Inspection Reports for
Elm Terrace Gardens

The visit was complaint-related and incident-driven, focusing on resident treatment and medication errors. Substantiation status is not explicitly stated.

The inspection found multiple violations including failure to treat residents with dignity and respect, inadequate staff training on resident needs, and medication administration errors resulting in resident harm. Plans of correction were accepted and implemented.

The inspection found violations related to resident record confidentiality, medication administration documentation, and failure to follow prescriber's orders. Plans of correction were accepted and implemented with ongoing audits and staff education.

The visit was complaint-related due to allegations of medication administration errors and abuse. The complaint was substantiated based on findings of missed medication doses and failure to report incidents.

The investigation found multiple deficiencies including failure to administer prescribed medication to a resident, failure to report the incident to the department, incomplete medical evaluation documentation, unlocked medication storage, and failure to follow prescriber's orders. The facility submitted a plan of correction which was accepted and later implemented.

The facility was found to have direct care staff deficiencies related to educational qualifications, with seven staff members lacking a high school diploma, GED, or active registry status. A plan of correction was submitted and fully implemented to address these issues, including termination and conditional re-hire pending GED enrollment.

The facility was found deficient in providing dignified dining assistance to residents, ensuring accurate Minimum Data Set (MDS) assessments, and maintaining sanitary food service practices. Deficiencies included staff standing over residents while feeding, inaccurate MDS documentation regarding pressure ulcers, and failure to change disposable gloves between dining tasks.

The inspection was complaint-related and incident-driven, including investigation of alleged abuse and failure to follow reporting requirements. The Department of Human Services investigated and was satisfied with subsequent reporting.

The facility was found to have deficiencies related to failure to report suspected resident abuse, inadequate assistance with activities of daily living as per resident support plans, resident abuse resulting in injury and death, and failure to document refusal or inability to sign support plans. Plans of correction were submitted and implemented with ongoing monitoring.

The inspection identified multiple deficiencies including breaches in resident record confidentiality, failure to provide required supervision leading to resident elopement, abuse concerns related to elopement risk, lack of required fire safety training for some staff, incomplete fire drill records, improper medication storage and administration documentation, and incomplete medical evaluations and support plans for residents in the secured dementia care unit. Plans of correction were accepted and implemented by 02/13/2025.

The inspection found multiple deficiencies related to treatment of residents, medication storage, positive interventions, and prohibitions on mechanical restraints. The facility implemented corrective actions including staff suspension and termination, in-service training, audits, and ongoing monitoring.

The inspection was complaint-related, but no deficiencies were found and the complaint was not substantiated.

No regulatory citations or deficiencies were identified as a result of this inspection.

The inspection was triggered by an incident involving suspected resident abuse, including theft and physical/verbal abuse captured on video, which was reported by family and staff. Staff Member B was terminated and reported to authorities. An internal investigation and corrective actions were implemented.

The inspection found multiple deficiencies including failure to immediately report suspected resident abuse, physical and verbal abuse of residents by staff, privacy violations due to unposted voice-activated devices, failure to ensure direct care staff completed required training, obstructed emergency egress signage, and failure to update support plans after resident falls. The submitted plan of correction was determined to be fully implemented.

The facility failed to implement care planned interventions for one of 19 sampled residents, specifically failing to place a fall mat as required for a resident at risk of falls, which was confirmed by observation and staff interview.

The submitted plan of correction was determined to be fully implemented as of the inspection date. The report details deficiencies related to resident abuse, mobility assessment, and support plan revisions, all of which have been addressed with updated plans and staff training.

The facility was found to have multiple deficiencies including failure to post regulations, improper refund processing after resident deaths, abuse and neglect issues related to a resident fall and COVID-19 exposure, privacy violations, lack of criminal background checks for staff, unsecured poisonous materials, uncovered trash receptacles, ventilation issues, furniture and equipment disrepair, incomplete first aid kits, kitchen sanitation and food safety violations, emergency procedure deficiencies, evacuation drill failures, incomplete medical evaluations, medication storage and prescription issues, incomplete resident records, and support plan documentation errors. Plans of correction were accepted and implemented by mid-November 2023.

The facility was found deficient in maintaining a safe and sanitary environment, timely notification of resident transfers to hospitals, development and implementation of complete care plans, adherence to physician medication orders, and provision of special eating equipment as ordered. Multiple residents were affected by these deficiencies.

The facility was found to have fully implemented the plan of correction related to violations involving resident dignity, respect, and privacy, including inappropriate staff behavior with a resident. Additional findings included a support plan signature deficiency which was also corrected. Continued compliance was required.

The visit was complaint-related with a follow-up type of Plan of Correction (POC) submission. The plan of correction was fully implemented as of the inspection date.

The inspection found multiple deficiencies related to medication administration and documentation, including failure to document Foley catheter output and missed or improperly timed medication administrations for Resident #1. Plans of correction were accepted and implemented.

The submitted plan of correction was determined to be fully implemented. Deficiencies included a delayed resident-home contract completion, incomplete medical evaluation missing special health/dietary needs, and a late incident report submission. Directed plans of correction were in place with completion dates in March 2022.

The visit was complaint-related due to an allegation by resident #1 that staff member A hit them on the head on 6/4/21. The complaint was substantiated by findings of failure to report and respond appropriately to the abuse allegation.

Multiple violations were found including failure to report suspected resident abuse timely, failure to suspend or supervise staff involved in abuse allegations, incomplete incident reporting, improper handling of poisonous materials, medication administration and documentation errors, failure to report medication refusals, incomplete follow-through on prescriber's orders, and incomplete resident records.

The inspection was triggered by a complaint, but no deficiencies or citations were found, indicating no substantiated issues.

No regulatory citations or deficiencies were identified as a result of this inspection.

Multiple deficiencies were identified including failure to provide timely assistance with activities of daily living, unsecured poisonous materials accessible to residents, lack of protective guards on heat sources, inadequate lighting at bedside, accumulation of lint in dryer vents, improper medication storage and documentation errors, incomplete resident support plans, missing call bell response times in the home's service description, and missing directions for key-locking devices at secure dementia care unit doors. Plans of correction were accepted or directed with follow-up submissions.

A written complaint regarding resident #1's care and treatment was filed on 1/8/21. The home failed to provide a status report within 2 business days and did not provide a written decision within 7 days after the complaint submission. The complaint was investigated and deficiencies were found.

The facility was found to have multiple deficiencies including failure to treat a resident with dignity and respect, failure to provide timely complaint status reports and written decisions, inadequate bedroom furniture for resident needs, insufficient supply of linens and towels, and incomplete medical evaluation documentation.

The submitted plan of correction was determined to be fully implemented. Several deficiencies related to criminal background checks, staff qualifications, and orientation training were cited and addressed with corrective actions.

The facility failed to immediately notify the resident and the resident's designated person of a report of suspected abuse involving a resident. The submitted plan of correction was reviewed and determined to be fully implemented.

No inspection findings are reported in this document. It primarily communicates the renewal of the facility's license and the requirement for future annual inspections.

The visit was complaint-related as indicated by the inspection reason. The complaint involved issues with emergency exit signage, medical evaluations, and support plan documentation. The submitted plan of correction was fully implemented.

The inspection found violations related to obstructed egress due to stop signs on emergency exit doors, incomplete annual medical evaluations for residents, missing medical evaluations for residents admitted to hospice, and lack of documentation for refusal to sign support plans. Plans of correction were submitted and fully implemented as of April 29, 2020.

The inspection was complaint-driven and the violations were substantiated as described in the deficiency descriptions.

The inspection found violations related to mail delivery on the secured dementia unit, denial of access to resident records, and improper wound care. The facility submitted plans of correction which were fully implemented by April 16, 2020.

The facility submitted a plan of correction which was determined to be fully implemented by January 9, 2020. Deficiencies included issues with contract signatures, signed statements, abuse reporting, lighting, refrigerator/freezer temperatures, evacuation drill timing, medical evaluations, medication labeling, storage procedures, resident rights education, and record content.

The inspection was triggered by a complaint and incident involving alleged improper treatment and seclusion of residents. Staff Member A was suspended and terminated following the incident. The complaint was substantiated as violations were found.

Violations of 55 Pa. Code Chapter 2600 related to Personal Care Homes were found, including failure to follow prescriber orders and prohibited seclusion practices. Plans of correction were submitted to address these issues.

The complaint involved a resident's designee who reported feeling threatened by the administrator during a meeting. The designee contacted local police who found no evidence of harassment or threats. The complaint was investigated with witness statements and observations documented.

Violations of 55 Pa. Code Ch. 2600 were found related to resident rights and support plan needs. Specific issues included a complaint of retaliation against a resident's designee and failure to document behavioral management needs in a resident's support plan.

No regulatory citations or deficiencies were identified during this inspection.

The inspection was triggered by a complaint/incident as stated on page 2. The violations relate to mistreatment and neglect of residents as described in the deficiency descriptions.

Violations of 55 Pa. Code Ch. 2600 related to treatment of residents, medication storage and administration, and positive intervention techniques were found. Plans of correction were partially implemented with ongoing re-education and procedural improvements.

No inspection findings are reported in this document. It primarily communicates license renewal approval and the requirement for a future annual inspection.

Multiple violations of the Personal Care Homes regulations were found, including deficiencies in staff training, fire safety, medication administration, water temperature control, resident assessment support plans, and medical evaluations for secured dementia care residents. Plans of correction were developed and partially implemented by June 5, 2019.

No regulatory citations were identified as a result of this inspection.

No inspection findings are reported in this document. It is an administrative notice confirming license renewal and outlining future inspection requirements.

The revised license confirms the maximum capacity of 250 persons for the facility and a secured dementia care unit capacity of 24. The license expiration date remains unchanged.

The investigation was triggered by an incident involving medication administration errors for two residents. The violations were substantiated and a plan of correction was approved and partially implemented as of 03/22/18.

Violations were found related to medication administration errors involving prescribed nebulizer and potassium chloride treatments. The facility implemented a plan of correction to ensure proper medication administration and communication with families.

The inspection identified violations including outdated or dented food items, failure of a resident to evacuate during fire drills, and improper calibration of a resident's glucometer. Plans of correction were submitted and partially implemented to address these issues.

No inspection findings are reported in this document. It confirms that a regular license is being issued and that an onsite inspection will be conducted within the next twelve months as required by regulation.

The investigation was triggered by an incident involving resident #1 who required routine safety checks every 2 hours. The resident was not checked as required on 12/5/16, leading to an adverse event.

The facility failed to perform routine safety checks every 2 hours for a resident as required. The resident was found unresponsive on the floor next to their bed during an overnight check, indicating noncompliance with safety protocols.

Violations were found related to medication administration, specifically an incident where a resident was administered an incorrect dose of Clonazepam and the home failed to submit an incident report timely. A plan of correction was developed to address the medication error and improve staff training and notification protocols.

No inspection findings are reported in this document. It confirms receipt of the renewal application and issuance of a regular license.

The facility was found to be in compliance with 55 Pa.Code Chapter 2600 relating to Personal Care Homes.

The Department has issued a regular license in response to the renewal application and notified the facility that an onsite inspection will be conducted within the next twelve months to ensure compliance with applicable regulations.