Inspection Report
Follow-Up
Census: 64
Capacity: 101
Deficiencies: 3
Jun 24, 2025
Visit Reason
The visit was a follow-up review to verify that the submitted plan of correction for previous deficiencies was fully implemented at Logan Square Enhanced Senior Living.
Findings
The submitted plan of correction was found to be fully implemented, with continued compliance required. Deficiencies related to emergency management agency submission, fire drill records, and evacuation procedures were addressed with corrective actions and education.
Deficiencies (3)
| Description |
|---|
| The home’s written emergency procedures had not been submitted annually to the local emergency management agency. |
| Fire drill records were missing required information such as date, evacuation time, number of residents and staff participating, alarm operability, and exit routes used. |
| The home did not meet the designated safe evacuation time of 10 minutes during certain fire drills. |
Report Facts
License Capacity: 101
Residents Served: 64
Residents Served in Secured Dementia Care Unit: 10
Current Hospice Residents: 2
Total Daily Staff: 93
Waking Staff: 70
Inspection Report
Renewal
Census: 62
Capacity: 101
Deficiencies: 5
Jan 7, 2025
Visit Reason
The inspection was conducted as part of a renewal, complaint, provisional, and incident review of the facility license.
Findings
The facility was found to be in compliance overall, but several deficiencies were cited including lack of criminal background checks for contracted staff, failure to notify the fire department in writing, past due medical evaluations, medication storage and documentation errors, and missing documentation of fire safety inspections. Plans of correction were accepted and implemented with proposed completion dates by March 10, 2025.
Deficiencies (5)
| Description |
|---|
| Staff persons A and B were contracted workers with unsupervised access without criminal background checks as required. |
| The home did not have documentation of written notification to the local fire department regarding the address, bedroom locations, and evacuation assistance. |
| Resident #1’s most recent medical evaluation was past due. |
| A jar of A&D ointment prescribed to deceased resident #3 was found in resident #4’s room. |
| Several blood-sugar readings for resident #5 were logged incorrectly in the medication administration record. |
Report Facts
License Capacity: 101
Residents Served: 62
Secure Dementia Care Unit Capacity: 14
Residents Served in Secure Dementia Care Unit: 8
Current Hospice Residents: 2
Total Daily Staff: 96
Waking Staff: 72
Residents with Mobility Need: 34
Residents with Physical Disability: 62
Inspection Report
Renewal
Census: 67
Capacity: 101
Deficiencies: 35
Feb 5, 2024
Visit Reason
The inspection was conducted as a renewal and provisional licensing inspection of Logan Square Enhanced Senior Living to assess compliance with 55 Pa. Code Chapter 2600 relating to Personal Care Homes.
Findings
Multiple violations were found including failure to post current license and violation reports, delayed access to records, carbon monoxide detector placement issues, incomplete resident contracts, staff hiring and training deficiencies, fire safety orientation lapses, improper storage of poisonous materials, uncovered trash receptacles, furniture and equipment hazards, outdated food storage, emergency procedure submission delays, disabled smoke detectors during renovations, fire extinguisher inspection lapses, medication storage and administration issues, incomplete resident support plans, and privacy violations due to lack of signage for video recording.
Deficiencies (35)
| Description |
|---|
| The home's current violation report and 55 PA. Code Chapter 2600 were not posted in a conspicuous and public place. |
| Delayed provision of ancillary staff list to Department agents. |
| Carbon monoxide detector in kitchen was within 15 feet of gas appliances. |
| Resident contract not dated or unsigned. |
| Staff hiring files lacked timely criminal background checks. |
| Administrator failed to complete required annual training hours. |
| Direct care staff did not receive required fire safety and emergency preparedness orientation. |
| Direct care staff did not complete required orientation on resident rights, emergency medical plan, and abuse reporting within 40 hours. |
| Direct care staff did not complete required 12 hours of annual training. |
| Direct care staff did not receive required annual training on medication administration, dementia care, infection control, and other topics. |
| Training records missing for staff member. |
| Staff training plan lacked required details including names, duties, and scheduled training. |
| Procedures for bedside mobility devices lacked periodic assessment for proper installation and appropriateness. |
| Bedside mobility devices not securely attached to bedframes and uncovered openings exceeding FDA guidelines. |
| Poisonous materials unlocked and accessible to residents not assessed as safe to use them. |
| Trash receptacle in 5th floor guest bathroom uncovered. |
| Heater in resident bathroom dirty, damaged and uncovered exposing heating coils. |
| Residents #3 and #7 lacked operable lamp or light source at bedside. |
| Unlabeled and undated food items found in Memory Care kitchen refrigerator and freezer. |
| Excessive lint in lint trap of 5th floor dryer and broken lint trap in 8th floor dryer. |
| Emergency procedures not submitted annually to local emergency management agency. |
| Smoke detectors covered or disabled during renovations without fire watch procedures. |
| Fire extinguisher in home’s bus lacked inspection tag. |
| Resident #7 stored medications unlocked and unattended in bedroom. |
| Expired medication found in medication cart. |
| Unlabeled medication container found in resident medication bin. |
| Medications prescribed as needed were not available in the home. |
| Medication administration training records missing or invalid for several staff. |
| Resident #2 not educated on right to refuse medication. |
| Resident preadmission screening form completed after admission date. |
| Resident support plans lacked documentation of bedside mobility device needs and related details. |
| Resident #15 did not sign support plan. |
| Resident #1 support plan did not address behavioral or cognitive needs. |
| Resident records missing race, hair color, eye color, religious affiliation, and recent photograph. |
| Home did not keep a log of destroyed resident records. |
Report Facts
License Capacity: 101
Residents Served: 67
Residents Served in Secure Dementia Care Unit: 8
Hospice Residents: 2
Total Daily Staff: 105
Waking Staff: 79
Residents Served: 61
Residents Served in Secure Dementia Care Unit: 8
Hospice Residents: 1
Total Daily Staff: 89
Waking Staff: 67
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff person A | Named in delayed access to ancillary staff list, medication administration violations, and medication storage violations | |
| Staff person B | Named in contact list violation and fire safety orientation violation | |
| Staff person C | Named in medication administration training and medication administration violations | |
| Staff person D | Named in medication administration training and medication administration violations | |
| Staff person E | Named in medication administration training and medication administration violations | |
| Executive Director | Executive Director | Named in multiple findings and corrective actions throughout the report |
| Administrator | Administrator | Named in multiple findings and corrective actions throughout the report |
| Maintenance Director | Maintenance Director | Named in fire safety, smoke detector, and equipment maintenance violations |
| Health & Wellness Director | Health & Wellness Director | Named in medication storage and resident care plan violations |
| Housekeeping Director | Housekeeping Director | Named in lint trap and trash receptacle violations |
Inspection Report
Renewal
Census: 67
Capacity: 101
Deficiencies: 37
Feb 5, 2024
Visit Reason
The inspection was conducted as a renewal and provisional licensing inspection of Logan Square Enhanced Senior Living to assess compliance with 55 Pa. Code Chapter 2600 relating to Personal Care Homes.
Findings
Multiple violations were found including issues with posting licenses, access to records, compliance with health and safety laws, contract documentation, staff hiring and training, resident equipment safety, medication management, emergency procedures, and resident records. Plans of correction were proposed with follow-up dates.
Deficiencies (37)
| Description |
|---|
| The home's current violation report and a copy of 55 PA. Code Chapter 2600 were not posted in a conspicuous and public place. |
| Staff person A was unable to provide a listing of ancillary staff until after 2:30 PM when requested by Department agents. |
| Carbon monoxide detector for the kitchen was within 15 feet of gas appliances, violating installation standards. |
| Resident contract for Resident #1 was signed but not dated. |
| Resident contract for Resident #2 was not signed by the resident. |
| Resident #2's record did not contain a signed statement acknowledging receipt of resident rights and complaint procedures. |
| Several staff members had incomplete or untimely criminal background checks. |
| Staff person A completed only 23 hours of required annual training in 2023. |
| Staff persons B and F did not receive required orientation on fire safety and emergency preparedness topics. |
| Staff persons B and F did not complete required orientation training within 40 scheduled working hours. |
| Direct care staff person D received only 2 hours of annual training in 2023. |
| Direct care staff persons C and D did not receive required annual training on multiple topics including medication self-administration and care for residents with dementia. |
| The home does not have a training record for staff member E. |
| The home's staff training plan did not include required details such as names, positions, duties, and scheduled training dates for staff. |
| The home's procedures for bedside mobility devices did not include periodic assessment for proper installation and maintenance. |
| Resident #3 and #4 had bedside mobility devices not securely attached to bedframes and with uncovered openings exceeding FDA guidelines. |
| Poisonous materials such as antibacterial soap and toothpaste were unlocked and accessible to resident #5, who was not assessed as capable of safe use. |
| Uncovered trash can found in 5th floor guest bathroom. |
| Heater in resident #6's bathroom was dirty, damaged, and uncovered with exposed heating coils. |
| Residents #3 and #7 did not have operable lamps or light sources at bedside. |
| Unlabeled and undated food items found in refrigerator and freezer of Memory Care kitchen. |
| Excessive lint in lint trap of 5th floor dryer and broken lint trap in 8th floor dryer. |
| Home's written emergency procedures had not been submitted to local emergency management agency since 01/18/23. |
| Smoke detectors on floors 5, 6, 7, and 8 were disabled or covered during renovations, and fire watch procedures were not documented. |
| Fire extinguisher in the home's bus lacked inspection tag. |
| Resident #7 had several unlocked, unattended medications in their room. |
| Expired medication Senna 8.6 MG Tabs found in medication cart. |
| Unlabeled container of Latanoprost Ophthalmic Solution found in resident #11's medication bin. |
| Resident #12 and #13 prescribed medications were not available in the home. |
| Medication administration training records for staff person C and others were incomplete or missing. |
| Resident #2 had not been educated on the right to refuse medication. |
| Resident #14's preadmission screening form was completed after admission date. |
| Support plans for residents #3, #4, and #6 did not fully document bedside mobility device needs and related information. |
| Resident #15 participated in support plan development but did not sign the plan. |
| Support plan for resident #1 did not address behavioral or cognitive needs. |
| Resident #14's record lacked race, hair color, eye color, religious affiliation, identifying marks, and recent photograph. |
| Home did not keep a log of destroyed resident records. |
Report Facts
License Capacity: 101
Residents Served: 67
Residents Served in Secure Dementia Care Unit: 8
Hospice Residents: 2
Staffing Hours: 105
Waking Staff: 79
Mobility Need: 38
Residents Served: 61
Total Daily Staff: 89
Waking Staff: 67
Mobility Need: 28
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff person A | Named in findings related to delayed access to staff list, medication errors, and unlocked medications | |
| Staff person B | Named in findings related to incomplete orientation and training, and inaccurate staff list | |
| Staff person C | Named in findings related to incomplete medication administration training and medication errors | |
| Staff person D | Named in findings related to incomplete medication administration training and medication errors | |
| Staff person E | Named in findings related to incomplete medication administration training and medication errors | |
| Staff person F | Named in findings related to incomplete orientation and training | |
| Executive Director | Named in multiple findings and plans of correction overseeing compliance and audits | |
| Administrator | Named in multiple findings and plans of correction overseeing compliance and audits | |
| Maintenance Director | Named in findings related to safety equipment, fire safety, and maintenance audits | |
| Health & Wellness Director | Named in findings related to medication management, resident safety, and staff education | |
| Housekeeping Director | Named in findings related to cleanliness and lint trap maintenance |
Inspection Report
Monitoring
Census: 59
Capacity: 101
Deficiencies: 0
Nov 30, 2023
Visit Reason
The inspection was a provisional, monitoring visit conducted as a partial, unannounced inspection on 11/30/2023.
Findings
No regulatory citations or deficiencies were identified during this inspection.
Report Facts
Total Daily Staff: 90
Waking Staff: 68
License Capacity: 101
Residents Served: 59
Secured Dementia Care Unit Capacity: 14
Secured Dementia Care Unit Residents Served: 8
Hospice Current Residents: 2
Residents Diagnosed with Mental Illness: 2
Residents Diagnosed with Intellectual Disability: 0
Residents Receiving Supplemental Security Income: 0
Residents Age 60 or Older: 59
Residents with Mobility Need: 31
Residents with Physical Disability: 31
Inspection Report
Monitoring
Census: 56
Capacity: 56
Deficiencies: 4
Sep 22, 2023
Visit Reason
The inspection was a monitoring visit conducted on September 22, 2023, as part of a partial, unannounced inspection to assess compliance with regulations for a newly licensed personal care home.
Findings
The facility was found to be in substantial compliance but not fully licensed due to use of a previous legal entity's license. Several citations were noted including failure to post the current license, uncovered trash receptacles, food stored on the floor, and unlabeled leftover food. Plans of correction were accepted for all deficiencies.
Deficiencies (4)
| Description |
|---|
| The legal entity and facility is not licensed as of the date of this inspection; the facility is using a license issued to the previous legal entity. |
| There was a full, uncovered, unattended trash can in the main kitchen. |
| Twenty-two boxes of Poland Spring Water were stored on the floor in the lower-level garage. |
| There was an unlabeled, undated container of pickles and a container of fruit salad in the main refrigerator. |
Report Facts
License Capacity: 56
Residents Served: 56
Secured Dementia Care Unit Capacity: 14
Secured Dementia Care Unit Residents Served: 9
Hospice Residents: 1
Total Daily Staff: 82
Waking Staff: 62
Boxes of Water Stored on Floor: 22
Inspection Report
Plan of Correction
Census: 52
Capacity: 52
Deficiencies: 1
Aug 17, 2023
Visit Reason
The inspection was a partial, unannounced follow-up visit conducted on 08/17/2023 to verify the implementation of a previously submitted plan of correction.
Findings
The submitted plan of correction was determined to be fully implemented. The main deficiency involved a delayed fire safety inspection and drill report, which was subsequently received and documented.
Deficiencies (1)
| Description |
|---|
| The last fire safety inspection and drill observed by a fire safety expert was conducted on 07/26/22, and the inspection report was not on hand at the time of the visit. |
Report Facts
License Capacity: 52
Residents Served: 52
Secured Dementia Care Unit Capacity: 14
Secured Dementia Care Unit Residents Served: 9
Current Hospice Residents: 1
Residents Age 60 or Older: 52
Residents Diagnosed with Mental Illness: 4
Residents with Mobility Need: 32
Residents with Physical Disability: 32
Total Daily Staff: 84
Waking Staff: 63
Loading inspection reports...
