Deficiencies per Year
24
18
12
6
0
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Complaint Investigation
Census: 59
Capacity: 100
Deficiencies: 5
Apr 14, 2025
Visit Reason
The inspection was conducted as a complaint investigation to review compliance with regulations at Exton Senior Living.
Findings
Multiple deficiencies were found including unsecured poisonous materials, unsanitary conditions with strong urine odor, missing emergency telephone numbers by resident phones, inoperable bedside lamps, and outdated posted menus. Plans of correction were accepted and implemented with ongoing audits and staff training scheduled.
Complaint Details
The inspection was triggered by a complaint, as stated under Inspection Information with Reason: Complaint. The plan of correction was reviewed and found fully implemented on follow-up.
Deficiencies (5)
| Description |
|---|
| Poisonous materials were not kept locked and inaccessible to residents in the Secure Care Dementia Unit. |
| Sanitary conditions were not maintained; a powerful urine odor was present in a resident's room and the Secure Dementia Care Unit. |
| Emergency telephone numbers were not posted on or by the telephone in a resident's room. |
| Resident's bedside lamp was inoperable. |
| The home's weekly menu was outdated and incorrectly posted in the Secure Dementia Care Unit. |
Report Facts
Residents Served: 59
License Capacity: 100
Capacity of Secure Dementia Care Unit: 22
Residents Served in Secure Dementia Care Unit: 18
Current Residents on Hospice: 5
Residents Age 60 or Older: 58
Residents with Mobility Need: 20
Inspection Report
Complaint Investigation
Census: 53
Capacity: 100
Deficiencies: 2
Jan 27, 2025
Visit Reason
The inspection was conducted as a complaint investigation to review compliance with regulations related to resident medical evaluations and support plans.
Findings
The inspection found deficiencies in resident medical evaluations, specifically missing medical information pertinent to emergency diagnosis and treatment, and undated forms. Additionally, a resident support plan did not include a no added sodium diet as required by the resident's medical evaluation.
Complaint Details
The visit was complaint-related as indicated by the inspection information. The complaint involved incomplete medical evaluations and support plan deficiencies. The plan of correction was accepted and fully implemented by 03/18/2025.
Deficiencies (2)
| Description |
|---|
| Resident medical evaluation did not include medical information pertinent to diagnosis and treatment in case of an emergency and special health or dietary needs; the form was undated. |
| Resident support plan did not include a no added sodium diet as specified in the resident's medical evaluation. |
Report Facts
Residents Served: 53
License Capacity: 100
Secured Dementia Care Unit Capacity: 22
Secured Dementia Care Unit Residents Served: 16
Hospice Current Residents: 2
Residents Age 60 or Older: 52
Residents with Mobility Need: 22
Total Daily Staff: 75
Waking Staff: 56
Inspection Report
Renewal
Census: 59
Capacity: 100
Deficiencies: 23
Oct 23, 2024
Visit Reason
The inspection was a renewal visit conducted on October 23 and 24, 2024, to assess compliance with licensing requirements and verify correction of previous deficiencies.
Findings
The inspection identified multiple deficiencies including unsigned resident contracts, delayed refunds after resident death, staff training and qualification issues, medication management problems, safety concerns with resident equipment, and incomplete resident support plans. Plans of correction were submitted and partially implemented by the follow-up dates.
Deficiencies (23)
| Description |
|---|
| Resident-home contracts for residents #1 and #2 were not signed by the residents. |
| Refund of previously paid charges was not processed timely after the death of resident #3. |
| Resident #1 and #2's records lacked signed statements acknowledging receipt of resident rights and complaint procedures. |
| Direct care staff person A did not have a high school diploma, GED, or active registry status on the Pennsylvania nurse aide registry. |
| On overnight shifts on 10/14/24 and 10/19/24, only one staff person certified in first aid, obstructed airway techniques, and CPR was present for 59 residents. |
| Direct care staff person A began providing unsupervised ADL services without completing required training and competency testing. |
| Bedside mobility devices for residents #2 and #4 were not securely attached to bed frames, creating entrapment hazards. |
| Hot water temperature in resident #1 and #2's bathroom sinks exceeded 120°F. |
| First aid kit in the Life Stories Unit contained expired antiseptic. |
| Resident #5 did not have access to an operable lamp or source of lighting at bedside. |
| Administrator was not familiar with the emergency preparedness plan for the local municipality. |
| Fire drills were routinely held on the same day of the week (Monday). |
| Smoking area had pillows not labeled as fire resistant. |
| Staff person C transporting residents had not completed initial new hire direct care staff training. |
| Resident #5 had non-prescribed medication (Vanicream Skin Cream) in medication cart without physician order. |
| Expired medications (Triamcinolone Acetonide Cream) were stored in resident #5's medication cart. |
| Pharmacy label for resident #5's medication did not match administration instructions on MAR. |
| Resident #5's prescribed medication Guaifenesin Tab 600 MG ER was not available in the home. |
| Resident #5's glucose readings log for October was not available. |
| Resident #5's Vanicream Skin Cream and Dexcom G7 Sensor were not prescribed by an authorized prescriber. |
| Resident #5 was wearing a Dexcom G7 Sensor but the home and resident had no access to device data history. |
| Residents #1 and #2 were not educated on their right to refuse medication if they believed there was a medication error. |
| Resident support plans for residents #2 and #6 did not reflect use of bedside mobility devices or related risks and instructions. |
Report Facts
Total Daily Staff: 78
Waking Staff: 59
Residents Served: 59
License Capacity: 100
Secured Dementia Care Unit Capacity: 22
Secured Dementia Care Unit Residents Served: 16
Hospice Residents: 3
Residents 60 Years or Older: 58
Residents with Mobility Need: 19
Inspection Report
Follow-Up
Census: 59
Capacity: 100
Deficiencies: 1
Apr 4, 2024
Visit Reason
The inspection visit on April 4, 2024, was a partial, unannounced follow-up inspection triggered by an incident report related to a fire in the home.
Findings
The facility was found to have fully implemented the submitted plan of correction regarding the delayed reporting of a fire incident that occurred on March 30, 2024. Continued compliance is required.
Deficiencies (1)
| Description |
|---|
| The home did not report the fire incident to the Department until April 2, 2024, which was beyond the required 24-hour reporting timeframe. |
Report Facts
License Capacity: 100
Residents Served: 59
Memory Care Unit Capacity: 22
Residents Served in Memory Care Unit: 13
Current Hospice Residents: 2
Residents with Mobility Need: 32
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Administrator was out of town during the incident and later conducted an in-service training on reportable incidents |
Inspection Report
Renewal
Census: 49
Capacity: 100
Deficiencies: 8
Sep 21, 2023
Visit Reason
The inspection was conducted as a renewal and complaint investigation to review compliance and verify the submitted plan of correction.
Findings
The inspection found multiple deficiencies including unsigned resident contracts, improper treatment of a resident, furniture and equipment issues, missing first aid kit items, lack of bedside lighting for several residents, emergency water supply issues, evacuation drill timing failure, and unsigned support plans. All deficiencies had plans of correction accepted and were implemented by November 27, 2023.
Complaint Details
The inspection included a complaint investigation related to treatment of a resident who was yelled at by staff. The complaint was addressed with staff retraining and resident follow-up.
Deficiencies (8)
| Description |
|---|
| Resident-home contracts for two residents were not signed by the residents. |
| Staff person was observed yelling at a resident in a disrespectful manner. |
| Resident 4's bathroom sink was clogged and would not drain; Resident 5's enabler bar did not have a cover with an opening over 12 inches. |
| First aid kit in the main kitchen did not include breathing shield and eye coverings. |
| Residents 1, 4, 5, and 6 did not have access to a source of light that can be turned on/off at bedside. |
| Emergency water supply was toppled over with broken gallons leaking onto the floor. |
| During a fire drill on August 30, 2023, the home exceeded the maximum safe evacuation time by 8 seconds. |
| Resident 2 participated in the development of the support plan but did not sign it, nor was a reason indicated. |
Report Facts
License Capacity: 100
Residents Served: 49
Secured Dementia Care Unit Capacity: 11
Residents Served in SDCU: 11
Staffing Hours: 69
Waking Staff: 52
Evacuation Drill Time: 908
Inspection Report
Monitoring
Census: 47
Capacity: 100
Deficiencies: 4
Apr 20, 2023
Visit Reason
The visit was a partial, unannounced monitoring inspection conducted by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing on 04/20/2023 to review compliance with regulatory requirements.
Findings
The inspection found multiple medication-related deficiencies including expired medications in the medication cart, missing pharmacy label direction change stickers, lack of medication availability, and medication administration errors. The facility submitted a plan of correction which was accepted and fully implemented by 07/06/2023.
Deficiencies (4)
| Description |
|---|
| Expired medications for residents #1 and #2 were found in the home's 2nd floor medication cart. |
| Resident #3's medication pharmacy label did not have a direction change sticker after an order change. |
| Resident #3's prescribed medication as needed was not available in the home. |
| Resident #3 was administered medication twice in one day despite being prescribed three times a day. |
Report Facts
License Capacity: 100
Residents Served: 47
Secured Dementia Care Unit Capacity: 32
Secured Dementia Care Unit Residents Served: 12
Residents Age 60 or Older: 46
Residents with Mobility Need: 21
Total Daily Staff: 68
Waking Staff: 51
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| V. Graham | Wellness & Operations Specialist (Eastern Region) | Named in plan of correction training and bi-weekly audit implementation |
Inspection Report
Follow-Up
Census: 53
Capacity: 100
Deficiencies: 8
Feb 27, 2023
Visit Reason
The inspection was a partial, unannounced visit conducted due to an incident at the facility.
Findings
The report details multiple medication-related deficiencies including discontinued medications kept in the medication cart, missing medications, lack of procedures to investigate medication errors, incomplete medication records, failure to follow prescriber's orders, delayed resident assessment, and failure to document refusal or inability to sign support plans. The submitted plan of correction was accepted and fully implemented by July 6, 2023.
Deficiencies (8)
| Description |
|---|
| Discontinued medication was found in the home's medication cart for Resident #1. |
| Medication prescribed as needed was not available in the home for Resident #1. |
| The home's procedures do not include a process to investigate and account for missing medications and medication errors. |
| Discrepancy of 4 narcotic pills missing; staff member stealing medication and not administering as documented for Resident #2. |
| Medication administration records for Residents #1 and #3 do not indicate the name of medication, frequency of administration, or diagnosis/purpose. |
| Resident #1 was administered medication not following prescriber's orders on specified dates and times. |
| Resident #2's assessment was not completed within 15 days of admission. |
| The home did not document notation of inability or refusal to sign the support plan for Resident #2. |
Report Facts
License Capacity: 100
Residents Served: 53
Secured Dementia Care Unit Capacity: 32
Secured Dementia Care Unit Residents Served: 16
Current Hospice Residents: 2
Residents Age 60 or Older: 52
Residents with Mobility Need: 21
Missing Narcotic Pills: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Veronica Graham | Wellness & Operations Specialist - Eastern Region | Responsible for auditing assessments, DME and RASP dates, and conducting bi-weekly audits. |
Inspection Report
Complaint Investigation
Census: 47
Capacity: 100
Deficiencies: 6
Dec 13, 2022
Visit Reason
The inspection was conducted as a complaint and incident investigation at Exton Senior Living, triggered by allegations of resident abuse and neglect.
Findings
The investigation found multiple violations involving verbal and physical abuse, neglect, and mistreatment of residents by Staff member A, including failure to report abuse incidents timely. Staff members A and B were terminated, and a plan of correction was implemented and accepted.
Complaint Details
The complaint investigation substantiated multiple abuse and neglect violations involving Staff member A and Staff member B. The abuse included verbal and physical mistreatment of residents and failure to report incidents timely as required by law.
Deficiencies (6)
| Description |
|---|
| Failure to immediately report suspected resident abuse as required by law. |
| Failure to report the incident to the Department within 24 hours as required. |
| Neglect and verbal abuse of resident 1, including refusal to assist and inappropriate language. |
| Physical abuse of resident 2 by forcefully grabbing forearms causing bruises. |
| Neglect and verbal abuse of resident 3, including turning off call bell and yelling. |
| Failure to treat residents with dignity and respect, including verbal insults and forceful handling. |
Report Facts
License Capacity: 100
Residents Served: 47
Secured Dementia Care Unit Capacity: 32
Residents Served in Dementia Unit: 15
Current Hospice Residents: 2
Residents 60 Years or Older: 46
Residents with Mobility Need: 20
Total Daily Staff: 67
Waking Staff: 50
Inspection Report
Renewal
Census: 51
Capacity: 100
Deficiencies: 11
Jun 6, 2022
Visit Reason
The inspection was conducted as a renewal inspection of the Exton Senior Living facility, including a full unannounced review on 06/06/2022 with follow-up activities through 06/21/2022.
Findings
The inspection identified multiple deficiencies related to sanitary conditions, food storage, medication administration, fire drill documentation, and support plan signatures. Plans of correction were submitted and accepted or directed, with implementation confirmed by 12/19/2022.
Deficiencies (11)
| Description |
|---|
| Floor in the kitchen had grease and water spills under the grill; carpet in memory care hallway had a brown stain appearing to be feces. |
| Food was stored on the floor in the freezer, refrigerator, and kitchen floor. |
| A cat present in the home did not have a current certificate of rabies vaccination. |
| Fire drill records for drills conducted on 3/16/22, 4/22/22, and 5/31/22 did not include specific exits utilized. |
| Resident #1 self-administers medications but has not been assessed by a qualified medical professional regarding ability and need for reminders. |
| Medications for multiple residents were pre-poured in medicine cups inside medication cart, which is not allowed. |
| OTC medications and CAM belonging to resident #1 were not labeled with the resident's name. |
| Resident #1's prescribed topical ointment medication was not available in the home. |
| Resident #1 had A&D ointment in room but it was not included on the medication administration record. |
| Resident #1 was prescribed several creams that were not administered on 6/6/22 because medication was not available; staff person signed MAR incorrectly. |
| Residents #5, #6, #7, #8, and #9 participated in support plan development but did not sign the support plan. |
Report Facts
License Capacity: 100
Residents Served: 51
Secured Dementia Care Unit Capacity: 22
Secured Dementia Care Unit Residents Served: 17
Hospice Current Residents: 6
Residents with Mobility Need: 27
Total Daily Staff: 78
Waking Staff: 59
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Wellness & Operations Specialist (Eastern Region), LPN and Train the Trainer Certified | Conducted mandatory trainings related to medication administration, self-administration assessment, labeling, and storage procedures. | |
| Administrative Services Director | Responsible for assuring compliance with vaccination records for animals. | |
| Resident Wellness Director | Responsible for audits and assuring signatures on support plans. | |
| Lead Inspector | Conducted the full inspection on 06/06/2022. |
Inspection Report
Follow-Up
Census: 49
Capacity: 100
Deficiencies: 4
Feb 2, 2022
Visit Reason
The inspection visit was a partial, unannounced follow-up to review the submitted plan of correction related to an incident at the facility.
Findings
The submitted plan of correction was determined to be fully implemented, with continued compliance required. Several deficiencies related to staff orientation and background checks were identified and addressed with corrective plans.
Deficiencies (4)
| Description |
|---|
| Criminal background check was not completed prior to staff person A's first day of work. |
| Staff person A did not receive orientation on fire safety and emergency preparedness topics on the first day of work. |
| Staff person A did not complete required training on resident rights, emergency medical plan, mandatory reporting of abuse and neglect, and reporting of reportable incidents within 40 scheduled work hours. |
| Staff person A began providing unsupervised ADL services without completing and passing the Department-approved direct care training course and competency test. |
Report Facts
License Capacity: 100
Residents Served: 49
Secured Dementia Care Unit Capacity: 22
Secured Dementia Care Unit Residents Served: 16
Hospice Residents: 4
Total Daily Staff: 65
Waking Staff: 49
Residents 60 Years or Older: 48
Residents with Mobility Need: 16
Inspection Report
Census: 52
Capacity: 100
Deficiencies: 0
Nov 22, 2021
Visit Reason
The inspection was conducted as a partial, unannounced visit due to an incident at the facility.
Findings
No regulatory citations or deficiencies were identified during the inspection.
Report Facts
License Capacity: 100
Residents Served: 52
Secured Dementia Care Unit Capacity: 22
Secured Dementia Care Unit Residents Served: 17
Hospice Residents: 5
Total Daily Staff: 79
Waking Staff: 59
Notice
Capacity: 100
Deficiencies: 0
Sep 22, 2021
Visit Reason
This document serves as a renewal notification and issuance of a regular license for Exton Senior Living, a Personal Care Home, following receipt of the renewal application dated September 17, 2021.
Findings
The Department confirms issuance of a regular license and advises that an onsite annual inspection will be conducted within the next twelve months to ensure compliance with applicable regulations.
Report Facts
Maximum capacity: 100
Secure Dementia Care Unit capacity: 32
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary, Office of Long-term Living | Signed the renewal notification letter. |
Inspection Report
Complaint Investigation
Census: 58
Capacity: 100
Deficiencies: 3
Apr 16, 2021
Visit Reason
The inspection was conducted as a complaint investigation at Exton Senior Living to review compliance with regulations and assess the submitted plan of correction.
Findings
The inspection found multiple medication-related deficiencies including unavailable PRN medications, missing documentation of medication administration, and failure to administer prescribed medications due to unavailability. The facility submitted and implemented a plan of correction addressing these issues.
Complaint Details
The inspection was triggered by a complaint and included a follow-up on the submitted plan of correction, which was determined to be fully implemented.
Deficiencies (3)
| Description |
|---|
| Resident #1 and Resident #2 had prescribed PRN medications that were not available in the home on 4/16/21. |
| Resident #3's medication administration record did not include the initials of the staff person who administered Acetaminophen on 4/16/21 at 6:00 A.M. |
| Resident #1 was not administered Lansoprazole and Lisinopril from 4/1/21 to 4/8/21 because the medications were not available in the home. |
Report Facts
License Capacity: 100
Residents Served: 58
Secured Dementia Care Unit Capacity: 32
Secured Dementia Care Unit Residents Served: 21
Hospice Current Residents: 6
Resident Mobility Need: 28
Total Daily Staff: 86
Waking Staff: 65
Inspection Report
Renewal
Census: 55
Capacity: 100
Deficiencies: 9
Mar 8, 2021
Visit Reason
The inspection was conducted as a renewal visit to review compliance with licensing requirements at EXTON SENIOR LIVING.
Findings
The facility had multiple deficiencies including repeat violations related to criminal background checks, sanitary conditions, food labeling, annual medical evaluations, medication administration documentation, support plan signatures, preadmission screening, and record entries legibility. Plans of correction were submitted and implemented with ongoing audits and re-education to ensure compliance.
Deficiencies (9)
| Description |
|---|
| Criminal background checks were not completed timely for staff, resulting in a repeat violation. |
| Sanitary conditions were not maintained in a staff PPE change room restroom, including no paper towels and feces on the toilet seat. |
| Unlabeled and undated leftover food (bowl of French fries) found in the secured dementia care unit refrigerator. |
| Resident #1's annual medical evaluation was overdue, last completed on 06/15/2020 instead of annually. |
| Medication administration record for Resident #2 lacked initials of staff administering Alprazolam on 03/04/2021 at 08:00 PM. |
| Medication administered to Resident #3 without following prescriber's order to check blood pressure before administration. |
| Resident Assessment-Support Plan for Resident #4 was not signed by the assessor. |
| Written cognitive preadmission screening for Residents #5 and #6 were not completed within 72 hours prior to admission to the secured dementia care unit. |
| Entries on controlled substance sign-out sheets for Residents #1 and #6 were altered or crossed out without proper notation. |
Report Facts
License Capacity: 100
Residents Served: 55
Capacity of Secured Dementia Care Unit: 32
Residents Served in Secured Dementia Care Unit: 19
Current Residents Receiving Hospice: 7
Residents Age 60 or Older: 55
Residents with Mobility Need: 27
Total Daily Staff: 82
Waking Staff: 62
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