Inspection Report
Follow-Up
Census: 49
Capacity: 100
Deficiencies: 6
Sep 3, 2025
Visit Reason
The inspection was a partial, unannounced follow-up visit triggered by a complaint and incident to verify the implementation of a previously submitted plan of correction.
Findings
The facility was found to have fully implemented the submitted plan of correction addressing multiple deficiencies including direct care staff training, locking poisonous materials, unobstructed egress, medication storage, medication labeling, and adherence to prescriber's orders. Continued compliance and monitoring were required.
Complaint Details
The visit was complaint-related and incident-related as stated in the inspection information section.
Deficiencies (6)
| Description |
|---|
| Direct care staff person provided unsupervised ADL services without dated documentation of completing and passing the Department-approved direct care training course and competency test. |
| Poisonous materials (Tide Clear and Fresh Pods) were unlocked and accessible in the Secured Dementia Care Unit to residents not assessed as capable of safely using or avoiding poisons. |
| A cleaning cart blocked egress from the top of the 2nd floor stairwell leading to the 1st floor. |
| Prescription medications were torn on pill slots but remained in place, indicating improper medication storage. |
| The pharmacy label for a resident's medication did not include the prescribed dosage and instructions for administration. |
| A resident was prescribed medication to be taken three times daily but was not administered the medication at specified times. |
Report Facts
Residents Served: 49
License Capacity: 100
Secured Dementia Care Unit Capacity: 22
Residents Served in Secured Dementia Care Unit: 12
Current Hospice Residents: 4
Total Daily Staff: 61
Waking Staff: 46
Residents with Mobility Need: 12
Residents Age 60 or Older: 49
Residents with Physical Disability: 1
Inspection Report
Complaint Investigation
Census: 46
Capacity: 100
Deficiencies: 9
Jul 29, 2025
Visit Reason
The inspection was conducted as a partial, unannounced visit due to a complaint and incident involving suspected resident abuse and other regulatory concerns.
Findings
The inspection found multiple deficiencies including failure to immediately report suspected resident abuse, incomplete resident home contracts, inadequate staffing in the secured dementia care unit, untrained direct care staff providing unsupervised ADL services, broken equipment (lamp light switch), lack of resident education on medication refusal rights, unsigned support plans, and missing posted directions for key-locking devices.
Complaint Details
The visit was complaint-related, triggered by an allegation of suspected rough handling of a resident by staff, which was not reported to the local area agency on aging. The complaint was substantiated with findings of failure to report and other related deficiencies.
Deficiencies (9)
| Description |
|---|
| Failure to immediately report suspected abuse of a resident to the local area agency on aging. |
| Resident home contract was not signed by the resident. |
| Resident record did not contain a signed statement acknowledging receipt of resident rights and complaint procedures. |
| Inadequate staffing for the 3:00 PM to 11:00 PM shift in the secured dementia care unit to meet resident needs. |
| Direct care staff person provided unsupervised ADL services without completing required Department-approved training and competency test. |
| Broken light switch on lamp in resident's room, making it non-operational. |
| Resident was not educated on the right to refuse medication if a medication error is suspected. |
| Resident support plan was not signed by the staff person who completed the plan. |
| Directions for operating the magnetic locking mechanism on a fire tower exit door were not conspicuously posted. |
Report Facts
Residents Served: 46
License Capacity: 100
Residents in Secured Dementia Care Unit: 12
Residents with Physical Disability: 1
Residents with Mobility Need: 21
Resident Wellness Associates Scheduled: 2
Total Daily Staff: 67
Waking Staff: 50
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrator/Executive Operations Officer | Informed of staffing violation and resident behavior incidents | |
| Executive Operations Officer | Responsible party for multiple plans of correction including abuse reporting, contract signatures, staff training, and audits | |
| Resident Wellness Director or Designee | Responsible for staffing adjustments, support plan audits, and ongoing monitoring | |
| Maintenance Supervisor | Responsible for repair of broken lamp switch | |
| Maintenance Director or Designee | Responsible for posting directions and conducting audits of key-locking devices | |
| Administrative Services Director or Designee | Responsible for auditing resident contracts and support plan signatures |
Inspection Report
Renewal
Census: 41
Capacity: 100
Deficiencies: 17
Apr 15, 2025
Visit Reason
The inspection was conducted as a renewal inspection along with complaint and provisional reviews on April 15 and 16, 2025, to determine compliance with 55 Pa. Code Chapter 2600 relating to Personal Care Homes.
Findings
The facility was found to be in compliance overall, but several deficiencies were cited including issues with resident dignity and respect, privacy violations, incomplete criminal background checks, lack of certified staff for first aid/CPR, insufficient annual training for direct care staff, unsecured poisonous materials, sanitary condition concerns, inadequate lighting, refrigerator temperature violations, lint accumulation in dryers, incomplete medication records, medication storage and administration errors, failure to follow prescriber's orders, and improper discharge notification procedures. Plans of correction were submitted and accepted with follow-up monitoring.
Deficiencies (17)
| Description |
|---|
| Resident #1 was not treated with dignity and respect; staff member used inappropriate language and failed to provide privacy during toileting. |
| Resident #1 did not have privacy during dressing and toileting; apartment door was left open exposing resident. |
| Staff member C did not have a completed criminal background check on file. |
| No staff certified in first aid, obstructed airway techniques, and CPR were present during night shifts when 41 residents were present. |
| Direct care staff persons D and E did not receive required 12 hours of annual training in 2024. |
| Direct care staff persons D and E did not receive required annual training topics including medication self-administration, dementia care, infection control, and safe management techniques. |
| Direct care staff persons D, E, C, and F did not receive required annual training on fire safety, emergency preparedness, resident rights, and Older Adult Protective Services Act. |
| Poisonous materials were unlocked and accessible to residents in the memory care unit. |
| Sanitary conditions were not maintained; black stains in bathroom and water leak in boiler room causing damage. |
| Resident #3 did not have access to an operable lamp or source of lighting at bedside. |
| Refrigerator temperature exceeded required maximum of 40°F on multiple occasions. |
| Lint accumulation was found in the lint trap of the 2nd floor dryer. |
| Fire safety inspection and drill were overdue; last conducted on 10/28/24 exceeding one year from previous inspection. |
| Resident #4's medication record did not include a current list of medications, missing Vitamin D3. |
| Resident #5's glucose checks did not match MAR readings on multiple dates. |
| Resident #6 was not administered prescribed Acetaminophen due to medication unavailability. |
| Resident #7 was discharged without a 30-day advance written notice or physician certification letter. |
Report Facts
License Capacity: 100
Residents Served: 41
Secure Dementia Care Unit Capacity: 22
Residents Served in Secure Dementia Care Unit: 11
Hospice Residents: 7
Residents with Mobility Need: 30
Total Daily Staff: 71
Waking Staff: 53
Inspection Dates: 2
Plan of Correction Follow-Up Date: May 16, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff member B | Named in resident dignity and respect violation involving inappropriate language and behavior | |
| Staff member C | Named in criminal background check deficiency and annual training deficiency | |
| Direct care staff person D | Named in annual training deficiencies | |
| Direct care staff person E | Named in annual training deficiencies | |
| Staff person F | Named in annual training deficiency | |
| Resident Wellness Director | Responsible for auditing medication and training compliance | |
| Executive Operations Officer | Involved in investigations, suspensions, training, and follow-up actions |
Inspection Report
Monitoring
Census: 43
Capacity: 100
Deficiencies: 6
Mar 5, 2025
Visit Reason
The visit was an unannounced partial inspection conducted as a monitoring review to verify the implementation of a previously submitted plan of correction.
Findings
The inspection found multiple deficiencies including obstructed emergency egress, improper combustible storage and accessibility, inoperable smoke detectors and fire safety system failures, unsafe smoking area conditions, and incomplete support plan signatures. The facility has implemented corrective actions and ongoing monitoring plans for each deficiency.
Deficiencies (6)
| Description |
|---|
| A laminated picture of a stop sign was hung on the emergency exit by the laundry room, obstructing egress. |
| A dirty rag and an open bottle of sealant were stored on top of the home's boiler, near heat sources. |
| A gas propane tank was unlocked, unattended, and accessible to residents on the patio outside of the dining room. |
| The fire alarm and sprinkler systems were not fully functional since 1/23/2025 due to a burst sprinkler pipe; multiple fire safety system components failed inspection. |
| The designated smoking area had spent cigarettes littered on the ground and an open, non-fireproof trash can stored next to gasoline containers and other flammable materials. |
| A resident participated in the development of the support plan but did not sign it, with no indication the resident was given the opportunity to sign. |
Report Facts
Residents served: 43
License capacity: 100
Capacity of secured dementia care unit: 22
Residents served in secured dementia care unit: 9
Current hospice residents: 8
Residents age 60 or older: 43
Residents with mobility need: 23
Residents with physical disability: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Named in multiple findings related to removal of hazards, staff training, and ongoing compliance monitoring | |
| Director of Safety and Maintenance | Named in finding related to inoperable smoke detector and fire safety system issues | |
| Resident Wellness Director/Designee | Named in finding related to support plan signature review and audits |
Inspection Report
Follow-Up
Census: 42
Capacity: 100
Deficiencies: 8
Jan 7, 2025
Visit Reason
The visit was a partial, unannounced follow-up inspection to verify the implementation of a previously submitted plan of correction.
Findings
The facility was found to have fully implemented the submitted plan of correction related to medication management deficiencies, including medication storage, administration, documentation, and error reporting. Continued compliance is required.
Deficiencies (8)
| Description |
|---|
| Medications that were discontinued remained in the medication cart. |
| Expired medications were found in the medication cart. |
| Medications prescribed for residents were not available in the home when needed. |
| Glucose checks were documented inaccurately with recorded numbers not matching readings. |
| Medication administration records did not include all prescribed medications. |
| Medications were held without documented parameters for holding. |
| Medications were not administered due to unavailability, yet records indicated administration. |
| Medication errors were not reported to residents, their designated persons, or prescribers as required. |
Report Facts
License Capacity: 100
Residents Served: 42
Secured Dementia Care Unit Capacity: 22
Secured Dementia Care Unit Residents Served: 6
Hospice Current Residents: 8
Total Daily Staff: 68
Waking Staff: 51
Inspection Report
Follow-Up
Census: 43
Capacity: 100
Deficiencies: 4
Jan 3, 2025
Visit Reason
The visit was a follow-up review conducted on February 26, 2025 and March 14, 2025 to assess the implementation of the plan of correction submitted for violations identified during the January 3 and 14, 2025 inspections.
Findings
The facility was found to have not implemented the submitted plan of correction for multiple violations related to resident care, including inadequate assistance with activities of daily living, abuse and neglect related to elopement risks, insufficient staffing to meet resident needs, and incomplete support plan documentation. Evidence of completion was not implemented as of the follow-up dates.
Deficiencies (4)
| Description |
|---|
| Resident #1 was transferred using a Hoyer lift by only one staff person despite the support plan requiring three-person assistance. |
| Resident #2 eloped from the Secure Dementia Care Unit multiple times, including a 48-minute elopement in cold weather without a coat, indicating neglect and failure to prevent elopement. |
| Staffing levels in the Secure Dementia Care Unit were insufficient, with only one direct care person present for five residents, failing to meet the needs specified in resident assessments and support plans. |
| Resident #1's support plan was not signed by any participants as required. |
Report Facts
License Capacity: 100
Residents Served: 43
Secured Dementia Care Unit Capacity: 22
Secured Dementia Care Unit Residents Served: 5
Hospice Residents: 10
Staffing - Total Daily Staff: 70
Staffing - Waking Staff: 53
Elopement Duration: 48
Elopement Search Duration: 43
Distance Traveled During Elopement: 100
Inspection Report
Complaint Investigation
Census: 42
Capacity: 100
Deficiencies: 7
Oct 28, 2024
Visit Reason
The inspection was conducted as a complaint investigation and incident review following concerns raised about resident care and safety at Glen Mills Senior Living.
Findings
The inspection found multiple deficiencies including failure to provide required assistance with activities of daily living, neglect and abuse of residents, unsanitary conditions, missing soap dispensers, failure to follow prescriber's orders for medication administration, elopement risks due to unsecured dementia unit, and incomplete resident records.
Complaint Details
The visit was complaint-related, triggered by incidents involving neglect, abuse, elopement, and failure to follow care plans and prescriber orders. Substantiation status is not explicitly stated.
Deficiencies (7)
| Description |
|---|
| Resident did not receive required assistance with toileting and bladder/bowel management during quarantine periods. |
| Resident was neglected and subjected to unsanitary conditions, improper meal service, and improper medication administration. |
| Resident eloped multiple times from the secured dementia unit due to unchanged and easily accessible exit code. |
| Sanitary conditions were not maintained; housekeeping failed to clean resident rooms during quarantine periods. |
| No soap dispenser in shared bathroom located in room 321. |
| Resident's glucose checks were not completed as prescribed and insulin doses were not administered as ordered. |
| Resident record did not include a copy of the reportable for an elopement incident. |
Report Facts
License Capacity: 100
Residents Served: 42
Residents in Secured Dementia Care Unit Capacity: 22
Residents in Secured Dementia Care Unit Served: 6
Current Hospice Residents: 10
Staffing Hours: 65
Waking Staff: 49
Number of Residents Diagnosed with Mental Illness: 6
Number of Residents with Mobility Need: 23
Number of Residents with Physical Disability: 1
Number of Residents 60 Years or Older: 42
Number of Residents Receiving Supplemental Security Income: 0
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| DON | Director of Nursing | Named in multiple findings related to training, review of resident assessments, medication administration, and elopement prevention. |
| Lead med-tech | Involved in resident assessment reviews and medication administration oversight. | |
| ASD | Responsible for weekly resident check-ins to ensure needs are met. | |
| Administrator | Responsible for ensuring staff training on resident care, rights, abuse, and neglect. | |
| Memory Care Director | Responsible for implementing hourly safety checks and elopement prevention training. | |
| Maintenance Director | Installed soap dispenser and involved in elopement training. | |
| LPN supervisor | Involved in medication administration oversight. |
Inspection Report
Complaint Investigation
Census: 49
Capacity: 100
Deficiencies: 0
Jun 17, 2024
Visit Reason
The inspection was conducted as a complaint investigation during an unannounced partial licensing inspection of the facility.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Complaint Details
The inspection was complaint-related, but no deficiencies were found and no follow-up was required.
Report Facts
License Capacity: 100
Residents Served: 49
Memory Care Capacity: 22
Memory Care Residents Served: 9
Current Hospice Residents: 10
Resident Support Staff Hours: 0
Total Daily Staff: 77
Waking Staff: 58
Residents Age 60 or Older: 49
Residents with Mobility Need: 28
Residents with Physical Disability: 1
Inspection Report
Enforcement
Census: 44
Capacity: 100
Deficiencies: 21
Apr 23, 2024
Visit Reason
The inspection was conducted as a renewal licensing inspection of Glen Mills Senior Living to assess compliance with 55 Pa. Code Chapter 2600 relating to Personal Care Homes.
Findings
Multiple violations were found including deficiencies in signage, personal hygiene, privacy, training records, lighting, surfaces, medication management, emergency procedures, fire drills, smoking area safety, dietary needs, and resident records. A provisional license was issued with required corrections and fines pending.
Deficiencies (21)
| Description |
|---|
| Entrance lacks a 'No Smoking' sign and no indication that smoking is only permitted in designated areas. |
| Privacy signs posted outside resident #3's apartment were not properly informing staff of resident's requirements. |
| Staff training records did not include number of hours trained on transcripts. |
| Staff training plan lacked name, position, duties, and scheduled training details for direct care staff. |
| Memory care emergency exit fire tower lacked adequate lighting; lights were inoperable. |
| Ceiling in disrepair above second set of doors; ceiling tiles missing and evidence of leaking. |
| Residents #4 and #5 did not have operable lamps or lighting sources at bedside. |
| Written emergency procedures not submitted or updated since April 20, 2022. |
| Obstructive signage posted on north wing fire tower door interfering with egress. |
| Fire drill records lacked location, number of residents, and evacuation time details. |
| Fire drills routinely held at same time and day of week, not varied as required. |
| Designated smoking area lacked fireproof receptacles and proper signage. |
| Resident #4 served incorrect diet inconsistent with physician-prescribed mechanical soft diet. |
| Discontinued and expired medications found in medication cart for residents #3 and #4. |
| Medication Acetaminophen 325mg tabs not available in home for resident #3. |
| Medication administration records lacked diagnosis or purpose for medications for residents #3 and #4. |
| Resident #3 was administered medication incorrectly and missed doses due to unavailability. |
| Preadmission screening forms for residents #2 and #4 lacked determination that needs can be met by home services. |
| Support plans for residents #1 and #4 did not specify how physical assistance needs would be addressed. |
| Directions for operating locking mechanism not posted for Secure Dementia Care Unit (SDCU). |
| Resident records for #3 and #6 lacked photographs no more than 2 years old. |
Report Facts
License Capacity: 100
Residents Served: 44
Secured Dementia Care Unit Capacity: 22
Residents Served in Dementia Unit: 4
Staffing Hours - Total Daily Staff: 59
Staffing Hours - Waking Staff: 44
Deficiency Counts: 24
Inspection Report
Renewal
Census: 44
Capacity: 100
Deficiencies: 20
Apr 23, 2024
Visit Reason
The inspection was conducted as a renewal licensing inspection of Glen Mills Senior Living to assess compliance with 55 Pa. Code Chapter 2600 relating to Personal Care Homes.
Findings
Multiple violations were found including issues with signage, personal hygiene, privacy, training records, lighting, surfaces, emergency procedures, fire drills, smoking area safety, dietary needs, medication management, resident records, and key-locking devices. Plans of correction were proposed with various completion dates.
Deficiencies (20)
| Description |
|---|
| Entrance of the home lacks a 'No Smoking' sign and no indication that smoking is only permitted in designated areas. |
| Resident #3's privacy was compromised by posted signs outside their apartment without proper notification. |
| Staff training records lacked documentation of hours trained and training plan lacked required details. |
| Memory care emergency exit fire tower lacked adequate lighting. |
| Ceiling in disrepair above second set of doors to enter the home with missing ceiling tiles and evidence of leaking. |
| Residents #4 and #5 did not have operable lamps at bedside. |
| Written emergency procedures had not been updated or submitted since April 20, 2022. |
| Obstructed egress due to posted signs on fire exit door. |
| Fire drill records lacked required details such as location, number of residents, and evacuation time. |
| Fire drills were routinely held at the last week of the month at similar times. |
| Designated smoking area lacked fireproof receptacles and signage. |
| Resident #4 was served a diet inconsistent with prescribed mechanical soft diet. |
| Medications for residents #3 and #4 were expired or discontinued but still present in medication cart. |
| Resident #3's prescribed medication was not available in the home. |
| Medication administration records lacked diagnosis or purpose for medications for residents #3 and #4. |
| Resident #3 was administered medication incorrectly and some medications were not administered due to unavailability. |
| Preadmission screening forms for residents #2 and #4 lacked determination that needs could be met by the home. |
| Support plans for residents #1 and #4 did not specify how physical assistance needs would be addressed. |
| Directions for operating home's locking mechanism were not posted for the Secure Dementia Care Unit. |
| Resident records for residents #3 and #6 did not include a photograph no more than 2 years old. |
Report Facts
License Capacity: 100
Residents Served: 44
Secured Dementia Care Unit Capacity: 22
Secured Dementia Care Unit Residents Served: 4
Current Hospice Residents: 10
Residents 60 Years or Older: 44
Residents with Mobility Need: 15
Residents with Physical Disability: 28
Deficiencies Cited: 24
Inspection Report
Complaint Investigation
Census: 46
Capacity: 100
Deficiencies: 12
Dec 21, 2023
Visit Reason
The inspection was conducted as a complaint investigation with an unannounced partial inspection on 12/21/2023, followed by off-site reviews and plan of correction submissions.
Findings
The facility was found to have multiple deficiencies including failure to report incidents timely, lack of hospice license documentation, inadequate staffing affecting resident care, absence of CPR-certified staff during a shift, insufficient annual training hours for direct care staff, sanitary issues, inoperable bathroom ventilation, equipment malfunction, unlocked medications in resident rooms, failure to follow prescriber's orders, and medication error reporting failures. All deficiencies had plans of correction accepted and were implemented by 03/06/2024.
Complaint Details
The inspection was complaint-driven as indicated by the reason 'Complaint' and the unannounced partial inspection on 12/21/2023.
Deficiencies (12)
| Description |
|---|
| Failure to submit incident reports to the Department for unwitnessed fall and medication administration errors. |
| Hospice services provided without a copy of the hospice license. |
| Resident did not receive repositioning as required due to lack of available direct care staffing. |
| No staff present certified in first aid, obstructed airway techniques, and CPR during a shift with 46 residents. |
| Direct care staff person received only 8.75 hours of annual training instead of required 12 hours. |
| Direct care staff did not receive training in emergency preparedness and crisis response during the training year. |
| Bathroom ceiling had mildew or mold stain from a water leak. |
| Bathroom lacked operable window or ventilation fan; exhaust fan was inoperable. |
| Prep refrigerator was out of order. |
| Medications and syringes were unlocked, unattended, and accessible in resident rooms. |
| Failure to follow prescriber's orders including failure to notify hospice and medication administration errors. |
| Medication error was not immediately reported to resident, designated person, and prescriber. |
Report Facts
License Capacity: 100
Residents Served: 46
Secured Dementia Care Unit Capacity: 22
Residents Served in Dementia Unit: 7
Hospice Residents: 5
Residents with Mobility Need: 23
Residents 60 Years or Older: 46
Direct Care Staff Annual Training Hours: 8.75
Total Daily Staff: 69
Waking Staff: 52
Inspection Report
Follow-Up
Census: 45
Capacity: 100
Deficiencies: 5
Nov 21, 2023
Visit Reason
The inspection visit on 11/21/2023 was a complaint-related partial inspection with an unannounced notice, followed by a plan of correction submission and document review.
Findings
The facility was found to have multiple deficiencies including failure to timely report incidents to the department, incomplete medical evaluations, discrepancies in resident assessments, and incomplete documentation in resident support plans. The submitted plan of correction was determined to be fully implemented as of 01/05/2024.
Complaint Details
The inspection was complaint-related, triggered by concerns about incident reporting and resident care documentation. The complaint was addressed through a follow-up inspection and plan of correction submission.
Deficiencies (5)
| Description |
|---|
| Failure to report incidents to the department within 24 hours as required. |
| Incomplete medical evaluation for resident #1, missing special health or dietary needs and incomplete body positioning/movement information. |
| Resident #1's additional assessment was not completed annually as required. |
| Discrepancies in mobility assessments for resident #1 between different documents. |
| Resident #1 and #2's support plans had multiple differences and incomplete medical diagnoses documentation. |
Report Facts
License Capacity: 100
Residents Served: 45
Secured Dementia Care Unit Capacity: 22
Secured Dementia Care Unit Residents Served: 5
Hospice Residents: 5
Total Daily Staff: 69
Waking Staff: 52
Residents with Mobility Need: 24
Inspection Report
Follow-Up
Census: 45
Capacity: 100
Deficiencies: 14
Aug 28, 2023
Visit Reason
The inspection was a partial announced follow-up visit conducted on 08/28/2023 to review compliance and verify correction of previous deficiencies at Glen Mills Senior Living.
Findings
Multiple deficiencies were identified related to facility safety, resident accommodations, and dining services, including issues with carbon monoxide detector placement, bathroom ventilation, lack of furniture in resident areas, missing bedroom furnishings, unlabeled leftover food, and missing posted menus and activity calendars. All deficiencies had plans of correction accepted and were implemented by 10/13/2023.
Deficiencies (14)
| Description |
|---|
| The distance between fossil fuel burning equipment and the door was less than 15 feet and carbon monoxide detector was not installed outside the door. |
| Bathrooms in bedrooms #115, 117, and 120 lacked operable windows or ventilation fans. |
| No furniture was available on the patio to accommodate residents, families, and visitors. |
| No mattresses were present in bedrooms 104 and 109. |
| No chairs were present in bedroom 109. |
| No pillows, bed linens, or blankets that were clean and in good repair in bedrooms 104 and 109. |
| No storage area for clothing including chest of drawers or wardrobe space accessible to resident in bedroom 109. |
| No bedside table or shelf in bedroom 109. |
| No operable lamp or source of lighting at bedside in bedroom 109. |
| No toilet paper provided for toilets in bathrooms of bedrooms 104 and 109. |
| Unlabeled and undated leftover food items including jams, meat, carrots, cakes, and bagels. |
| Condiments were not available at dining tables. |
| Weekly menus stating specific food served were not posted in a conspicuous and public place in the memory care unit. |
| No current weekly activity calendar posted in a conspicuous and public place; posted calendar was dated 8/28/2023. |
Report Facts
License Capacity: 100
Residents Served: 45
Secured Dementia Care Unit Capacity: 22
Secured Dementia Care Unit Residents Served: 0
Hospice Residents: 3
Resident Age 60 or Older: 44
Residents Diagnosed with Mental Illness: 1
Residents Diagnosed with Intellectual Disability: 1
Residents with Mobility Need: 13
Resident Support Staff: 0
Total Daily Staff: 58
Waking Staff: 44
Inspection Report
Census: 38
Capacity: 100
Deficiencies: 0
Dec 8, 2022
Visit Reason
The inspection was conducted as a partial, unannounced licensing inspection due to an incident at the facility.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Total Daily Staff: 49
Waking Staff: 37
Resident Support Staff: 0
Current Hospice Residents: 5
Residents 60 Years or Older: 38
Residents Diagnosed with Mental Illness: 1
Residents with Mobility Need: 11
Inspection Report
Renewal
Census: 41
Capacity: 100
Deficiencies: 29
Sep 28, 2022
Visit Reason
The inspection was an unannounced full renewal and incident review conducted on 09/28/2022 and 09/29/2022 to assess compliance with licensing requirements and investigate incidents.
Findings
Multiple deficiencies were identified including failure to timely report incidents, expired licenses, incomplete resident records, missing signatures on contracts and support plans, inadequate staff orientation and training, unsafe storage and handling of medications, sanitary issues, and fire safety violations. Plans of correction were accepted and implemented by 11/16/2022.
Deficiencies (29)
| Description |
|---|
| Failure to report missing ordered items for Resident #1 within 24 hours. |
| Boiler certificate expired and not renewed timely. |
| Resident-home contracts for residents #2, #3, and #4 were not signed appropriately. |
| Resident #2 and #3 did not have signed statements acknowledging receipt of resident rights and complaint procedures. |
| Criminal background checks not completed timely for staff and contractors. |
| Direct care staff person B's LPN license expired and no other qualifications available. |
| Direct care staff persons A, C, and D did not receive required orientation on fire safety and emergency preparedness topics. |
| Direct care staff persons A, C, and D did not complete training on resident rights, emergency medical plan, abuse reporting, and incident reporting within 40 scheduled hours. |
| Ancillary staff person A did not have general orientation to specific job functions. |
| Staff records lacked documentation of orientation and annual staff training. |
| Sanitary conditions not maintained; brown substance observed on ceiling and wall. |
| Emergency telephone numbers missing on or by telephone in resident room. |
| Unlabeled and undated canned goods found in kitchen pantry. |
| Accumulation of lint in commercial dryer lint trap and drum. |
| Unannounced fire drill not held during February 2022. |
| Annual fire safety inspection and drill last conducted on 04/12/2022; previous was 10/30/2019. |
| Fire drill records did not fully document exit routes for multiple drills. |
| Medical evaluation for resident #3 not completed within required timeframe. |
| Designated smoking area had seat cushions not labeled as fire resistant. |
| Resident smoking outside designated smoking area. |
| Resident #3 self-administering medications without documented assessment by qualified medical professional. |
| Resident #3's medication record did not include a current list of medications; some medications missing or outdated. |
| Expired medication found in resident #3's medication box. |
| Medications prescribed for resident #5 were not available in the home. |
| Procedures for safe use of medications and medical equipment not followed, including incomplete investigation and notification of missing controlled substances. |
| Resident #3's preadmission screening form completed after admission. |
| Preadmission screening form for resident #2 incomplete with missing name and signature of screener. |
| Support plans for residents #3, #4, and #5 not signed by staff member or resident as required. |
| Resident #3's record lacked a photograph no more than 2 years old. |
Report Facts
Residents Served: 41
License Capacity: 100
Total Daily Staff: 53
Waking Staff: 40
Inspection Report
Renewal
Census: 35
Capacity: 100
Deficiencies: 12
Aug 19, 2021
Visit Reason
The inspection was a full, unannounced renewal inspection conducted on 08/19/2021 and 08/20/2021 to assess compliance with licensing regulations at Glen Mills Senior Living.
Findings
The inspection identified multiple deficiencies related to housekeeping staffing, furniture and equipment maintenance, food storage, lint removal, medical evaluations, medication labeling, storage, administration, and resident education on medication refusal rights. Plans of correction were accepted and implemented for all deficiencies.
Deficiencies (12)
| Description |
|---|
| Insufficient housekeeping and dining staff on duty to meet residents' needs, resulting in uncleaned rooms and bathrooms. |
| Sink in second floor television lounge was clogged and HVAC system was not working properly. |
| No thermometer in the ice cream freezer. |
| Ice cream containers in freezer were opened and unsealed. |
| Accumulation of lint in the lint trap of the dryer in the third floor laundry room. |
| Resident #1's medical evaluation lacked a general physical examination; Resident #2's evaluation lacked special health or dietary needs. |
| Tube belonging to resident #3 was not labeled with the resident's name. |
| Medications prescribed to residents #3 and #4 were missing or not available in the home. |
| Resident #3's medication administration record did not indicate diagnosis or purpose for medication including PRN. |
| Resident #3's medication administration record lacked initials of staff administering or removing medications on specified dates. |
| Resident #3 was not administered a prescribed medication on 8/19/21 at 8:00 am due to medication unavailability. |
| Resident #5 was not educated on the right to refuse medication and no signed documentation was available. |
Report Facts
License Capacity: 100
Residents Served: 35
Hospice Residents: 5
Residents 60 Years or Older: 34
Residents with Mobility Need: 10
Total Daily Staff: 45
Waking Staff: 34
Inspection Report
Complaint Investigation
Census: 37
Capacity: 100
Deficiencies: 5
May 4, 2021
Visit Reason
The inspection was conducted as a partial, unannounced incident investigation related to a complaint or allegation at the facility.
Findings
The inspection identified multiple deficiencies including an incident of inappropriate sexual contact between a staff member and a resident, medication management issues such as discontinued medications remaining in the medication cart, missing medications, incomplete medication records, and missing documentation of medication administration times and staff initials.
Complaint Details
The visit was complaint-related due to an incident on 04/20/2021 involving inappropriate sexual contact between a staff member (Staff B) and resident 1. The allegation was reported immediately, investigated by the Administrator, and reported to governing agencies and state police. Staff B was placed on administrative leave and resigned during the investigation.
Deficiencies (5)
| Description |
|---|
| Inappropriate sexual contact occurred between resident 1 and staff B, which was interrupted by staff A. Staff B did not have a work order and was not authorized to be in the resident's bedroom. |
| Murine Ear Wax Removal System 6.5%, prescribed for resident #1, was in the home's medication cart despite being discontinued on 04/21/2021. |
| Resident #1 was prescribed Loperamide HCL 2 mg, Refresh Tears 0.5% Drops, and Milk of Magnesia as needed, but these medications were not available in the home. |
| Resident #1's medication administration record did not indicate the diagnosis for Voltaren Gel and Debrox Ear Drops prescribed for 7 days starting 04/26/2021. |
| Resident #1’s May medication administration record did not include the initials of the staff person who administered Simbrinza 1%-0.2% Drops on 05/01, 05/02, and 05/03/2021 at 08:00 PM. |
Report Facts
License Capacity: 100
Residents Served: 37
Total Daily Staff: 45
Waking Staff: 34
Medication Administration Record Missing Initials: 3
Medication Cart Audit Frequency: 4
Medication Cart Audit Frequency: 1
Notice
Capacity: 100
Deficiencies: 0
Oct 4, 2021
Visit Reason
The document serves as a certificate of compliance and confirms the renewal of the license to operate Glen Mills Senior Living, a Personal Care Home. It also notifies that an onsite inspection will be conducted within the next twelve months as required by state regulations.
Findings
The Department has issued a regular license in response to the renewal application and advises that an annual onsite inspection will be conducted within the next twelve months. Enforcement actions will be taken if noncompliance is found during the inspection.
Report Facts
Total licensed capacity: 100
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary, Office of Long-term Living | Signed the renewal notice letter |
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