Inspection Report
Monitoring
Census: 48
Capacity: 81
Deficiencies: 4
Jul 31, 2025
Visit Reason
The visit was a partial, unannounced monitoring inspection conducted on 07/31/2025 to review compliance with licensing requirements and assess the facility's corrective actions.
Findings
The inspection identified multiple deficiencies including lack of properly installed carbon monoxide detectors, unsecured medications in resident living units, incomplete resident assessments, and inadequate support plans. The facility submitted and implemented plans of correction for all deficiencies, with ongoing audits and training scheduled.
Deficiencies (4)
| Description |
|---|
| No carbon monoxide detector was present near the gas oven/range, and battery-operated detector lacked date of battery installation. |
| Medications were found unsecured on a resident's nightstand despite the resident being unable to self-administer medications. |
| Resident assessments did not include required elements such as medication self-administration ability, mobility needs, memory status, and other health-related needs. |
| Resident support plans did not include descriptions or plans to meet the needs of indicated diagnoses. |
Report Facts
Total Daily Staff: 63
Waking Staff: 47
Residents Served: 48
License Capacity: 81
Current Hospice Residents: 6
Residents 60 Years or Older: 48
Residents Diagnosed with Mental Illness: 3
Residents with Mobility Need: 15
Residents with Physical Disability: 1
Inspection Report
Complaint Investigation
Census: 46
Capacity: 81
Deficiencies: 1
May 19, 2025
Visit Reason
The inspection was conducted as a partial, unannounced visit triggered by a complaint and incident review on 05/19/2025.
Findings
The inspection found that numerous open bottles of over-the-counter medications were unsecured in a resident's bedside drawer, despite the resident being deemed not competent to self-administer medications. A plan of correction was submitted and fully implemented.
Complaint Details
The visit was complaint-related and incident-driven. The plan of correction was reviewed and determined to be fully implemented.
Deficiencies (1)
| Description |
|---|
| Numerous open bottles of over-the-counter medications were found unsecured in a resident's bedside drawer, violating medication storage regulations. |
Report Facts
License Capacity: 81
Residents Served: 46
Current Hospice Residents: 7
Resident with Mental Illness: 1
Residents with Mobility Need: 16
Residents 60 Years or Older: 46
Residents with Physical Disability: 1
Total Daily Staff: 62
Waking Staff: 47
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Health and Wellness Director | Educated resident and staff on medication safety and conducted follow-up audits |
Inspection Report
Renewal
Census: 46
Capacity: 81
Deficiencies: 21
May 5, 2025
Visit Reason
The inspection was conducted as a renewal inspection with an incident review, including an unannounced full inspection on 05/05/2025 and 05/06/2025.
Findings
The inspection identified multiple deficiencies including failure to post license inspection summaries conspicuously, delayed access to resident records, delayed abuse reporting, medication management issues, inadequate staffing and training, fire safety violations, emergency preparedness deficiencies, and unsecured resident records. Plans of correction were directed and implemented with follow-up audits and training scheduled.
Deficiencies (21)
| Description |
|---|
| License inspection summaries were not posted in a conspicuous and public place. |
| Delayed provision of resident records to Department agents upon request. |
| Failure to immediately report suspected resident abuse to the local Area Agency on Aging and Department. |
| Physical abuse of resident #1 by direct care staff resulting in bruising. |
| Administrator was not present an average of 36 hours per week during April 2025. |
| Lack of qualified staff to administer medications during overnight shifts. |
| Insufficient staff trained in first aid and CPR during overnight shifts. |
| Direct care staff did not receive required annual training on medication self-administration, resident needs, mental illness care, fire safety, and emergency preparedness. |
| Emergency telephone numbers were not posted in resident living units #2 and #3. |
| Missing or damaged window screens in resident #2's living unit. |
| Emergency preparedness plan was not posted in a conspicuous and public place. |
| Missed unannounced fire drills in January, March, and April 2024; fire alarm not operative during July 2024 drill. |
| Fire drill record for October 2024 missing the date of the drill. |
| Fire alarm was not activated during the fire drill on 12/31/2024 at 11:00pm. |
| Exit sign near family dining room pointed in the opposite direction of the emergency exit. |
| Discontinued medication (Jardiance) present in resident #2's medication roll pack. |
| Pharmacy label for resident #3's medication did not match prescribed dosage and instructions. |
| Prescribed Nitroglycerin medication for resident #2 was not present in the residence for administration. |
| Discontinued medication orders remained on resident #3's medication administration record (MAR). |
| Resident #3's support plan did not include current hospice services and frequency. |
| Unlocked office accessible with numerous current and past resident records unsecured. |
Report Facts
License Capacity: 81
Residents Served: 46
Hospice Residents: 7
Residents 60 Years or Older: 46
Residents Diagnosed with Mental Illness: 1
Residents with Mobility Need: 18
Residents with Physical Disability: 2
Total Daily Staff: 64
Waking Staff: 48
Missed Fire Drills: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Health and Wellness Director | Health and Wellness Director | Named in multiple medication management and resident care findings. |
| Executive Director | Executive Director | Named in multiple findings related to plan of correction implementation and staff training. |
| Direct Care Staff Person B | Direct Care Staff | Named in abuse and training deficiencies. |
| Direct Care Staff Person D | Direct Care Staff | Named in training deficiencies. |
| Environmental Services Manager | Environmental Services Manager | Responsible for audits related to fire drills, exit signs, and carbon monoxide detectors. |
Inspection Report
Complaint Investigation
Census: 49
Capacity: 81
Deficiencies: 5
Dec 27, 2024
Visit Reason
The inspection was conducted as a partial, unannounced visit triggered by a complaint and incident reported at the facility.
Findings
The inspection identified multiple deficiencies including failure to timely report an incident of alleged rough treatment by a caregiver, lack of dignity and respect in resident care, incomplete medical evaluations, incomplete resident assessments, and unsigned support plans without documented refusal or inability to sign. Corrective plans of action were submitted and implemented.
Complaint Details
The visit was complaint-related, triggered by an incident where a resident reported rough handling and inappropriate behavior by a caregiver. The caregiver was suspended and terminated following the incident.
Deficiencies (5)
| Description |
|---|
| Failure to report an incident of alleged rough treatment by a caregiver to the Department within 24 hours. |
| Resident was not treated with dignity and respect; caregiver was rough, tossed resident, used foul language. |
| Medical evaluation for a resident did not include information on overall health status, body positioning/movement stimulation, immunization status, and head injury/trauma. |
| Resident assessments did not include diagnoses as indicated on medical evaluations. |
| Support plans for residents were not signed nor was there notation of refusal or inability to sign. |
Report Facts
Residents served: 49
License capacity: 81
Staffing hours: 60
Staffing hours: 45
Current residents in hospice: 9
Residents age 60 or older: 49
Residents with mental illness: 2
Residents with mobility need: 11
Residents with physical disability: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Caregiver B | Caregiver | Named in dignity/respect violation for rough handling and use of foul language; suspended and terminated. |
| Executive Director | Responsible for reporting incidents to licensing department and overseeing corrective actions and audits. | |
| Health and Wellness Director | Provided training on resident rights and medical evaluation compliance; responsible for audits and ensuring documentation completeness. | |
| Care Team Manager | Responsible for supervising caregiver performance and verifying resident care compliance. |
Inspection Report
Complaint Investigation
Census: 45
Capacity: 81
Deficiencies: 0
Aug 15, 2024
Visit Reason
The inspection was conducted as a complaint investigation at the facility on 08/15/2024.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Complaint Details
The inspection was complaint-related, but no deficiencies or citations were found, indicating no substantiated issues.
Report Facts
Residents Served: 45
License Capacity: 81
Current Hospice Residents: 5
Residents Diagnosed with Mental Illness: 5
Residents Diagnosed with Intellectual Disability: 5
Residents with Physical Disability: 2
Residents with Mobility Need: 2
Residents 60 Years or Older: 45
Inspection Report
Complaint Investigation
Census: 42
Capacity: 81
Deficiencies: 8
Jun 13, 2024
Visit Reason
The inspection was an unannounced partial inspection conducted due to a complaint and interim review of the facility.
Findings
Multiple deficiencies were identified including missing criminal background checks for staff, lack of required qualifications for direct care staff, incomplete fire safety and job duty orientations, incomplete rights and abuse training, incomplete direct care training, medication storage and calibration issues, and failure to follow prescriber's medication orders.
Complaint Details
The inspection was complaint-related and interim in nature. The complaint triggered an unannounced partial inspection on 06/13/2024.
Deficiencies (8)
| Description |
|---|
| Staff person D did not have a criminal background check completed. |
| Direct care staff person A does not have a high school diploma, GED, or active registry status on the Pennsylvania nurse aide registry. |
| Direct care staff persons A and B did not receive orientation in general fire safety and emergency preparedness including evacuation procedures, staff duties during fire drills, designated meeting place, smoking safety procedures, use of fire extinguishers, smoke detectors, fire alarms, and emergency notification. |
| Direct care staff persons A and B did not receive orientation on their job duties. |
| Direct care staff persons A and B did not complete required training within 40 scheduled working hours on resident rights, emergency medical plan, mandatory abuse reporting, reporting incidents, safe management techniques, and core competency training. |
| Direct care staff person A did not complete the Department-approved direct care training course and pass the competency test as required. |
| Medication storage and equipment issues: Resident #3 and #4's blood glucose monitoring devices were not calibrated to the current date and time; multiple discrepancies in blood glucose documentation were noted. |
| Failure to follow prescriber's orders: Resident #2 and #4 did not receive prescribed medications due to unavailability; resident #3's blood glucose was checked only twice and sliding scale insulin was administered only twice instead of prescribed three times. |
Report Facts
Residents Served: 42
License Capacity: 81
Staff Audit Rate: 5
Plan of Correction Completion Date: 2024
Inspection Report
Complaint Investigation
Census: 45
Capacity: 81
Deficiencies: 0
Apr 2, 2024
Visit Reason
The inspection was conducted as a complaint investigation with an unannounced partial inspection on 04/02/2024.
Findings
No regulatory citations or deficiencies were identified during this inspection.
Complaint Details
The inspection was complaint-related; however, no deficiencies were found and no follow-up was required.
Report Facts
Residents Served: 45
License Capacity: 81
Current Hospice Residents: 7
Resident Support Staff: 0
Total Daily Staff: 66
Waking Staff: 50
Residents Age 60 or Older: 45
Residents Diagnosed with Mental Illness: 1
Residents with Mobility Need: 21
Residents with Physical Disability: 1
Inspection Report
Renewal
Census: 52
Capacity: 81
Deficiencies: 16
Jan 12, 2024
Visit Reason
The inspection was conducted as a full, unannounced visit for renewal, complaint, and incident reasons.
Findings
The inspection identified multiple deficiencies including delays in providing access to records, incomplete criminal background checks, missing staff training, medication storage and documentation issues, incomplete support plans, and failure to conduct monthly fire drills. Plans of correction were submitted and later fully implemented.
Deficiencies (16)
| Description |
|---|
| Delayed access to final support plans and training documents for staff. |
| Staff person D did not have a completed criminal background check at hire. |
| Staff persons D and E did not receive required fire safety orientation training on the first day. |
| Staff person A did not receive required 40-hour orientation training including resident rights and abuse reporting. |
| Ancillary staff person A did not receive general orientation to job functions prior to working. |
| Staff persons A, B, and C did not receive 16 hours of annual training related to job duties during 2023. |
| Staff persons A, B, C did not receive required annual training in fire safety, emergency preparedness, resident rights, Older Adult Protective Services Act, falls prevention, and new population groups. |
| Staff persons A, B, C did not receive required dementia-specific training during 2023; staff person E did not receive 4 hours dementia training within 30 days of hire. |
| Residents were charged fees for furniture and linens contrary to regulations; contracts lacked required provisions. |
| Unannounced fire drills were not held in December 2022, January 2023, May 2023, July 2023, and October 2023. |
| Resident #7 did not have an annual in-person medical evaluation completed by due date. |
| Medications for residents #3 and #5 were not available in the residence during inspection. |
| Medication administration records for residents #2 and #5 did not include all ordered medications. |
| Resident #3's wound care medical need was not documented in the annual support plan. |
| Support plans for residents #2, #3, and #6 were not signed and dated by the staff who completed them. |
| Preliminary support plans were not attached to or incorporated into resident-residence contracts for residents #1, #2, #3, #4, #5, and #6. |
Report Facts
License Capacity: 81
Residents Served: 52
Hospice Residents: 11
Staffing Hours: 66
Waking Staff: 50
Months without fire drills: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff person A | Named in findings related to missing 40-hour orientation, ancillary staff orientation, annual training, dementia training, and annual training content. | |
| Staff person B | Named in findings related to missing 2023 training, annual training, dementia training, and annual training content. | |
| Staff person C | Named in findings related to missing 2023 training, annual training, dementia training, and annual training content. | |
| Staff person D | Named in findings related to missing criminal background check, missing fire safety orientation, and dementia training. | |
| Staff person E | Named in findings related to missing fire safety orientation and dementia training. | |
| Executive Director | Responsible for audits, training, and corrective actions throughout the report. | |
| Health and Wellness Director | Responsible for medication audits, training, and compliance. | |
| Care Team Manager | Responsible for auditing resident support plans and updating service plans. |
Inspection Report
Complaint Investigation
Census: 58
Capacity: 81
Deficiencies: 10
Aug 10, 2023
Visit Reason
The inspection was a complaint investigation conducted as a partial, unannounced review on August 10, 14, and September 6, 2023, to assess compliance with licensing requirements at Hawthorne Woods AL.
Findings
The inspection identified multiple deficiencies including failure to implement the submitted plan of correction, inadequate assistance with activities of daily living, unqualified direct care staff, staff sleeping on duty, incomplete dementia training, unsanitary resident rooms, uncovered trash cans, inoperable laundry equipment, and incomplete resident support plans and records.
Complaint Details
The inspection was conducted as a complaint investigation with unannounced partial visits on August 10, 14, and September 6, 2023. The submitted plan of correction was determined not to be implemented.
Deficiencies (10)
| Description |
|---|
| Resident #1 was not assisted to bed before 7:00 p.m. despite requesting help between 6:30 p.m. and 6:45 p.m. |
| Direct care staff person A did not have a high school diploma, GED, or active registry status and provided care during multiple overnight shifts. |
| Direct care staff persons A and B were observed sleeping on duty multiple times in the second-floor sitting room. |
| Staff person C's dementia-specific training documentation was misplaced and had an incorrect date. |
| Resident room was very dirty with food particles, dried urine, and a pungent odor. |
| Trash can in first-floor common restroom had no lid. |
| One washer and two dryers in laundry were inoperable; fluorescent light in resident room flickered. |
| Resident #2's linens had to be changed and taken home for laundering by a family member due to lack of timely laundry service. |
| Final support plans for residents #1, #2, and #3 lacked required quarterly reviews. |
| Resident #1's most recent photo was outdated beyond two years. |
Report Facts
License Capacity: 81
Residents Served: 58
Current Residents in Hospice: 10
Residents with Mental Illness: 4
Residents with Mobility Need: 15
Residents Age 60 or Older: 58
Residents with Physical Disability: 1
Total Daily Staff: 73
Waking Staff: 55
Inspection Report
Complaint Investigation
Census: 59
Capacity: 81
Deficiencies: 0
Jul 13, 2023
Visit Reason
The inspection was conducted as a complaint investigation at the facility on 07/13/2023.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Complaint Details
The inspection was triggered by a complaint, but no deficiencies or regulatory citations were found, indicating no substantiated issues.
Report Facts
License Capacity: 81
Residents Served: 59
Current Hospice Residents: 10
Residents Age 60 or Older: 59
Residents with Mobility Need: 40
Inspection Report
Follow-Up
Census: 67
Capacity: 81
Deficiencies: 2
Jan 6, 2023
Visit Reason
The inspection was a partial, unannounced follow-up visit triggered by an 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 related to safeguarding resident money and property and ensuring annual medical evaluations are complete with all required elements. The community disputes one finding regarding safeguarding valuables but has taken corrective actions including audits and staff education.
Deficiencies (2)
| Description |
|---|
| Resident #1 was not provided a key to a locked drawer to safeguard valuables, resulting in missing money and an uncashed check. |
| Resident #1’s most recent annual medical evaluation was incomplete, missing the date of in-person evaluation, medical professional's license number, and signature date. |
Report Facts
License Capacity: 81
Residents Served: 67
Current Hospice Residents: 13
Residents 60 Years or Older: 67
Residents with Mobility Need: 35
Residents with Physical Disability: 2
Total Daily Staff: 103
Waking Staff: 77
Resident Support Staff: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lauren Houston | Administrator | Named as facility administrator |
Inspection Report
Complaint Investigation
Census: 69
Capacity: 81
Deficiencies: 1
Dec 1, 2022
Visit Reason
The inspection was conducted as a complaint and incident investigation regarding an allegation of abuse involving a resident at the assisted living facility.
Findings
The facility failed to report an incident of alleged abuse to the Department within the required 24-hour timeframe. The Bureau of Human Services Licensing did not substantiate the complaint but cited the facility for failure to report the incident timely. A plan of correction was submitted and fully implemented.
Complaint Details
The complaint involved an allegation of abuse of resident #1. The facility did not notify the Department until after an agent was on-site. The Bureau did not substantiate the abuse allegation but cited the facility for failure to report the incident timely as required by 55 Pa. Code § 2800.15.
Deficiencies (1)
| Description |
|---|
| Failure to report an incident of alleged abuse to the Department within 24 hours as required by law. |
Report Facts
License Capacity: 81
Residents Served: 69
Current Residents in Hospice: 11
Residents Age 60 or Older: 69
Residents Diagnosed with Mental Illness: 1
Residents with Mobility Need: 15
Residents with Physical Disability: 2
Inspection Report
Original Licensing
Census: 70
Capacity: 81
Deficiencies: 5
Sep 23, 2022
Visit Reason
The inspection was conducted due to a change in legal entity operating the assisted living residence, with partial inspections on September 23 and 26, 2022, as part of the licensing process for the new provider.
Findings
The facility was found to be in substantial compliance with regulations, but the licensing inspector was unable to complete a full inspection due to the new legal entity. Several deficiencies were cited related to staffing levels, sanitary conditions, emergency telephone numbers, furniture and equipment repair, and unobstructed egress, all of which had corrective plans accepted and implemented.
Deficiencies (5)
| Description |
|---|
| Insufficient staffing on night shift to meet resident care and emergency needs, with only two staff scheduled for 67 residents including 25 with mobility needs. |
| Unsanitary conditions found on shower chairs with feces and blackish substances present. |
| No emergency phone numbers posted on or near the cordless telephone and base in bedroom #G70. |
| Cover over the enabler on resident #1’s bed was in disrepair with torn netting hanging down. |
| Emergency exit door on the Garden level Garden Sunroom required force to open due to dirt buildup on threshold obstructing egress. |
Report Facts
Residents served: 70
License capacity: 81
Residents with mobility needs: 25
Residents requiring two staff assistance: 6
Staff on night shift: 2
Total daily staff: 95
Waking staff: 71
Current residents in hospice: 10
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