Inspection Reports for
Elizabethtown Personal Care
141 HEISEY AVENUE,, ELIZABETHTOWN, PA, 17022
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Inspection Report — Feb 18, 2026
Renewal
Date: Feb 18, 2026
Visit Reason
The inspection was conducted as a renewal inspection of the Elizabethtown Personal Care Home to assess compliance with 55 Pa. Code Chapter 2600 regulations.
Findings
The facility was found to have multiple deficiencies including issues with record confidentiality, staff training, sanitary conditions, medication administration, fire safety, and resident abuse reporting. Plans of correction were directed with expected completion dates mostly in April 2026.
Citations (32)
2600.17 Resident records were found unlocked and accessible with lists of residents including sensitive information displayed.
2600.60a Staffing did not meet medication administration requirements during overnight shifts with only uncertified staff present.
2600.65f Direct care staff members D and E lacked required annual training in medication self-administration and care for residents with mental illness or intellectual disability for 2025.
2600.65g Direct care staff members D and E did not receive training in emergency preparedness, Older Adult Protective Services Act, and falls prevention in 2025.
2600.85a Sanitary conditions were not maintained; stained bath mat and dirty bathtub floor were observed.
2600.85e Trash outside the home was not properly contained; dumpster lid was open and full of trash.
2600.100a The exterior concrete ramp had damaged and uneven surfaces posing tripping hazards.
2600.107d The home’s written emergency procedures were not reviewed, updated, or submitted to the local emergency management agency as required.
2600.124 The home lacked documentation of written notification to the local fire department regarding address, bedroom locations, and evacuation assistance.
2600.127a A portable electric space heater was found in the first floor staff/reception area, which is prohibited.
2600.132b The last fire safety inspection and supervised fire drill by a fire safety expert was not conducted as required.
2600.132d The home did not have a maximum safe evacuation time specified by a fire safety expert and exceeded evacuation times during multiple drills.
2600.132f The home did not alternate exit routes during fire drills, repeatedly using the same exits.
2600.141a Resident medical evaluations were incomplete or missing required information including vital signs, immunization history, and signatures.
2600.144c The designated smoking area had cigarette butts discarded improperly on steps, sidewalks, and garden areas.
2600.182c Medication administration was deficient; staff failed to observe a resident ingesting medication as prescribed.
2600.183b Prescription and OTC medications and syringes were found unlocked and accessible to residents.
2600.183e Medications were stored improperly with loose pills, leaking bottles, unlabeled opened medications, and expired inhalers.
2600.185a Resident glucometer was incorrectly labeled and blood sugar readings were inconsistent between meter and records.
2600.187a Medication records lacked diagnosis or purpose for prescribed medications.
2600.187d The home failed to follow prescriber’s orders; medication was not administered as prescribed due to unavailability.
2600.190a Staff member A had not successfully completed the Department-approved medication administration course or competency testing.
2600.190b Staff member A had not completed required diabetes patient education and administered insulin without proper training.
2600.224a Resident was admitted without a completed preadmission screening form.
2600.225c Resident assessments were not completed timely; previous assessments were outdated.
2600.227h Resident refused to sign support plan but no notation of refusal or inability to sign was documented.
2600.252 Resident record did not contain a preadmission screening.
2600.251b Resident record entries contained correction fluid on admission, assessment, and support plan documents.
2600.15a The home failed to immediately report suspected resident abuse incidents to the local Area Agency on Aging as required.
2600.16c The home failed to report incidents or conditions to the Department’s personal care home complaint hotline within 24 hours as required.
2600.23a The home failed to provide required assistance with activities of daily living for residents needing 24-hour supervision.
2600.42b Resident was subjected to groping and inappropriate touching by another resident; incidents were reported but never addressed.
Report Facts
Residents Served: 25
Total Daily Staff: 25
Waking Staff: 19
Residents Served: 28
Total Daily Staff: 28
Waking Staff: 21
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff Member A | Named in findings related to medication administration training, abuse observation, and insulin injections | |
| Staff Member B | Administrator | Named in findings related to abuse reporting and incident management |
| Staff Member D | Named in findings related to staff training deficiencies and abuse incident | |
| Staff Member E | Named in findings related to staff training deficiencies |
Inspection Report — Jan 21, 2026
Complaint Investigation
Date: Jan 21, 2026
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 information section stating 'Reason: Complaint'.
Findings
The facility was found to have deficiencies related to incomplete and unsigned annual medical evaluations, failure to conduct medical evaluations after changes in resident conditions, and failure to update resident assessments following significant condition changes.
Citations (3)
141b1 - Annual Medical Evaluation: A resident's current medical evaluation was not signed and dated by a physician, physician’s assistant, or certified registered nurse practitioner.
141b2 - Medical Evaluation Changes: The facility failed to have a resident evaluated by a physician after significant changes in mobility and health condition occurred.
225c - Additional Assessment: The resident's assessment was not updated to reflect significant changes in condition including mobility and incontinence.
Report Facts
Residents Served: 31
Resident Support Staff: 31
Total Daily Staff: 31
Waking Staff: 23
Inspection Report — Aug 12, 2025
Complaint Investigation
Date: Aug 12, 2025
Visit Reason
The inspection was conducted as a complaint investigation to review compliance with regulatory requirements and assess the facility's response to reported issues.
Complaint Details
The inspection was complaint-driven as indicated by the reason 'Complaint' and involved review of multiple deficiencies related to resident care, safety, and facility conditions.
Findings
The facility was found deficient in timely incident reporting, sanitary conditions, maintenance of surfaces, exterior hazards, food storage, annual medical evaluations, smoking area safeguards, and resident assessments and support plans. Corrective actions were implemented with expected compliance dates mostly by October 2025.
Citations (9)
16c - The facility failed to report a resident death to the department within 24 hours.
85a - The facility failed to maintain bathrooms and resident areas in a clean and sanitary condition, including presence of feces, urine, and black spots in multiple locations.
88a - The facility failed to maintain interior surfaces in good repair and free of hazards, including missing tiles, rust stains, buckling floors, and water stains.
100a - The facility failed to keep the exterior of the building and grounds clean and free of hazards, evidenced by toilet paper remnants outside due to sewage backup.
103d - The facility failed to store crates of milk off the kitchen floor in the walk-in refrigerator.
141b1 - The facility failed to ensure a resident had a current annual medical evaluation within the required timeframe.
144c1 - The facility failed to maintain proper safeguards in the smoking area, resulting in cigarette butts discarded in non-designated areas.
225c - The facility failed to provide a resident a timely annual assessment and failed to include observed behaviors and interventions to prevent property damage.
227d - The facility failed to have a resident's support plan accurately reflect observed behavioral concerns and lacked interventions for staff to follow.
Report Facts
Residents Served: 28
Total Daily Staff: 31
Waking Staff: 23
Resident with Supplemental Security Income: 12
Residents 60 Years or Older: 25
Residents Diagnosed with Mental Illness: 22
Residents Diagnosed with Intellectual Disability: 1
Residents with Mobility Need: 3
Residents with Physical Disability: 0
Hospice Current Residents: 1
Inspection Report — Dec 10, 2024
Renewal
Date: 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.
Citations (11)
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
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 — Sep 11, 2024
Follow-Up
Date: 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.
Citations (7)
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
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 — Apr 2, 2024
Renewal
Date: 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.
Citations (39)
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
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 — Jul 13, 2023
Enforcement
Date: 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.
Citations (23)
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
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 — Mar 22, 2023
Re-Inspection
Date: 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 personal care home to verify compliance with applicable regulations.
Findings
The facility was found to be in substantial compliance with regulations. Several deficiencies were identified related to resident equipment safety, emergency telephone postings, first aid kit contents, bedroom furnishings, and medication administration, all of which were corrected promptly with education and monitoring plans implemented.
Citations (8)
81b - Resident Personal Equipment: Resident #1 had unsecured enabler bars on the bed posing an entrapment risk. The bars moved 3 to 4 inches when weight was applied.
91 - Telephone Numbers: Emergency telephone numbers for the nearest hospital and fire department were missing on or by telephones in multiple resident rooms.
96a - First Aid Kit: The first aid kit in the 2nd floor medication room was missing a thermometer and adhesive bandages.
101j2 - Bedroom Chairs: Bedroom #26 was occupied by two residents but had only one chair.
101j6 - Mirror: There was no mirror in the bedroom of resident #2.
101j7 - Lighting/Operable Lamp: Residents #3 and #4 did not have access to a source of light that could be turned on or off at bedside.
187b - Date/Time of Medication Administration: Resident #5's medication administration record was signed for morning medications not yet taken; medications were found on the nightstand.
187d - Follow Prescriber's Orders: Resident #5 had prescribed medications to be administered at 8:00 AM that were not taken at the prescribed time.
Report Facts
Residents Served: 32
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