conspicuous and public place in the home. |
| Criminal background checks were not completed prior to date of hire for multiple staff persons. |
| An unlabeled bottle of a corrosive chemical was found in a locked maintenance room. |
| First Aid kit on second floor was missing tweezers. |
| Refrigerator used for resident food stored at 44°F and freezer at 12°F, exceeding required temperatures. |
| Resident medical evaluations missing required sections including body positioning, health status, cognitive function, and mobility assessment. |
| Medication Administration Record (MAR) contained incorrect administration times for several medications. |
| Medication room door and medication refrigerator were found unlocked with controlled substances accessible. |
| Medication label did not match prescribed dosage for Vitamin D3. |
| Medications prescribed as PRN were not available in the home at time of inspection. |
| Narcotic log sheets were incomplete with missing documentation of last dose administration. |
| Medication records lacked documentation of medication discontinuation and missing initials for medication administrations. |
| Resident contracts did not document education on right to refuse medication if suspected error. |
| Preadmission screening forms were not completed for admitted residents. |
| Resident support plans lacked documentation on how medical and psychological needs would be met. |
| Resident records lacked identifying marks, eye color, hair color, race, and preferred language. |
| Direct care staff did not receive required fire safety and emergency preparedness orientation on first day. |
| Direct care staff did not complete required training on resident rights, emergency medical plan, and mandatory reporting within first 40 hours. |
| Poisonous materials stored in unlabeled containers were found and disposed of. |
| Resident medical evaluations missing blood pressure, height, weight, pulse, temperature, medical diagnoses, emergency medical information, allergies, and medication regimen. |
| Staff administering medications were not currently trained and certified in Department-approved medication administration course. |
| Staff administering insulin had not completed required diabetic education within past 12 months. |
| Resident records did not include religion and height information. |
Report Facts
License Capacity: 39
Residents Served: 29
Staffing Hours: 29
Waking Staff: 22
Controlled Substances Syringes: 12
Temperature: 44
Temperature: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff Person A | Hired without completed criminal background check; lacked fire safety and rights training; medication administration issues | |
| Staff Person B | Hired without completed criminal background check; lacked fire safety and rights training; insulin administration without required diabetic education | |
| Staff Person C | Hired without completed criminal background check; lacked fire safety and rights training; medication administration certification expired | |
| Resident Services Coordinator | Corrected medication administration records and completed preadmission screening forms | |
| Personal Care Home Administrator | Provided education to staff, conducted audits, and oversaw plans of correction |
Inspection Report
Re-Inspection
Census: 32
Capacity: 32
Deficiencies: 8
Mar 22, 2023
Visit Reason
The inspection was conducted due to a change in legal entity and as a re-inspection of the newly licensed facility to ensure compliance with applicable regulations.
Findings
The facility was found to be in substantial compliance with regulations. Several deficiencies were identified related to resident personal equipment, emergency telephone numbers, first aid kit contents, bedroom furniture, lighting, and medication administration, all of which were corrected promptly with education and monitoring plans implemented.
Deficiencies (8)
| Description |
|---|
| Resident #1 had uncovered enabler bars on bed posing an entrapment risk; bars were unsecured and moved when weight applied. |
| Emergency telephone numbers for nearest hospital and fire department were not posted on or by telephones in multiple rooms. |
| First aid kit in 2nd floor med room was missing a thermometer and adhesive bandages. |
| Bedroom #26 occupied by 2 residents had only 1 chair. |
| No mirror in the bedroom of resident #2. |
| Residents #3 and #4 did not have access to operable lighting at bedside. |
| Resident #5's medication administration record was signed indicating medications were given, but medications were still on nightstand at time of inspection. |
| Resident #5 was prescribed medications to be administered at 8:00 AM but had not taken them at time of inspection. |
Report Facts
Residents served: 32
Deficiencies cited: 8
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