Inspection Report
Renewal
Census: 65
Capacity: 88
Deficiencies: 5
Jul 23, 2025
Visit Reason
The inspection was conducted as a renewal inspection combined with an incident review, including a follow-up on the submitted plan of correction.
Findings
The facility was found to have several deficiencies including expired batteries in carbon monoxide detectors, sanitary issues such as an unlabeled disposable razor and unlabeled soap in community shower areas, a hole in drywall in a resident's room, and lack of operable bedside lighting in a resident room. All deficiencies had plans of correction accepted and were implemented by the time of the report.
Deficiencies (5)
| Description |
|---|
| Expired batteries in carbon monoxide detector dated 2/1/22 on second floor outside mechanical room. |
| Unlabeled blue colored plastic disposable razor found in soap dish in second-floor secure dementia care unit community shower area. |
| Medium sized hole in drywall approximately 8 inches by 6 inches behind recliner chair in resident room #201. |
| No operable source of light at bedside in resident room #122. |
| Bar of white-colored unlabeled hand soap in soap dish in second-floor secure dementia care unit community shower area. |
Report Facts
License Capacity: 88
Residents Served: 65
Residents in Secured Dementia Care Unit: 29
Current Hospice Residents: 6
Total Daily Staff: 97
Waking Staff: 73
Inspection Report
Partial
Census: 69
Capacity: 88
Deficiencies: 0
Apr 1, 2025
Visit Reason
The inspection was conducted as a licensing inspection by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing, due to an incident.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Residents Served: 69
License Capacity: 88
Residents Served: 30
Current Residents: 4
Residents Age 60 or Older: 70
Residents Diagnosed with Mental Illness: 2
Residents Diagnosed with Intellectual Disability: 1
Residents with Mobility Need: 36
Residents Receiving Supplemental Security Income: 0
Residents with Physical Disability: 0
Inspection Report
Complaint Investigation
Census: 63
Capacity: 88
Deficiencies: 1
Dec 19, 2024
Visit Reason
The inspection was conducted as a complaint and incident investigation at Halcyon Senior Living.
Findings
The report found a violation related to the treatment of a resident who felt dizzy and fell out of a chair, with staff making a disrespectful comment that negatively affected the resident. A plan of correction was implemented including staff supervision, education, and resident interviews to ensure compliance with dignity and respect standards.
Complaint Details
The visit was complaint-related and involved an incident where a resident felt dizzy, fell, and was treated disrespectfully by staff. The resident reported feeling 'Low' and 'like I wasn’t worth nothing' due to a staff comment.
Deficiencies (1)
| Description |
|---|
| A resident was treated without dignity and respect, including a disrespectful comment made by staff after the resident fell and required emergency assistance. |
Report Facts
License Capacity: 88
Residents Served: 63
Secured Dementia Care Unit Capacity: 44
Secured Dementia Care Unit Residents Served: 28
Hospice Current Residents: 4
Residents Age 60 or Older: 63
Residents Diagnosed with Mental Illness: 2
Residents with Mobility Need: 33
Inspection Report
Renewal
Census: 51
Capacity: 88
Deficiencies: 4
Jul 12, 2024
Visit Reason
The inspection was conducted as a renewal licensing inspection for Halcyon Senior Living to ensure 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 identified related to staff training on medication self-administration, emergency preparedness, dementia care, and medication labeling. Plans of correction were directed and implemented to address these issues.
Deficiencies (4)
| Description |
|---|
| Direct care staff person A did not receive medication self-administration training during the 2023 training year. |
| Direct care staff person A did not receive training on Emergency Preparedness Procedures and The Older Adult Protective Services Act (OAPSA) during the 2023 training year. |
| Resident #1's medication label was incorrect, indicating a different dosage frequency than prescribed. |
| Direct care staff person A routinely working in the secured dementia care unit received only 3.75 hours of dementia training during the 2023 training year, less than the required 6 hours. |
Report Facts
License Capacity: 88
Residents Served: 51
Secured Dementia Care Unit Capacity: 44
Residents Served in Secured Dementia Care Unit: 20
Hospice Residents: 4
Total Daily Staff: 78
Waking Staff: 59
Inspection Report
Follow-Up
Census: 55
Capacity: 88
Deficiencies: 4
Apr 24, 2024
Visit Reason
The inspection was a partial, unannounced follow-up visit conducted on 04/24/2024 to review the facility's plan of correction related to prior incidents and fines.
Findings
The report found multiple deficiencies related to delayed reporting of suspected resident abuse, incomplete medication labeling, medication administration documentation errors, and failure to follow prescriber's orders. The facility submitted and implemented a plan of correction with staff education and auditing measures.
Deficiencies (4)
| Description |
|---|
| Delayed reporting of suspected resident abuse to the Department of Aging, not immediately reported as required. |
| No pharmacy label for resident oral concentrate medications and incomplete sliding scale order on labels. |
| Medication administration times and dates were not properly documented on the medication administration record. |
| Failure to follow prescriber's orders including missed doses without documented reasons, improper splitting of tablets, and administration without required vital sign checks. |
Report Facts
License Capacity: 88
Residents Served: 55
Residents in Secured Dementia Care Unit: 21
Hospice Residents: 6
Residents with Mobility Need: 32
Residents Diagnosed with Intellectual Disability: 1
Total Daily Staff: 87
Waking Staff: 65
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Direct Care Staff Person A | Director of Nursing | Notified of suspicious bruising on resident and involved in abuse reporting deficiency |
| Direct Care Staff Person B | Administrator | Notified Department of Human Services Licensing of suspected abuse incident and involved in abuse reporting deficiency |
| Direct Care Staff Person C | Administered medication without documentation on 4/16/24 | |
| Direct Care Staff Person D | Administered medication with incorrect documentation on 4/23/24 |
Inspection Report
Renewal
Census: 51
Capacity: 88
Deficiencies: 29
Nov 27, 2023
Visit Reason
The inspection was a renewal inspection conducted as a result of licensing inspections on November 27, 2023, January 23, 2024, and January 29, 2024, to assess compliance with 55 Pa. Code Chapter 2600 relating to Personal Care Homes.
Findings
Multiple violations were found related to resident contracts, quality management, staff training, fire safety orientation, medical evaluations, dietary needs, medication administration, and facility safety. A provisional license was issued due to failure to submit or comply with an acceptable plan of correction.
Deficiencies (29)
| Description |
|---|
| Resident #1 did not have a resident-home contract completed until 3/22/23. |
| Resident #2's resident-home contract, dated 1/30/23, was not signed by the resident. |
| The home did not implement its quality management plan at its most recent meeting on 9/11/23. |
| No staff certified in first aid, obstructed airway techniques, and CPR were present during specified times despite residents being present. |
| Staff persons did not receive orientation on the location and use of fire extinguishers on their first day of work. |
| Staff persons did not complete required 40 hours of training on reporting reportable incidents and conditions. |
| Ancillary staff person did not receive training in resident rights, Older Adult Protective Services Act, falls and accident prevention, and emergency preparedness during 2022. |
| The first aid kit in the second floor nurses station did not include eye coverings and a breathing shield. |
| The handle to the gate in the far right corner of the courtyard was missing and the gate was unable to be opened. |
| Two unlabeled bars of soap were found in the shower stall in the common first floor shower room. |
| The home rules did not specify whether pets were permitted on the premises despite multiple pets visiting the home. |
| Emergency procedures binder was not posted in a public and conspicuous place. |
| Alternate exit routes were not used during fire drills held monthly from 11/15/22 through 10/30/23. |
| Resident #1's initial medical evaluation did not include the resident's pulse rate; this area of the form was blank. |
| Resident #3's most recent medical evaluation did not indicate a diagnosis of Alzheimer's disease or other dementia. |
| Resident #5 was prescribed a pureed diet with honey thickened liquids but was regularly served peanut butter and jelly sandwiches for lunch and dinner. |
| Resident #5's dietary restrictions were not fully documented or followed; patient refused diet modifications. |
| Resident #5's preadmission screening form did not include the resident's ability to safely use and avoid poisonous materials. |
| Resident #2's initial assessment did not include care and services required for multiple diagnoses. |
| Resident #3's most recent assessment indicated moderate mobility assistance but did not reflect total assistance of 2 staff persons. |
| Resident #5's most recent support plan was not signed by the resident and lacked notation regarding the resident's ability to sign. |
| Resident #5, who does not have a primary diagnosis of Alzheimer's or other dementia, resides in the secured dementia care unit and cannot independently operate the locking mechanism to exit. |
| Resident #4's record included a photograph dated more than 2 years old. |
| Resident #5's preadmission screening form did not include ability to safely use and avoid poisonous materials. |
| Resident #8's most recent medical evaluation was not updated despite significant change. |
| Resident #9's initial medical evaluation did not indicate the need for a secured dementia care unit. |
| Resident #6's medication administration record indicated Eucerin cream was not administered as ordered on specified dates. |
| Resident #7's glucometer was not calibrated to the correct time. |
| Resident #6's January 2024 medication administration record indicated medication was not administered at specified times. |
Report Facts
Fine amount per violation: 260
Census: 52
Total Capacity: 88
Residents served in secured dementia care unit: 19
Staffing hours - Total daily staff: 83
Staffing hours - Waking staff: 62
Inspection Report
Renewal
Census: 51
Capacity: 88
Deficiencies: 33
Nov 27, 2023
Visit Reason
The inspection was a renewal visit conducted as a result of licensing inspections on November 27, 2023, January 23, 2024, and January 29, 2024, to assess compliance with 55 Pa. Code Chapter 2600 relating to Personal Care Homes.
Findings
Multiple violations were found related to resident contracts, quality management, staff training, emergency preparedness, medical evaluations, dietary needs, medication administration, and facility safety. A provisional license was issued due to failure to submit and comply with an acceptable plan of correction. Numerous deficiencies were noted with plans of correction and some not yet implemented as of the report date.
Deficiencies (33)
| Description |
|---|
| Resident #1 did not have a resident-home contract completed until 3/22/23. |
| Resident #2's resident-home contract, dated 1/30/23, is not signed by the resident. |
| The home did not implement its quality management plan at its most recent meeting on 9/11/23. |
| No staff certified in first aid and CPR were present during times when residents were present. |
| Staff persons did not receive orientation on the location and use of fire extinguishers. |
| Staff persons did not complete required training in reporting of reportable incidents and conditions within 40 scheduled hours. |
| Ancillary staff did not receive training in resident rights, Older Adult Protective Services Act, falls and accident prevention, and emergency preparedness. |
| The first aid kit in the second floor nurses station did not include eye coverings and a breathing shield. |
| The handle to the gate in the far right corner of the courtyard was missing and the gate was unable to be opened. |
| Two unlabeled bars of soap were found in the shower stall in the common first floor shower room. |
| The home rules do not specify whether pets are permitted on the premises; multiple pets visit the home. |
| Emergency procedures were not posted in a public and conspicuous place. |
| Alternate exit routes during fire drills were not completed; only one exit route was indicated. |
| Resident #1's initial medical evaluation did not include the resident's pulse rate. |
| Resident #4's most recent medical evaluation did not indicate a diagnosis of Alzheimer's disease or other dementia. |
| Resident #5 was prescribed a pureed diet but was regularly served peanut butter and jelly sandwiches. |
| Resident #5's dietary needs were not properly documented or followed; patient refused diet modifications. |
| Resident #5's preadmission screening form did not include the resident's ability to safely use and avoid poisonous materials. |
| Resident #2's initial assessment did not include care and services required for multiple diagnoses. |
| Resident #3's most recent assessment indicates moderate mobility assistance but requires total assistance of 2 staff persons. |
| Resident #5's most recent support plan was not signed by the resident and lacked notation regarding ability to sign. |
| Resident #5, who does not have a primary diagnosis of Alzheimer's or dementia, resides in the secured dementia care unit and cannot independently operate the locking mechanism to exit. |
| Resident #4's record included a photograph dated more than 2 years ago. |
| Resident #5's preadmission screening form did not include ability to safely use and avoid poisonous materials. |
| Resident #8's most recent medical evaluation was not updated despite significant change. |
| Resident #9's initial medical evaluation did not indicate the need for a secured dementia care unit. |
| Resident #6's medication administration record indicated medication was not available in the home when administered. |
| Resident #1's glucometer reading was inconsistent with medication administration record. |
| Resident #7's glucometer was not calibrated to the correct time. |
| Resident #6's January 2024 medication administration record indicated medication was not administered because it was not available in the home. |
| Resident #3's initial medical evaluation did not have indication that the medical professional who performed the evaluation was contacted or gave permission to correct the evaluation. |
| Resident #5's diet was verified to be correct and order is correct in TabulaPro after medication errors. |
| Resident #5's diet was verified to be correct and order is correct in TabulaPro after medication errors. |
Report Facts
Fine amount: 260
Census: 51
Capacity: 88
Residents in Secure Dementia Care Unit: 19
Staffing: 83
Waking Staff: 62
Inspection Report
Census: 52
Capacity: 88
Deficiencies: 0
Jun 30, 2023
Visit Reason
The inspection was conducted as a partial, unannounced visit due to an incident.
Findings
No regulatory citations or deficiencies were identified during this inspection.
Report Facts
License Capacity: 88
Residents Served: 52
Secured Dementia Care Unit Capacity: 44
Secured Dementia Care Unit Residents Served: 17
Residents Diagnosed with Mental Illness: 1
Residents with Mobility Need: 22
Residents 60 Years of Age or Older: 52
Residents with Physical Disability: 1
Inspection Report
Follow-Up
Census: 56
Capacity: 88
Deficiencies: 8
Oct 28, 2022
Visit Reason
The inspection was an unannounced partial review conducted due to an incident, with a focus on verifying the implementation of a previously submitted plan of correction.
Findings
The facility was found to have multiple deficiencies including an expired posted license, delayed reporting of suspected resident abuse, failure to conduct criminal background checks, incomplete staff qualifications documentation, lack of required direct care training, missing preadmission screening, incomplete support plans, and missing resident signatures on support plans. The submitted plan of correction was determined to be fully implemented.
Deficiencies (8)
| Description |
|---|
| The license posted on the home's bulletin board near the front desk expired 8/31/22. |
| Delayed reporting of suspected abuse of resident #1; the incident was not reported to the Department immediately as required. |
| Staff person B began working without a requested criminal history background check. |
| Staff person B did not have documentation of a high school diploma, GED, or active registry status on the Pennsylvania nurse aide registry. |
| Staff person B provides unsupervised ADL services without documentation of completion and passing of the Department-approved direct care training course and competency test. |
| Resident #1 was admitted without a completed preadmission screening form. |
| Resident #1's support plan did not accurately document required total physical assistance with bladder and bowel management as indicated in assessments. |
| Resident #1 participated in the development of the support plan but did not sign the support plan. |
Report Facts
Residents Served: 56
License Capacity: 88
Residents Served in Secured Dementia Care Unit: 22
Current Hospice Residents: 5
Residents Age 60 or Older: 55
Residents Diagnosed with Mental Illness: 2
Residents Diagnosed with Intellectual Disability: 0
Residents with Mobility Need: 28
Residents with Physical Disability: 4
Inspection Report
Complaint Investigation
Census: 57
Capacity: 88
Deficiencies: 3
Sep 13, 2022
Visit Reason
The inspection was conducted as a complaint investigation following allegations of resident abuse and concerns about the facility's ability to meet resident needs.
Findings
The investigation found that resident #1 physically abused resident #2, resulting in a hip fracture. The facility failed to properly assess and refer resident #1 despite a history of aggressive behavior. Multiple repeat violations were noted related to abuse, assessment, and referral procedures.
Complaint Details
The complaint investigation was substantiated with findings of physical abuse by resident #1 against resident #2, resulting in injury and hospitalization. The facility was found noncompliant in admission screening and assessment procedures related to resident #1.
Deficiencies (3)
| Description |
|---|
| Resident #1 physically abused resident #2, causing injury; staff failed to prevent further harm. |
| Facility admitted a resident with a history of problematic aggressive behavior without appropriate referral to an assessment agency. |
| Resident #1's initial assessment did not accurately reflect the resident's aggressive behavior and needs. |
Report Facts
License Capacity: 88
Residents Served: 57
Residents in Secured Dementia Care Unit: 23
Residents with Mobility Need: 27
Residents 60 Years or Older: 44
Residents Diagnosed with Mental Illness: 2
Residents Diagnosed with Physical Disability: 2
Staffing Hours - Total Daily Staff: 84
Staffing Hours - Waking Staff: 63
Inspection Report
Complaint Investigation
Census: 59
Capacity: 88
Deficiencies: 5
Jul 26, 2022
Visit Reason
The inspection was conducted as a complaint investigation and incident review at Halcyon Senior Living, including an unannounced partial inspection on 07/26/2022 and follow-up reviews.
Findings
The inspection identified multiple medication-related deficiencies including presence of discontinued medications, missing medications from medication administration records, failure to follow prescriber's orders, and incomplete documentation of medication administration. A support plan revision deficiency was also noted related to resident supervision and monitoring.
Complaint Details
The inspection was triggered by a complaint and incident. The report documents multiple medication management violations and a support plan deficiency. The plan of correction was accepted and fully implemented as of the follow-up reviews.
Deficiencies (5)
| Description |
|---|
| Discontinued OTC and prescription medications were still present in the med cart and home after resident's death. |
| Medications were missing from the Medication Administration Record (MAR) on multiple dates and times. |
| Medication administration documentation was not initialed by staff on multiple occasions. |
| Resident was not administered prescribed medications due to unavailability in the home on multiple dates and times. |
| Support plan for resident requiring supervision was inadequate and did not address extensive supervision needs. |
Report Facts
License Capacity: 88
Residents Served: 59
Secured Dementia Care Unit Capacity: 44
Secured Dementia Care Unit Residents Served: 24
Current Hospice Residents: 6
Residents Age 60 or Older: 57
Residents with Mental Illness: 2
Residents with Mobility Need: 29
Inspection Report
Renewal
Census: 65
Capacity: 88
Deficiencies: 11
Apr 4, 2022
Visit Reason
The inspection was conducted as a renewal inspection with an incident review at Halcyon Senior Living.
Findings
Multiple deficiencies were identified including breaches in resident record confidentiality, privacy issues with bathroom locks, unqualified direct care staff, unsanitary conditions, lint accumulation in dryers, incomplete medical evaluations, medication storage and administration errors, failure to follow prescriber's orders, incomplete resident assessments, inadequate supervision leading to abuse, and failure to immediately implement supervision plans for alleged abuse.
Deficiencies (11)
| Description |
|---|
| Resident records were unlocked, unattended and accessible at the nurses' station. |
| Bathroom lock was inoperable on the door of bedroom 212’s shared bathroom. |
| Direct care staff person did not have a high school diploma, GED, or active nurse aide registry status. |
| Feces smeared on toilet seat and unlabeled used bars of soap in shower rooms. |
| Accumulation of lint in dryers in the laundry room. |
| Medical evaluations for residents #7 and #8 were incomplete in certain areas. |
| Medication bottle lacked an open date; medication administration records missing diagnoses and purposes for medications. |
| Medication for resident #6 was not administered because it was not available in the home. |
| Resident assessments were incomplete or inaccurate regarding diagnoses and behavioral issues. |
| Staff person A yelled at resident #1 and accused the resident of lying; failure to immediately implement supervision or suspension. |
| Inadequate supervision led to resident #5 hitting resident #6 resulting in a concussion; failure to intervene promptly. |
Report Facts
License Capacity: 88
Residents Served: 65
Secured Dementia Care Unit Capacity: 40
Residents Served in Dementia Unit: 31
Hospice Residents: 5
Staffing Hours - Total Daily Staff: 107
Staffing Hours - Waking Staff: 80
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff person A | Named in abuse and supervision plan deficiencies related to yelling at resident #1 and failure to implement immediate supervision. | |
| Staff person B | Witnessed abuse incident involving staff person A and resident #1. | |
| Staff person C | Informed about the abuse incident involving staff person A. | |
| Staff person D | Involved in supervision failure during resident altercation in dementia care unit. |
Notice
Capacity: 88
Deficiencies: 0
Jul 30, 2021
Visit Reason
This document serves as a certificate of compliance and notification of license renewal for Halcyon Senior Living, a Personal Care Home, confirming the facility's authorized capacity and informing about the requirement for an annual onsite inspection within the next twelve months.
Findings
The Department issued a regular license in response to the renewal application and advised that an annual inspection will be conducted within the next twelve months to ensure compliance with applicable regulations.
Report Facts
Maximum licensed capacity: 88
Secure Dementia Care Unit capacity: 44
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Gregory S. Gramm | Administrator | Recipient of the license renewal notification |
| Jamie L. Buchenauer | Deputy Secretary, Office of Long-term Living | Signed the license renewal notification letter |
Inspection Report
Routine
Deficiencies: 0
Jun 21, 2021
Visit Reason
The inspection was conducted as a licensing inspection by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing.
Findings
No regulatory citations were identified as a result of this inspection.
Inspection Report
Complaint Investigation
Census: 24
Capacity: 88
Deficiencies: 4
Apr 23, 2021
Visit Reason
The inspection was conducted as a complaint investigation following allegations related to delayed staff response to a resident's call bell for assistance with incontinence care.
Findings
The investigation found that staff failed to provide timely incontinence care to resident #1 from approximately 11:30 PM on 4/10/21 until 7:30 AM on 4/11/21, and the incident was not reported promptly to the local Area Agency on Aging or the Department of Human Services. Staff Person A was suspended and subsequently terminated. The facility implemented staff training and enhanced supervision to prevent recurrence.
Complaint Details
The complaint involved allegations of neglect related to delayed response to a resident's call bell for incontinence care. The complaint was substantiated as staff failed to provide timely care and failed to report the incident promptly. Staff Person A was suspended and terminated following investigation.
Deficiencies (4)
| Description |
|---|
| Failure to provide timely incontinence care to resident #1 from 11:30 PM on 4/10/21 until 7:30 AM on 4/11/21. |
| Failure to immediately report the incident to the local Area Agency on Aging and Department of Human Services. |
| Staff Person A continued to work unsupervised after the incident despite allegations. |
| Resident #1 was neglected in violation of abuse and neglect regulations. |
Report Facts
Licensed Capacity: 88
Residents Served: 24
Secured Dementia Care Unit Capacity: 44
Current Hospice Residents: 3
Residents Age 60 or Older: 23
Residents with Mobility Need: 9
Inspection Report
Follow-Up
Census: 18
Capacity: 88
Deficiencies: 7
Feb 12, 2021
Visit Reason
The inspection was a full, unannounced renewal inspection conducted to review compliance and verify the submitted plan of correction.
Findings
The facility had multiple deficiencies including incomplete resident-home contracts, inadequate staffing for safe evacuation, snow accumulation obstructing fire exits, lack of operable bedside lamps for a resident, and locked fire exit doors requiring significant force to open. All deficiencies had plans of correction implemented by the facility.
Deficiencies (7)
| Description |
|---|
| Resident-home contract for resident #1 was incomplete and missing resident name and date. |
| Resident-home contract for resident #1 lacked signatures of administrator and resident. |
| Staffing levels were inadequate to safely evacuate all residents in an emergency given resident mobility needs and fire safety evacuation time. |
| Approximately 1 inch of snow was accumulated on the landing and sidewalks outside fire exit doors from the back hall stairwell. |
| Resident #2 did not have an operable lamp or other source of lighting that can be turned on/off at bedside. |
| Significant bodily force was required to open fire exit doors at the back hall stairwell. |
| Resident #1’s preadmission screening form did not include determination that the home can meet resident's needs or that resident can safely use and avoid poisonous materials. |
Report Facts
Residents served: 18
License capacity: 88
Residents with mobility needs: 9
Residents requiring two-person assist: 4
Fire safety evacuation time: 6
Transfer time for resident #3: 5
Transfer time for resident #3: 7
Staff on duty per shift: 2
Snow accumulation: 1
Report
Jan 11, 2023
File
20230111_45109.pdf
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