Inspection Reports for
Frederick Living – Aspen Village
2849 BIG ROAD,, ZIEGLERVILLE, PA, 19492
Back to Facility Profile24 Reports
Inspection Report — Mar 5, 2026
Complaint Investigation
Date: Mar 5, 2026
Visit Reason
The inspection was conducted as a partial, unannounced visit due to an incident involving a resident exiting a secured dementia care unit without proper supervision.
Complaint Details
The visit was complaint-related due to an incident where a resident exited the secured dementia care unit unsupervised. The complaint was substantiated with findings of inadequate supervision and incomplete resident support plans.
Findings
The investigation found that a resident exited the secured unit unsupervised and was found outside in cold weather, posing a safety risk. Additional deficiencies included incomplete staff lists, missing bedside furniture and lighting for residents, and outdated resident assessments not reflecting current behaviors.
Citations (5)
42b - Abuse: A resident exited the secured unit unsupervised despite requiring 24-hour supervision and exit-seeking behavior. The resident was found outside in 15°F weather but sustained no injuries.
62 - Contact List: The initial staff list did not include a staff person involved in the incident, and a corrected list was provided hours later after request.
101j5 - Bedside Table/Shelf: A resident's bedroom lacked a bedside table or shelf as required.
101j7 - Lighting/Operable Lamp: A resident did not have access to a bedside light source that can be turned on or off.
225c - Additional Assessment: Resident assessments were not updated to reflect exit-seeking behavior and incidents of irritability, agitation, and aggression. No additional RASP was completed to address these behaviors.
Report Facts
Residents Served: 21
Staff Daily Total: 42
Waking Staff: 32
Outside Temperature: 15
Inspection Report — Sep 16, 2025
Renewal
Date: Sep 16, 2025
Visit Reason
The inspection was conducted as a renewal review of the facility license to verify compliance and implementation of the submitted plan of correction.
Findings
The facility was found to have deficiencies related to maintaining a current list of substitute personnel, annual staff training in fire safety, incomplete staff training plan dates, and improper medication storage practices. Plans of correction were accepted and implemented by the facility.
Citations (5)
Administrator could not provide a list of substitute personnel for the home.
Staff Member B did not receive required fire safety training in the 2024 training year.
Staff training plan did not include estimated dates for each training to be completed.
Medication cards were observed with punctured blister foil exposing medication to contamination or improper sanitation.
A roll pack of medications contained discontinued medications without proper pharmacy altered stickers and was taped shut improperly.
Report Facts
Residents Served: 19
Total Daily Staff: 38
Waking Staff: 29
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff Member A | Administrator | Named in deficiency for not providing a list of substitute personnel. |
| Staff Member B | Named in deficiency for not receiving required fire safety training. | |
| Director of Nursing | Director of Nursing (DON) | Provided education to pharmacy representative regarding medication packaging. |
Inspection Report — Jun 4, 2025
Follow-Up
Date: Jun 4, 2025
Visit Reason
The visit was an unannounced partial inspection conducted as a follow-up to review the submitted plan of correction for the facility.
Findings
The inspection found multiple deficiencies including missing resident contract signatures, abuse involving a staff member physically and verbally mistreating a resident, failure to follow safe management techniques, and lack of documentation for resident admission to the Secure Dementia Care Unit. The submitted plan of correction was accepted and fully implemented by the facility.
Citations (4)
The resident-home contract was not signed by the resident.
Staff Person A physically and verbally abused a resident during incontinence care, including striking the resident's hand and forearm.
Failure to use safe management techniques to de-escalate a resident exhibiting irritability and combative behavior.
No documentation that the resident and the resident's designated person have not objected to admission to the Secure Dementia Care Unit.
Report Facts
Residents Served: 23
Total Daily Staff: 46
Waking Staff: 35
Current Hospice Residents: 1
Residents Age 60 or Older: 23
Residents with Mobility Need: 23
Inspection Report — Oct 9, 2024
Renewal
Date: Oct 9, 2024
Visit Reason
The inspection was conducted as a renewal review of the Frederick Living - Aspen Village facility to assess compliance with applicable regulations and verify the implementation of the submitted plan of correction.
Findings
The inspection identified multiple deficiencies including lack of a ServSafe certified staff member on schedule, missing criminal background check for a contractor, insufficient first aid/CPR trained staff during certain shifts, evacuation time exceeding the maximum safe limit, incomplete posting of weekly menus, and deficiencies in resident support plans related to bedside mobility devices and missing resident signatures.
Citations (7)
No staff person on schedule was ServSafe certified as required by the PA Department of Agriculture Food Employee Certification Act.
A contractor painting room 3120 did not have a criminal background check on file.
Insufficient staff trained in first aid and CPR present during certain dates and times, failing to meet the required ratio.
Evacuation time during fire drill exceeded the maximum safe evacuation time specified by a fire safety expert.
The home's menu for the week following October 6, 2024, was not posted as required.
Resident support plan did not include intended use, risks, and safety details for bedside mobility device.
Resident did not sign the support plan and no notation was made explaining why.
Report Facts
Residents served: 23
Evacuation time (seconds): 692
Maximum safe evacuation time (seconds): 510
Residents in Magnolia House: 59
Inspection Report — Feb 5, 2024
Monitoring
Date: Feb 5, 2024
Visit Reason
The inspection was a monitoring visit conducted by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing on 02/05/2024 to review the facility's compliance and plan of correction implementation.
Findings
The inspection found multiple deficiencies including failure to maintain a current list of all staff including substitutes, lack of annual fire safety training by a qualified expert, inadequate system to safeguard resident laundry, incomplete support plans for residents addressing behavioral and communication needs, and missing inventories of residents' personal property in records. The submitted plan of correction was determined to be fully implemented as of the inspection date.
Citations (5)
The administrator does not maintain a list of staff persons that includes substitute or agency personnel.
The residence's staff did not receive training in fire safety completed by a fire safety expert or by a staff person trained by a fire safety expert during training year January 2023 to December 2023.
The home does not have a system to safeguard resident laundry from loss; unlabeled folded clothes were found in the activities room.
The support plan for certain residents does not address irritability, agitation, aggression, orientation, and communication of needs.
Records for residents do not include an inventory of the residents' personal property.
Report Facts
Residents Served: 30
Current Residents in Hospice: 4
Total Daily Staff: 60
Waking Staff: 45
Residents Age 60 or Older: 30
Residents with Mobility Need: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jonnie Voorhees | Named in relation to fire safety training certification |
Inspection Report — Dec 21, 2023
Follow-Up
Date: Dec 21, 2023
Visit Reason
The inspection was a partial, unannounced follow-up visit conducted due to an incident, to review the submitted plan of correction.
Findings
The submitted plan of correction was determined to be fully implemented, with continued compliance required. Two deficiencies were noted: missing criminal background check for a staff member and a malfunctioning exit door in the memory care unit.
Citations (2)
The home does not have the criminal background for staff person A.
The exit door leading to the outside area of the memory care unit malfunctioned and prolonged the closing of the door.
Report Facts
Residents Served: 26
Total Daily Staff: 52
Waking Staff: 39
Proposed Overall Completion Date: Feb 29, 2024
Inspection Report — Sep 20, 2023
Renewal
Date: Sep 20, 2023
Visit Reason
The inspection was conducted as a renewal and incident review of the Frederick Living - Aspen Village facility on 09/20/2023 and 09/22/2023.
Findings
The inspection identified multiple deficiencies including failure to immediately report suspected resident abuse, incomplete medical evaluations, inadequate staff training in fire safety and medication administration, lack of updated assessments for aggressive behavior, and missing conspicuous posting of directions for key-locking devices. The submitted plan of correction was determined to be fully implemented as of 02/12/2024.
Citations (9)
Failure to immediately report suspected abuse of a resident to the local area agency on aging.
Failure to report an incident to the Department’s personal care home regional office or complaint hotline within 24 hours.
Resident abuse resulting in injury and lack of updated behavioral assessment and support plan for aggressive behavior.
Staff person did not receive orientation on fire safety and emergency preparedness on first day of work.
Direct care staff did not receive required training in medication self-administration and other care needs during training year 2022.
Direct care staff did not receive training in fire safety completed by a fire safety expert during training year 2022.
Resident medical evaluation did not include medication regimen.
Resident assessment did not include appropriate assessment for aggression; new assessment was not completed.
Directions for operating the home's locking mechanism were not conspicuously posted near the door to the courtyard in the Secure Dementia Care Unit.
Report Facts
Residents Served: 20
Total Daily Staff: 40
Waking Staff: 30
Current Residents in Hospice: 3
Inspection Report — Sep 13, 2022
Follow-Up
Date: Sep 13, 2022
Visit Reason
The inspection was a partial, unannounced follow-up visit triggered by an incident to verify the implementation of a submitted plan of correction.
Findings
The facility was found to have fully implemented the plan of correction addressing deficiencies related to direct care staff qualifications, fire safety orientation, initial direct care training, and resident assessments. Continued compliance must be maintained.
Citations (4)
Direct care staff person A did not have a high school diploma, GED, or active registry status on the Pennsylvania nurse aide registry.
Staff person A did not receive orientation on fire safety and emergency preparedness topics including evacuation procedures, staff duties during fire drills, designated meeting place, smoking safety, fire extinguisher use, smoke detectors, fire alarms, and emergency telephone use.
Direct care staff person A began providing unsupervised ADL services prior to completing and passing the Department-approved direct care training course and competency test.
Resident #1's assessment did not reflect the resident's communication needs despite staff observations indicating the resident cannot verbalize needs and uses facial expressions and body language.
Report Facts
Residents Served: 24
Total Daily Staff: 48
Waking Staff: 36
Current Hospice Residents: 5
Inspection Report — Aug 9, 2022
Follow-Up
Date: Aug 9, 2022
Visit Reason
The inspection was conducted as a follow-up to review the submitted plan of correction related to an incident and record content deficiencies identified in the facility.
Findings
The facility was found to have fully implemented the submitted plan of correction regarding the final incident report and record content deficiencies, including missing resident information and incident reports in resident records.
Citations (3)
The home did not submit a final incident report as required.
Resident 1's record does not include race, religion, eyes color or hair color.
Resident 1's record does not include a record of incident reports for the individual resident.
Report Facts
Residents Served: 25
Total Daily Staff: 50
Waking Staff: 38
Inspection Report — May 25, 2022
Renewal
Date: May 25, 2022
Visit Reason
The inspection was a renewal visit conducted on 05/25/2022 to review compliance with licensing requirements for Frederick Living - Aspen Village.
Findings
The facility was found to have deficiencies related to incomplete fire drill records, failure to sound the fire alarm during a fire drill due to a COVID outbreak, and improper labeling of an opened medication bottle. Plans of correction were accepted and implemented for all deficiencies.
Citations (3)
Fire drill record for 04/20/2022 did not include exit routes used, number of residents in the home at the time of the drill, and number of residents evacuated.
During the fire drill on 01/31/2022, the fire alarm was not sounded due to a COVID outbreak; a silent drill was performed instead.
On 05/25/2022, an opened bottle of medication for resident #1 was not labeled with the date it was opened, contrary to manufacturer instructions.
Report Facts
Residents Served: 24
Current Hospice Residents: 4
COVID Positive Residents: 13
Total Residents During 01/31/2022 Fire Drill: 23
Inspection Report — Apr 15, 2022
Follow-Up
Date: Apr 15, 2022
Visit Reason
The inspection was a partial, unannounced follow-up visit conducted on 04/15/2022 to verify the implementation of a previously submitted plan of correction related to an incident.
Findings
The facility was found to have fully implemented the submitted plan of correction addressing multiple violations related to resident abuse reporting, supervision, notification, incident reporting, treatment of residents, and staff orientation and training. Continued compliance is required.
Citations (7)
Failure to immediately report suspected verbal abuse of a resident and complete the ACT 13 form.
Failure to immediately submit a plan of supervision or notice of suspension of the affected staff person to the Department.
Failure to notify the resident's designated person of a report of suspected abuse.
Failure to report incidents involving residents to the Department within 24 hours as required.
Staff member witnessed yelling at a resident and rushing another resident causing a bruise.
Staff member did not receive required orientation on fire safety and emergency preparedness topics on first day.
Staff member did not complete training on emergency medical plan within 40 scheduled work hours.
Report Facts
Residents Served: 25
Current Hospice Residents: 2
Total Daily Staff: 50
Waking Staff: 38
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Daniel Samai | Facility contact named in the cover letter regarding plan of correction implementation |
Notice — Jul 7, 2021
Date: Jul 7, 2021
Visit Reason
The document serves as a renewal notification and license issuance for Frederick Living - Aspen Village Personal Care Home, confirming receipt of the renewal application and advising of an upcoming annual inspection within twelve months.
Findings
No inspection findings are reported in this document; it is a license renewal notice with a certificate of compliance.
Report Facts
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary, Office of Long-term Living | Signed the renewal notification letter |
| Daniel Samai | PC Administrator | Recipient of the renewal notification letter |
Inspection Report — May 13, 2021
Renewal
Date: May 13, 2021
Visit Reason
The inspection was conducted as a renewal inspection of the Frederick Living - Aspen Village facility on 05/13/2021.
Findings
The inspection found that the facility had fully implemented the submitted plan of correction. Deficiencies included failure to post the current licensing inspection summary and regulations in a public area, absence of a bedside table next to a resident's bed, and lack of availability of a prescribed flu vaccine within the unit. Corrective actions were accepted and implemented during or shortly after the inspection.
Citations (3)
The home did not have a copy of the current licensing inspection summary and a copy of the regulations posted in a conspicuous and public place.
There was no bedside table next to resident #1's bed in their bedroom.
Resident #1 had an as needed order for flu vaccine, but the vaccine was not available within the unit.
Report Facts
Residents Served: 27
Total Daily Staff: 54
Waking Staff: 41
Inspection Report — Dec 8, 2020
Renewal
Date: Dec 8, 2020
Visit Reason
The inspection was a renewal licensing inspection conducted by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing on 12/08/2020.
Findings
The inspection identified multiple deficiencies including unsigned resident-home contracts, incomplete staff training in required areas, lack of a current staff training plan, missing emergency management agency submission, missing documentation of non-objection for admission to the secured dementia care unit, and insufficient dementia care training hours for direct care staff.
Citations (8)
25b Contract Signatures: The resident-home contract dated 11/26/2020 for resident #1 was not signed by the resident and administrator.
65f Training Topics: Direct care staff person A did not receive required training in resident needs, personal care service needs, and safe management techniques during 2019.
65g Annual Training Content: Staff person A did not receive training in fire safety, resident rights, and falls and accident prevention during 2019.
66a Staff Training Plan: The home did not have a staff training plan for 2021 at the time of inspection.
66b Training Plan Content: The staff training plan did not include the name, position, duties, required training courses, or scheduled training details for each direct care staff person.
107d Procedure Emergency Management Agency Submission: The home’s written emergency procedures had not been submitted to the municipal emergency management agency since 03/14/2019.
231e No Objection Statement: Resident #1 was admitted to the secured dementia care unit on 11/26/2020 without documentation that the resident and designated person had not objected to the admission.
236 Staff Training: Direct care staff person A working in the secured dementia care unit had only 1 hour of dementia care training during 2019 instead of the required 6 hours.
Report Facts
Residents Served: 29
Total Daily Staff: 58
Waking Staff: 44
Current Hospice Residents: 2
Completion Date: Jan 4, 2021
Completion Date: Jan 31, 2021
Completion Date: Dec 31, 2020
Completion Date: Jan 31, 2021
Completion Date: Jan 1, 2021
Completion Date: Jan 31, 2021
Notice — May 15, 2020
Date: May 15, 2020
Visit Reason
This document serves as a renewal notification and license issuance for Frederick Living - Aspen Village, a Personal Care Home, confirming the facility's authorized capacity and informing about the upcoming annual inspection.
Findings
No inspection findings are reported in this document. It confirms the issuance of a regular license following the renewal application and advises that an annual inspection will be conducted within the next twelve months.
Report Facts
Inspection Report — Feb 7, 2020
Annual Inspection
Date: Feb 7, 2020
Visit Reason
The inspection was conducted as part of the Pennsylvania Department of Human Services Bureau of Human Services Licensing annual licensing inspections.
Findings
The facility was found to be in compliance with 55 Pa. Code Ch. 2600 relating to Personal Care Homes.
Notice — Apr 9, 2019
Date: Apr 9, 2019
Visit Reason
The document is a renewal notification and license issuance for Frederick Living - Aspen Village Personal Care Home, confirming the facility's renewal application and license issuance.
Findings
No inspection findings are reported in this document. It states that an onsite inspection will be conducted within the next twelve months as required by regulation.
Report Facts
Inspection Report — Feb 8, 2019
Renewal
Date: Feb 8, 2019
Visit Reason
The inspection was a renewal inspection conducted by the Department's Bureau of Human Services Licensing on February 8, 2019, for Frederick Living - Aspen Village.
Findings
The facility was found to have a violation related to annual fire safety training, where the training for 2018 was completed online without a fire safety expert or certified trainer present. A plan of correction was submitted to ensure future training includes a fire safety expert or trained staff physically present.
Citations (1)
55 Pa. Code 2600.65(g) - The home's annual fire safety training for 2018 was conducted online without a fire safety expert or certified trainer present. The plan of correction includes ensuring a fire safety expert or trained staff is physically present during training sessions.
Report Facts
Number of Residents Served: 26
Number of Residents Served in Secured Dementia Care Unit: 28
Number of Current Hospice Residents: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kalle Reilly | Administrator | Named as administrator on violation report page 1. |
| Laura Strausser | Personal Care Administrator | Named as Personal Care Administrator and signer of plan of correction on pages 3 and 4. |
| Youn Hie Chung | Department representative on-site during inspection on 02/08/2019. |
Notice — Apr 17, 2018
Date: Apr 17, 2018
Visit Reason
The document serves as a renewal notification and license issuance for Frederick Living - Aspen Village Personal Care Home. It informs the facility of the requirement for an annual onsite inspection within the next twelve months.
Findings
No inspection findings are reported in this document. It is an administrative notice confirming license renewal and outlining inspection requirements.
Report Facts
Inspection Report — Sep 1, 2017
Complaint Investigation
Date: Sep 1, 2017
Visit Reason
The inspection was conducted as a complaint investigation following an incident involving resident interactions and alleged abuse at Frederick Living - Aspen Village.
Complaint Details
The investigation was triggered by an incident on 08/11/17 where Resident #1 assaulted Resident #2. The allegation was witnessed by staff and unprovoked by Resident #2. Resident #2 was sent to the hospital for emergency medical care and Resident #1 was hospitalized for psychiatric evaluation.
Findings
A violation of 55 Pa.Code Chapter 2600 was found where Resident #1 grabbed and forcefully pushed Resident #2, causing injury requiring staples. The facility submitted a plan of correction and showed partial implementation progress.
Citations (1)
Regulation 55 Pa.Code §2600.42(b) prohibits neglect, intimidation, abuse, mistreatment, or corporal punishment of residents. Resident #1 grabbed and forcefully pushed Resident #2 to the floor causing a 3 cm laceration requiring 4 staples.
Report Facts
Number of Residents Served: 26
Laceration size: 3
Staples required: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Laura Strausser | Personal Care Home Administrator | Named as facility administrator and legal entity representative signing the plan of correction. |
| Katie Reilly | PC Asst. Administrator | Signed the plan of correction document on 6/29/18. |
Inspection Report — Jul 3, 2017
Annual Inspection
Date: Jul 3, 2017
Visit Reason
The inspection was the Department of Human Services' annual licensing inspection of Frederick Living - Aspen Village conducted on July 3, 2017.
Findings
Violations of 55 Pa.Code Chapter 2600 related to personal care homes were found, including neglect and medication errors involving insulin administration. A plan of correction was submitted and partially implemented.
Citations (3)
Regulation 2600.42(b) - A resident was neglected when staff failed to perform prescribed accu-checks and withheld insulin doses multiple times. Staff Member A was identified as responsible and terminated following investigation.
Regulation 2600.187(d) - The home failed to follow the prescriber's directions when Staff Member A did not administer Novolog insulin at prescribed times for Resident #1. This was linked to the same staff member's neglect.
Regulation 2600.188(b) - A medication error occurred when Resident #1's missed insulin doses were not immediately reported to the resident, designated person, or prescriber until 6/27/17.
Report Facts
Number of Residents Surveyed: 28
Number of Residents Age 60 or Older: 29
Total Daily Staff: 58
Waking Staff: 44
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Laura Strausser | PC Administrator | Named as legal entity representative and signatory on violation reports and plans of correction. |
| Staff Member A | Identified as responsible for neglect, withholding insulin, and medication errors leading to termination. |
Inspection Report — Apr 5, 2017
Renewal
Date: Apr 5, 2017
Visit Reason
The document is a renewal license issued to Frederick Living - Aspen Village to operate a Personal Care Home. The Department advises that an onsite annual inspection will be conducted within the next twelve months as required by regulation.
Findings
No inspection findings are reported in this document. It primarily serves as a license renewal notification and outlines the requirement for a future annual inspection.
Report Facts
Inspection Report — Jun 6, 2016
Renewal
Date: Jun 6, 2016
Visit Reason
The inspection was conducted as part of the Department of Human Services' annual licensing renewal inspections on June 6 and June 7, 2016, for Frederick Living - Aspen Village.
Findings
Violations of 55 Pa.Code Chapter 2600 related to Personal Care Homes were found during the inspection. The violations included missing emergency phone service numbers in resident rooms and lack of notation for resident inability or refusal to sign support plans.
Citations (2)
55 Pa.Code §2600.91 requires emergency service numbers to be posted on or by each telephone. The telephones in rooms #1208 and #1314 did not have emergency service numbers posted nearby.
55 Pa.Code §2600.227(b) requires documentation if a resident or designated person is unable or refuses to sign the support plan. There was no notation on resident #1's support plan dated 2/16/2016 regarding inability or refusal to sign.
Report Facts
Number of Residents Served: 31
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Laura Strausser | Personal Care Administrator | Named in relation to the violations and plan of correction. |
Inspection Report — May 12, 2016
Renewal
Date: May 12, 2016
Visit Reason
The document is a renewal license issued to Frederick Living - Aspen Village for operating a Personal Care Home. It states the Department will conduct an onsite annual inspection within the next twelve months as required by regulation.
Findings
No inspection findings are reported in this document. It is a license renewal certificate and accompanying letter confirming receipt of the renewal application and outlining inspection requirements.
Report Facts
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