Inspection Reports for Harmony at West Shore
1910 Technology Pkwy, Mechanicsburg, PA 17050, United States, PA, 17050
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Inspection Report
Complaint Investigation
Census: 52
Capacity: 115
Deficiencies: 12
Jan 15, 2025
Visit Reason
The inspection was conducted due to a complaint and incident involving resident abuse and other regulatory concerns at the facility.
Findings
The inspection identified multiple violations including failure to provide immediate access to records, failure to report suspected resident abuse, medication errors, confidentiality breaches, resident abuse incidents, privacy violations, use of prohibited portable space heaters, incomplete resident assessments, failure to follow prescriber's orders, and deficiencies in support plan documentation and signatures.
Complaint Details
The visit was complaint-related due to allegations of resident abuse, failure to report abuse, medication errors, and other regulatory violations. The complaint was substantiated with multiple violations found during the inspection.
Deficiencies (12)
| Description |
|---|
| Failure to provide immediate access to resident and staff records upon request by Department agents. |
| Failure to immediately report suspected resident abuse incidents to the Area Agency on Aging (AAA). |
| Failure to report medication errors to the Department in a timely manner. |
| Resident records were left unsecured and accessible on an unlocked laptop screen. |
| Resident abuse incidents including physical abuse and improper restraint techniques were witnessed and documented. |
| Violation of resident privacy rights due to unauthorized video recording of care. |
| Use of prohibited portable space heater in a resident's room. |
| Resident was not properly assessed for self-administration of medications as required. |
| Failure to follow prescriber's medication orders for residents. |
| Incomplete or missing annual assessments for residents. |
| Support plan did not document resident's medical dietary needs correctly. |
| Support plans lacked signatures from residents or responsible parties indicating participation. |
Report Facts
License Capacity: 115
Residents Served: 52
Secured Dementia Care Unit Capacity: 35
Residents Served in Dementia Care Unit: 16
Current Hospice Residents: 3
Residents Age 60 or Older: 52
Residents with Mobility Need: 29
Residents with Physical Disability: 1
Total Daily Staff: 81
Waking Staff: 61
Inspection Report
Complaint Investigation
Census: 60
Capacity: 115
Deficiencies: 31
Jul 2, 2024
Visit Reason
The inspection was conducted as a complaint investigation with provisional and incident reasons, including unannounced visits on 07/02/2024, 07/03/2024, 07/05/2024, and 07/09/2024.
Findings
Multiple deficiencies were identified including delayed access to resident and staff records, failure to timely report and supervise abuse incidents, improper handling of medications, unsafe storage of poisonous materials, environmental hazards, incomplete medical evaluations and assessments, and confidentiality breaches. Plans of correction were accepted or directed with follow-up dates.
Complaint Details
The inspection was complaint-related with provisional and incident reasons. Multiple repeated violations were noted, including failure to report abuse, medication errors, and confidentiality breaches. The plan of correction was reviewed and found to be fully implemented as of the follow-up review on 10/01/2024.
Deficiencies (31)
| Description |
|---|
| Delayed access to resident and staff records requested by Department agents. |
| Failure to immediately report suspected resident abuse and submit required forms. |
| Failure to develop and implement a supervision plan or suspend staff involved in abuse allegations. |
| Failure to report abuse incidents to the Department within 24 hours. |
| Resident treated without dignity and respect; inappropriate staff-resident interactions. |
| Criminal background checks not obtained timely for certain staff members. |
| Poisonous materials not locked and accessible to residents unable to safely use or avoid them. |
| Trash receptacles in kitchens and bathrooms were uncovered, allowing insect and rodent penetration. |
| Floors had hazards such as a 3 inch divot under carpet posing tripping risk. |
| Emergency telephone numbers not posted by telephones with outside lines. |
| Furniture and equipment, including fire door locks, were not in good repair or safe condition. |
| Resident bedrooms lacked operable lamps or lighting sources at bedside. |
| Egress routes were obstructed by furniture and equipment. |
| Emergency evacuation diagrams did not include locations of pull stations and fire extinguishers. |
| Initial medical evaluations lacked required information such as allergies and diagnoses. |
| Residents did not have annual medical evaluations completed timely. |
| Resident special dietary needs were not accurately documented or met. |
| Prescription medications and syringes were not kept locked and accessible only to authorized staff. |
| Discontinued or expired medications were present in medication carts and resident rooms. |
| Prescription medication containers lacked proper pharmacy labels with required information. |
| Medications and medical equipment were not stored safely or available as prescribed. |
| Prescription medications were used by residents other than those prescribed. |
| Medication records did not accurately reflect route of administration or special precautions. |
| Refusals of prescribed medications were not documented or reported to prescribers as required. |
| Prescriber's orders were not followed; residents did not receive medications as ordered. |
| Resident assessments did not accurately reflect resident needs or were not completed timely. |
| Resident support plans lacked documentation on how needs will be met and were missing required signatures. |
| Resident support plans were not accessible to direct care staff at all times. |
| Residents were not assessed annually for continuing need for secured dementia care unit. |
| Directions for operating key-locking devices preventing immediate egress were not conspicuously posted. |
| Resident records were not maintained confidentially and were accessible to unauthorized persons. |
Report Facts
Residents Served: 60
License Capacity: 115
Residents Served in Secure Dementia Care Unit: 16
Capacity of Secure Dementia Care Unit: 35
Staffing Hours: 86
Waking Staff: 65
Deficiency Counts: 31
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Aleanah Cruz | Dietary Aide | Mentioned in relation to criminal background check timing |
| Ava Aquallo | Dietary Aide | Mentioned in relation to criminal background check timing |
| Stephanie Wolfley | Acting Healthcare Director | Mentioned in relation to leadership and training |
| Robert Musser | Executive Director | Mentioned in relation to leadership and training |
Inspection Report
Complaint Investigation
Census: 60
Capacity: 115
Deficiencies: 32
Jul 2, 2024
Visit Reason
The inspection was conducted as a complaint investigation with provisional and incident reasons, including follow-up on a plan of correction submission.
Findings
The inspection identified multiple deficiencies including delayed access to resident and staff records, failure to timely report and supervise abuse incidents, medication administration errors, unsecured poisonous materials, environmental hazards, incomplete medical evaluations, and confidentiality breaches. Plans of correction were accepted or directed with specified completion dates.
Complaint Details
The inspection was complaint-driven with provisional and incident reasons. Multiple repeated violations were noted, including failure to report abuse, medication errors, and confidentiality breaches.
Deficiencies (32)
| Description |
|---|
| Delayed access to resident and staff records upon Department request. |
| Failure to immediately report suspected resident abuse and incomplete abuse reporting forms. |
| Failure to develop and implement a supervision plan or suspend staff involved in abuse allegations. |
| Failure to report abuse incidents to the Department within 24 hours. |
| Resident treated without dignity and respect; inappropriate staff-resident interactions. |
| Criminal background checks not obtained timely for certain staff members. |
| Poisonous materials not locked and accessible to residents unable to safely use them. |
| Uncovered trash receptacles in kitchens and bathrooms. |
| Floor hazard due to a 3 inch divot under carpet posing tripping risk. |
| Emergency telephone numbers not posted by telephones with outside lines. |
| Furniture and equipment not in good repair; fire door lock systems exposed or damaged. |
| Resident bedrooms lacked operable lamps or lighting within reach at bedside. |
| Egress routes obstructed by furniture and equipment. |
| Emergency evacuation diagrams incomplete, missing pull stations and fire extinguisher locations. |
| Initial medical evaluations incomplete or missing required information such as allergies and diagnoses. |
| Annual medical evaluations not completed timely. |
| Resident special dietary needs not met or documented accurately. |
| Medications and syringes not kept locked and accessible only to authorized staff. |
| Discontinued or expired medications present in medication carts and resident rooms. |
| Prescription medication containers not properly labeled with required information. |
| Medication and medical equipment storage procedures inadequate, resulting in medication unavailability and inaccurate documentation. |
| Prescription medications lacked current prescriber orders. |
| Prescription medications used by residents other than those prescribed. |
| Medication records lacked accurate route of administration and special precautions. |
| Refusals of medications not documented or reported to prescribers as required. |
| Failure to follow prescriber's medication orders, including incorrect dosages and missed doses. |
| Resident assessments incomplete or inaccurate, missing key needs such as mobility or dietary requirements. |
| Resident support plans lacked documentation on how needs will be met and lacked required signatures. |
| Resident support plans not accessible to direct care staff at all times. |
| Residents not assessed annually for continuing need for secured dementia care unit. |
| Directions for operating key-locking devices not conspicuously posted near exit doors. |
| Resident records not maintained confidentially; records left unsecured and accessible to unauthorized persons. |
Report Facts
License Capacity: 115
Residents Served: 60
Residents Served in Secure Dementia Care Unit: 16
Staffing Hours - Total Daily Staff: 86
Staffing Hours - Waking Staff: 65
Deficiencies Cited: 33
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Aleanah Cruz | Dietary Aide | Named in relation to criminal background check deficiency. |
| Ava Aquallo | Dietary Aide | Named in relation to criminal background check deficiency. |
| Stephanie Wolfley | Acting Healthcare Director | Named in relation to leadership and training on medication and regulatory compliance. |
| Robert Musser | Executive Director | Named in relation to leadership, training, and oversight of compliance. |
Inspection Report
Follow-Up
Census: 78
Capacity: 115
Deficiencies: 3
Apr 17, 2024
Visit Reason
The inspection was a partial, unannounced follow-up visit conducted on 04/17/2024 to review the submitted plan of correction related to prior deficiencies and to verify compliance.
Findings
The submitted plan of correction was determined to be fully implemented as of the inspection date. Deficiencies related to medication self-administration assessment, prescription currency, and medication storage were addressed with training, audits, and removal of improper medications.
Deficiencies (3)
| Description |
|---|
| Resident self-administers prescribed medication without assessment by a qualified healthcare provider regarding ability to self-administer. |
| Discontinued medication was found in the home's medication cart after resident moved from secured dementia care unit to personal care. |
| Loose pills were observed in multiple medication carts in the facility, indicating improper medication storage. |
Report Facts
License Capacity: 115
Residents Served: 78
Secured Dementia Care Unit Capacity: 35
Secured Dementia Care Unit Residents Served: 18
Hospice Residents: 3
Residents with Mobility Need: 36
Residents with Physical Disability: 1
Total Daily Staff: 114
Waking Staff: 86
Inspection Report
Complaint Investigation
Census: 77
Capacity: 115
Deficiencies: 26
Dec 20, 2023
Visit Reason
The inspection was conducted as a complaint, incident, and interim review of the Harmony at West Shore facility on December 20-21, 2023 and February 22-23, 2024.
Findings
The inspection identified multiple violations including abuse incidents, medication errors, failure to follow prescriber's orders, unsafe storage of poisonous materials and medications, inadequate staff training, unsanitary conditions, and documentation deficiencies. Several violations were repeated from prior inspections. Plans of correction were proposed with some implemented and others pending.
Complaint Details
The inspection was complaint-driven, triggered by incidents and complaints regarding resident abuse, medication management, and facility conditions. The report includes substantiated findings of abuse and multiple regulatory violations.
Severity Breakdown
Class II: 7
Deficiencies (26)
| Description | Severity |
|---|---|
| Failure to report an incident of resident hitting another resident within 24 hours. | — |
| Resident abuse incidents involving physical altercations between residents. | Class II |
| No staff certified in first aid and CPR present during night shift. | — |
| New staff did not receive required fire safety orientation on first day. | — |
| Staff did not complete required 40-hour orientation training on resident rights, emergency medical plan, and abuse reporting. | — |
| Poisonous materials were unlocked and accessible to residents incapable of safe use. | — |
| Written emergency procedures not reviewed and submitted annually to local emergency management agency. | — |
| Fire drill records incomplete, missing evacuation times and participant counts. | — |
| Fire drill evacuation incomplete and exceeded maximum evacuation time. | — |
| Medical evaluation not completed within required timeframe prior to admission. | — |
| Expired prescription medications found in the home. | — |
| Loose pills found in medication carts. | — |
| Insulin pen not labeled with opening date. | — |
| Discrepancies between glucometer readings and medication administration records. | — |
| Controlled substance administration not properly documented with date, time, and staff initials. | — |
| Medications not administered as prescribed due to unavailability. | — |
| Insulin administered despite blood sugar levels below prescribed threshold. | — |
| Resident assessments and support plans not current or lacking required documentation. | — |
| Confidential resident information posted publicly. | — |
| Directions for operating key-locking devices not posted near exit door. | — |
| Refunds for discharged residents not issued timely. | — |
| Physical altercations between residents resulting in injuries. | Class II |
| Unlocked poisonous materials accessible to residents in secured dementia care unit. | Class II |
| Unsanitary conditions including urine odor and dried feces in resident bathrooms. | Class II |
| Medications and syringes not kept locked; loose pills found on floors and in medication carts. | Class II |
| Medication refusals not documented or reported to prescriber as required. | Class II |
Report Facts
License Capacity: 115
Residents Served: 77
Secured Dementia Care Unit Capacity: 35
Residents in Secured Dementia Care Unit: 23
Staffing Hours - Total Daily Staff: 123
Staffing Hours - Waking Staff: 92
Fine Amount: 385
Number of Violations with Fine: 4
Inspection Report
Complaint Investigation
Census: 72
Capacity: 115
Deficiencies: 20
Dec 20, 2023
Visit Reason
The inspection was conducted due to complaints and incidents reported at the facility, including a follow-up on prior violations and interim exit conference.
Findings
Multiple violations were found including abuse incidents, failure to report incidents timely, medication management issues, staff training deficiencies, sanitary condition problems, and record-keeping errors. Several violations were repeated from prior inspections. Plans of correction were accepted or directed with proposed completion dates.
Complaint Details
The inspection was complaint-driven due to incidents of resident abuse and other regulatory concerns. The abuse allegations were substantiated with multiple physical altercations documented between residents, resulting in injuries.
Severity Breakdown
Class II: 1
Deficiencies (20)
| Description | Severity |
|---|---|
| Failure to report an incident of resident hitting another resident within 24 hours. | — |
| Resident abuse incidents involving physical altercations between residents. | Class II |
| No staff certified in first aid and CPR present during night shift. | — |
| New staff did not receive required fire safety orientation on first day. | — |
| Direct care staff did not complete required orientation within 40 hours. | — |
| Poisonous materials were unlocked and accessible to residents incapable of safe use. | — |
| Written emergency procedures not reviewed and submitted annually to local emergency management agency. | — |
| Fire drill records incomplete, missing evacuation times and participant counts. | — |
| Residents unable to fully evacuate during fire drill and evacuation time exceeded limit. | — |
| Initial medical evaluation for a resident was completed after admission date. | — |
| Expired medications found in medication storage. | — |
| Loose pills found in medication carts. | — |
| Medication container not labeled with date opened. | — |
| Discrepancies between glucometer readings and medication administration record. | — |
| Controlled substance administration not recorded with date, time, and staff initials. | — |
| Medications not administered as prescribed due to unavailability. | — |
| Insulin administered despite blood sugar levels below prescribed threshold. | — |
| Resident assessments and support plans not current or lacking required documentation. | — |
| Records containing resident names were posted publicly, violating confidentiality. | — |
| Directions for operating key-locking devices not posted near exit door. | — |
Report Facts
License Capacity: 115
Residents Served: 72
Residents Served in Secure Dementia Care Unit: 22
Staffing Hours - Total Daily Staff: 102
Staffing Hours - Waking Staff: 77
Deficiencies Cited: 4
Fine per Violation per Day: 5
Total Fine per Violation: 385
Residents Served: 77
Residents Served in Secure Dementia Care Unit: 23
Staffing Hours - Total Daily Staff: 123
Staffing Hours - Waking Staff: 92
Inspection Report
Complaint Investigation
Census: 84
Capacity: 115
Deficiencies: 3
Oct 17, 2023
Visit Reason
The inspection was conducted as a complaint and incident investigation at the facility on 10/17/2023.
Findings
The report found multiple violations including failure to immediately report suspected resident abuse, an incident of resident-to-resident abuse resulting in injury, and a privacy violation involving unauthorized photographing of a resident. Plans of correction were accepted and implemented.
Complaint Details
The visit was complaint-related and substantiation is implied by the findings of abuse and privacy violations.
Deficiencies (3)
| Description |
|---|
| Failure to immediately report suspected resident-to-resident abuse to the local Area Agency on Aging. |
| Resident-to-resident abuse where Resident 2 hit Resident 1 with a wooden block causing injury requiring emergency room transfer. |
| Violation of resident privacy by photographing a resident on a staff member's private cell phone and circulating the photo among staff. |
Report Facts
License Capacity: 115
Residents Served: 84
Capacity of Secured Dementia Care Unit: 35
Residents Served in Secured Dementia Care Unit: 24
Current Hospice Residents: 9
Residents Age 60 or Older: 84
Residents with Mobility Need: 60
Inspection Report
Complaint Investigation
Census: 93
Capacity: 115
Deficiencies: 3
Jul 20, 2023
Visit Reason
The inspection was conducted as a complaint and incident investigation related to a resident injury and other compliance concerns at Harmony at West Shore.
Findings
The inspection found multiple violations including failure to accurately report a resident incident involving elopement and injury, neglect and abuse of a resident resulting in serious injuries and heat exhaustion, and incomplete support plans that did not address resident behaviors. Plans of correction were directed but not implemented as of the last follow-up.
Complaint Details
The complaint investigation was substantiated with findings of neglect and abuse related to Resident 1's elopement and injuries on 07/16/2023. The incident was not reported accurately and timely, and the resident suffered serious harm.
Deficiencies (3)
| Description |
|---|
| Failure to accurately report an incident involving Resident 1's elopement and injuries including heat stroke and burns. |
| Neglect and abuse of Resident 1 who was found after eloping with multiple injuries and heat exhaustion. |
| Support plan for Resident 1 did not include identified behaviors or required services. |
Report Facts
License Capacity: 115
Residents Served: 93
Residents Served in Secured Dementia Care Unit: 27
Residents with Mobility Need: 32
Residents with Physical Disability: 1
Incident Date: Jul 16, 2023
Incident Report Submission Date: Jul 17, 2023
Incident Reported Body Temperature: 102.5
Average High Temperature on Incident Day: 87
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Juliet Marsala | Deputy Secretary | Signed the letter regarding licensing and enforcement actions. |
Inspection Report
Complaint Investigation
Census: 100
Capacity: 115
Deficiencies: 10
May 30, 2023
Visit Reason
The inspection was conducted as a complaint investigation with announced partial inspections on May 30-31, 2023, to review compliance with licensing regulations.
Findings
Multiple violations were found including lack of required annual staff training, unsafe resident equipment posing entrapment risks, unsecured poisonous materials accessible to residents, unsanitary conditions, damaged surfaces posing hazards, medication management issues, and unsecured resident records. Plans of correction were accepted but many were not implemented as of the follow-up date.
Complaint Details
The inspection was complaint-driven as stated under Inspection Information with Reason: Complaint. The exit conference was held on 05/31/2023. No substantiation status is explicitly stated.
Deficiencies (10)
| Description |
|---|
| Direct care staff did not receive required annual training on multiple topics including medication self-administration and infection control. |
| Ancillary and direct care staff did not receive annual training on fire safety, emergency preparedness, resident rights, and other topics. |
| Uncovered enabler bars on resident beds posed entrapment risks. |
| Poisonous materials were found unlocked and accessible to residents unable to safely use or avoid them. |
| Sanitary conditions were not maintained; CPAP mask discoloration and soiled undergarments found in resident rooms. |
| Floors and walls had hazards including low spots under carpet, cracks in drywall, stained carpet, and bird nests obstructing dryer vents. |
| Resident bed linens were soiled with dried spots. |
| Prescription medications were found unlocked and unattended in resident rooms. |
| Medication record did not list a medication found in resident's possession. |
| Resident records were found unlocked and accessible in nurse's station. |
Report Facts
License Capacity: 115
Residents Served: 100
Residents in Secured Dementia Care Unit: 28
Residents in Hospice: 10
Total Daily Staff: 133
Waking Staff: 100
Inspection Report
Complaint Investigation
Census: 100
Capacity: 115
Deficiencies: 5
Apr 26, 2023
Visit Reason
The inspection was a complaint investigation conducted on April 26, 2023, as part of licensing inspections triggered by complaints at Harmony at West Shore.
Findings
Multiple violations were found including unsecured poisonous materials accessible to residents, unsanitary conditions with strong urine odors, tripping hazards due to loose carpet, broken glass in resident rooms, stained carpets, lint accumulation in dryers, and unsecured resident records on an unlocked laptop.
Complaint Details
The inspection was conducted as a complaint investigation with an interim exit conference on April 26, 2023.
Deficiencies (5)
| Description |
|---|
| Poisonous materials were unlocked and accessible to residents unable to safely use or avoid them in the secured dementia care unit and resident rooms. |
| Strong urine smell and liquid substances were present in the secured dementia care unit bathrooms and hallways. |
| Sticky floor in the public bathroom, loose carpet creating a tripping hazard, broken lightbulb glass on floor, hole in ceiling, stained carpet, and liquid substance on floor posing slipping hazard. |
| Accumulation of lint in the lint trap of clothes dryers, posing fire hazard. |
| Resident records were visible and accessible on an unlocked laptop on top of the medication cart. |
Report Facts
License Capacity: 115
Residents Served: 100
Residents in Secured Dementia Care Unit: 29
Current Hospice Residents: 10
Staffing Hours - Total Daily Staff: 134
Staffing Hours - Waking Staff: 101
Residents with Mobility Need: 34
Residents with Physical Disability: 1
Resident Records Visible on Laptop: 16
Lint Accumulation: 0.25
Inspection Report
Renewal
Census: 73
Capacity: 115
Deficiencies: 15
Mar 8, 2023
Visit Reason
The inspection was conducted as a renewal and complaint investigation of the Harmony at West Shore facility.
Findings
Multiple violations were found related to criminal background checks, staff training, resident safety, medication management, and documentation. Plans of correction were submitted and partially implemented, with some deficiencies not yet fully corrected as of the report date.
Deficiencies (15)
| Description |
|---|
| Staff Member A did not have a criminal background check completed until 3/9/23. |
| Insufficient number of staff certified in CPR and First Aid present during certain shifts. |
| Direct Care Staff Member C provided unsupervised ADL services without completing initial direct care training. |
| Uncovered enabler bars on Resident 1's and Resident 2's beds posed potential hazard. |
| Trash cans in kitchen were filled with trash and had broken lids exposing trash. |
| Fire damage on dining room patio wall with protruding nails presenting hazard. |
| Lint traps for dryers were last cleaned on 6/10/21, not regularly maintained. |
| Resident 3's and Resident 4's pets lacked current rabies vaccination certificates. |
| Medications and syringes were found unlocked and accessible to residents. |
| Insulin pens were not labeled with date opened as per manufacturer instructions. |
| Medications for Residents 8, 9, 10, and 11 were missing from the home. |
| Resident 8 was not administered prescribed insulin on multiple dates. |
| Resident 12's preadmission screening form lacked determination that needs could be met; Resident 13's form was completed after admission. |
| Resident 2's support plan was not revised timely to reflect changes in needs. |
| Residents 1, 2, and 6 through 13 had RASPs not completed on the Department’s standardized form and missing required language. |
Report Facts
License Capacity: 115
Residents Served: 73
Residents in Secured Dementia Care Unit: 32
Capacity of Secured Dementia Care Unit: 35
Current Hospice Residents: 7
Total Daily Staff: 111
Waking Staff: 83
Residents 60 Years or Older: 105
Residents with Mobility Need: 38
Staff Certified in CPR and First Aid Required per Shift: 3
Staff Certified in CPR and First Aid Present: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Juliet Marsala | Deputy Secretary, Office of Long-term Living | Signed the licensing letter regarding provisional license. |
| Executive Director | Named in multiple findings related to audits, corrections, and re-education. | |
| Healthcare Director | Named in findings related to medication management, staff training, and audits. | |
| Maintenance Director | Named in findings related to maintenance corrections and inspections. | |
| Dining Services Director | Named in findings related to kitchen trash can corrections. |
Inspection Report
Original Licensing
Census: 84
Capacity: 115
Deficiencies: 0
Jun 2, 2022
Visit Reason
The inspection was conducted as part of the licensing inspections on March 8 and 9, 2022 and June 2, 2022, to evaluate compliance with Pennsylvania Personal Care Homes regulations and to issue a regular license.
Findings
The facility was found to be in compliance with 55 Pa. Code Ch. 2600 relating to Personal Care Homes, and no deficiencies were found during the inspection.
Report Facts
Residents Served: 84
License Capacity: 115
Residents in Secured Dementia Care Unit: 30
Current Hospice Residents: 14
Residents with Mobility Need: 32
Residents Age 60 or Older: 84
Residents with Physical Disability: 1
Inspection Report
Renewal
Census: 80
Capacity: 115
Deficiencies: 12
Mar 8, 2022
Visit Reason
The inspection was conducted as a renewal, complaint, and provisional inspection to assess compliance with licensing requirements and regulations.
Findings
The facility was found to be in compliance with Personal Care Home regulations after corrections were made. Several deficiencies were identified and corrected, including posting the current inspection report, compliance with health and safety laws, trash management, emergency telephone numbers, fire safety inspection, smoking area guidelines, menus posting, preadmission screening, support plans, medication storage, and documentation.
Deficiencies (12)
| Description |
|---|
| The home's current inspection report, dated 07/29/21, was not posted in a conspicuous and public place in the home. |
| The home's boilers were last inspected on 10/23/19, with an expiration date of 10/23/21. |
| The lids on the right and left dumpsters were left open exposing the trash inside. |
| There are no emergency telephone numbers that included the nearest hospital and fire department on or by the telephones located in Resident Bedroom 414 and the nurses' station on second floor. |
| The last fire drill observed by a fire safety expert was conducted on 01/06/22. The home did not complete a fire safety inspection and supervised drill in December 2021. |
| The home does not permit smoking anywhere on the property. However, cigarette butts and two lighters were found in the home's back patio/concrete area. |
| The home's menu for the current and future weeks were not posted. |
| Resident 2 was admitted to the home on a redacted date in 2021; however, the resident's preadmission screening form was not completed until a later redacted date in 2021. |
| The assessments for Resident #3 and #4 do not indicate that either resident has a need for an enabler bar. The enabler bars were discovered on 03/09/22. |
| Prescription medications, OTC medications, CAM and syringes were found unlocked and stored in an area/container accessible in the resident's room. A small, peach-colored pill was found on the floor outside Resident Room #311. |
| A loose pill was found in the medication cart of the secured dementia care unit (SDCU). |
| Blood sugar readings documented on the medication administration record (MAR) for Resident 1 on multiple dates were incorrect or missing in the glucometer documentation. |
Report Facts
License Capacity: 115
Residents Served: 80
Secured Dementia Care Unit Capacity: 35
Secured Dementia Care Unit Residents Served: 26
Current Hospice Residents: 10
Residents Age 60 or Older: 80
Residents with Mobility Need: 30
Residents with Physical Disability: 2
Staffing Hours - Total Daily Staff: 110
Staffing Hours - Waking Staff: 83
Notice
Capacity: 115
Deficiencies: 0
Apr 30, 2021
Visit Reason
The document serves as a renewal notice confirming receipt of the renewal application for the Personal Care Home and informing that a regular license is being issued. It also advises that an annual inspection will be conducted within the next twelve months.
Findings
No inspection findings are reported in this document; it is a license renewal notice confirming compliance and issuance of a regular license.
Report Facts
Maximum capacity: 115
Secure Dementia Care Unit capacity: 35
Inspection Report
Renewal
Census: 66
Capacity: 115
Deficiencies: 16
Apr 27, 2021
Visit Reason
The inspection was a full, unannounced licensing inspection conducted for renewal and complaint reasons on multiple dates including 04/27/2021 through 04/29/2021 and 03/09/2021.
Findings
Multiple deficiencies were cited including medication errors, incomplete resident contracts, lack of staff training in first aid, CPR, fire safety, rights/abuse reporting, and orientation, improper storage of medications, missing medical evaluations, unsecured medication and incident reports, and failure to complete resident assessments and support plans timely.
Complaint Details
The inspection included complaint investigation related to medication errors and other resident care concerns. Medication errors were substantiated for multiple residents as detailed in the findings.
Deficiencies (16)
| Description |
|---|
| Several residents did not receive their prescribed morning medications on 4/18/2021 and 4/26/2021. |
| Resident-home contract for Resident #1 was not signed by the resident. |
| Staff persons A, B, C, D and G have not received orientation including evacuation procedures, fire drills, smoking policy, and emergency notification. |
| Staff persons A and B did not complete direct care training and competency test prior to providing unsupervised ADL services. |
| Lint accumulation found in lint traps of laundry dryers. |
| Resident #9 medical evaluation did not include information for blood pressure, temperature, height, pulse rate, body positioning, and date of form completion. |
| A bottle of fish oil capsules and vial of Amoxicillin prescribed to a non-resident were found unsecured in Resident #10's room. |
| Medication errors were not reported to residents' physicians for Residents #2, #3, #4, #5, #6, #7, and #8. |
| Resident #15 was admitted without an initial assessment completed within 15 days. |
| Resident #6's assessment did not include the need for the 2 one-half bedrails attached to the resident's bed. |
| Resident #6 RASP was not updated to include a plan to protect from potential dangers of the 2 one-half bedrails. |
| Resident #12 medical evaluation did not indicate a diagnosis of dementia or Alzheimer's disease. |
| Resident #1 cognitive preadmission screening was not completed. |
| Resident #1 had no documentation that the resident or designated person objected to admission to the secured dementia care unit. |
| Directions for operating the home's locking mechanism were not conspicuously posted near the main door, stairway, parking area, or gate of the Secure Dementia Care Unit (SDCU). |
| On 4/27/21, a binder containing resident care sheets, medication count sheets, and internal incident reports was found on top of the medication cart in the Harmony Square secured dementia care unit; these documents were not secured and accessible. |
Report Facts
Inspection dates: 4
Residents served: 66
Licensed capacity: 115
Secured dementia care capacity: 35
Hospice residents: 10
Staff total daily: 91
Waking staff: 68
Medication blood glucose readings: 4
Inspection Report
Renewal
Deficiencies: 0
Jan 15, 2021
Visit Reason
The inspection was conducted as part of the Pennsylvania Department of Human Services, Bureau of Human Service Licensing's licensing inspections on multiple dates in January 2021.
Findings
No regulatory citations were identified as a result of the inspection.
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