Inspection Reports for Fieldstone at Chester Springs
145 Byers Rd., Chester Springs, PA 19425, PA, 19425
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Inspection Report
Follow-Up
Census: 70
Capacity: 132
Deficiencies: 3
Aug 13, 2025
Visit Reason
The inspection was a partial, unannounced follow-up visit triggered by an incident to review the submitted plan of correction for previous deficiencies.
Findings
The facility was found to have implemented the submitted plan of correction fully, addressing medication administration training deficiencies, labeling of over-the-counter medications, and proper documentation on medication administration records.
Deficiencies (3)
| Description |
|---|
| Medication administered by direct-care staff not trained in medication administration. |
| Over-the-counter medication (Calmoseptine ointment) not labeled with resident's name. |
| Medication administrations not logged on the resident's MAR with correct staff initials; direct care staff applied medication but med techs logged with their own initials. |
Report Facts
License Capacity: 132
Residents Served: 70
Secured Dementia Care Unit Capacity: 50
Secured Dementia Care Unit Residents Served: 21
Hospice Current Residents: 3
Resident Age 60 or Older: 70
Residents with Mobility Need: 22
Total Daily Staff: 92
Waking Staff: 69
Inspection Report
Complaint Investigation
Census: 71
Capacity: 132
Deficiencies: 0
Jul 31, 2025
Visit Reason
The inspection was conducted as a complaint and incident investigation at the facility.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Complaint Details
The inspection was triggered by a complaint and incident, but no deficiencies or citations were found, indicating no substantiated issues.
Report Facts
Total Daily Staff: 90
Waking Staff: 68
Resident Support Staff: 0
License Capacity: 132
Residents Served: 71
Secured Dementia Care Unit Capacity: 50
Secured Dementia Care Unit Residents Served: 19
Hospice Current Residents: 2
Residents Age 60 or Older: 71
Residents with Mobility Need: 19
Residents Receiving Supplemental Security Income: 0
Residents Diagnosed with Mental Illness: 0
Residents Diagnosed with Intellectual Disability: 0
Residents with Physical Disability: 0
Inspection Report
Complaint Investigation
Census: 56
Capacity: 132
Deficiencies: 1
Jun 25, 2025
Visit Reason
The inspection was conducted as a partial, unannounced visit triggered by a complaint and incident review at the facility on 06/25/2025.
Findings
The inspection found deficiencies related to medication administration documentation where staff failed to initial medication administration records as required. A plan of correction was submitted and accepted, with training and audits scheduled to ensure compliance.
Complaint Details
The visit was complaint-related with a partial, unannounced inspection conducted on 06/25/2025. The submitted plan of correction was fully implemented and accepted.
Deficiencies (1)
| Description |
|---|
| Medication administration records did not include the initials of the staff person who administered medications at specified times. |
Report Facts
License Capacity: 132
Residents Served: 56
Secured Dementia Care Unit Capacity: 50
Secured Dementia Care Unit Residents Served: 16
Hospice Current Residents: 2
Residents Age 60 or Older: 56
Residents with Mobility Need: 17
Residents with Physical Disability: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Provided educational training and conducted audits related to medication administration deficiencies |
| Assistant DON | Assistant Director of Nursing | Reviewed medication administration records and identified staff not following procedures |
Inspection Report
Complaint Investigation
Census: 49
Capacity: 132
Deficiencies: 3
Mar 6, 2025
Visit Reason
The inspection was conducted as a complaint and incident investigation at Fieldstone at Chester Springs.
Findings
The inspection found deficiencies related to the treatment of a resident who was resistant to care, including staff laughing during care and failure to implement positive interventions. Plans of correction were accepted and implemented.
Complaint Details
The visit was complaint-related, investigating an incident where a resident was resistant to incontinence care and staff behavior was inappropriate. The complaint was substantiated with findings.
Deficiencies (3)
| Description |
|---|
| A resident was treated without dignity and respect; staff laughed while resident was resistant to care. |
| Failure to implement positive interventions to modify or eliminate resident's resistive behavior. |
| Prohibited procedures related to restraint and handling of resident during care. |
Report Facts
License Capacity: 132
Residents Served: 49
Secured Dementia Care Unit Capacity: 50
Secured Dementia Care Unit Residents Served: 18
Hospice Current Residents: 4
Residents Age 60 or Older: 49
Residents with Mobility Need: 19
Total Daily Staff: 68
Waking Staff: 51
Inspection Report
Renewal
Census: 38
Capacity: 132
Deficiencies: 7
Dec 4, 2024
Visit Reason
The inspection was a full, unannounced review conducted for provisional licensing purposes on 12/04/2024.
Findings
The inspection found multiple deficiencies including failure to post the current licensing inspection summary in a conspicuous place, improper food storage with opened and unsealed food items, outdated and unlabeled food items, medication availability issues for a resident, improper use of medication for behavior control without accurate diagnosis, and delays in resident assessments and support plans.
Deficiencies (7)
| Description |
|---|
| Failure to post the current Licensing Inspection Summary in a conspicuous and public place in the home. |
| Food stored in opened and unsealed bags in a stand-out freezer including French fries, chicken wings, carrots, chicken nuggets, bread, and crispy chicken pieces. |
| Outdated or unlabeled and undated food trays and bags in the kitchen refrigerator and freezer. |
| Medications prescribed to a resident were not available in the home during the inspection. |
| Medication administered to a resident for anxiety or agitation without an accurate diagnosis documented at the time of administration. |
| Resident's initial assessment was not completed within 15 days of admission. |
| Resident's initial support plan was not completed within 30 days of admission. |
Report Facts
License Capacity: 132
Residents Served: 38
Secured Dementia Care Unit Capacity: 22
Secured Dementia Care Unit Residents Served: 14
Hospice Current Residents: 3
Residents Age 60 or Older: 38
Residents with Mobility Need: 15
Total Daily Staff: 53
Waking Staff: 40
Inspection Report
Original Licensing
Capacity: 132
Deficiencies: 5
Aug 19, 2024
Visit Reason
The inspection was conducted as a new licensing inspection for the newly licensed personal care home facility, Fieldstone at Chester Springs, which was not yet serving four or more residents at the time of inspection.
Findings
The facility was found to be in substantial compliance with applicable regulations but was unable to complete a full inspection due to low census. Several deficiencies were cited related to emergency telephone numbers, furniture and equipment, toilet paper availability, soap dispensers, and fire extinguisher inspections, all of which had plans of correction accepted and were implemented by early September 2024.
Deficiencies (5)
| Description |
|---|
| No emergency telephone numbers posted on or by the telephones in bedrooms 3031, 3023, and 3001. |
| Missing food warmer in the Memory Care Unit 1st floor small kitchen and no refrigerator in the 2nd floor small kitchen; loose cover ring on handrail in bathroom of bedroom 3001. |
| No toilet paper provided for the toilet in bathroom 3013. |
| No soap dispensers within reach of each bathroom sink in Memory Care bathrooms, including bedrooms 157 A and B. |
| Fire extinguishers in the basement and Memory Care Unit small kitchen had not been inspected by a fire safety expert since June and July 2023 respectively. |
Report Facts
License Capacity: 132
Capacity of Secure Dementia Care Unit: 50
Residents Served at Inspection: 0
Number of Deficiencies Cited: 5
Number of Fire Extinguishers Inspected: 25
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