Inspection Report
Renewal
Census: 37
Capacity: 65
Deficiencies: 9
Jul 29, 2025
Visit Reason
The inspection was an unannounced renewal, provisional inspection conducted on 07/29/2025 to review compliance with licensing requirements and verify correction of previous deficiencies through a plan of correction submission.
Findings
The inspection identified multiple deficiencies including missing resident-home contracts, incomplete signed statements of resident rights, lack of thermometers in refrigerators/freezers, incomplete or untimely medical evaluations, untrained staff administering medications, missing preadmission screening forms, and incomplete resident discharge records. All deficiencies were addressed with detailed plans of correction, staff training, audits, and ongoing monitoring to ensure compliance.
Deficiencies (9)
| Description |
|---|
| Resident 1 did not have a resident-home contract. |
| Resident 1's record lacked a signed statement acknowledging receipt of resident rights and complaint procedures. |
| No thermometer in one of the standalone freezers in the basement and no thermometer in the bottom freezer of a kitchen refrigerator. |
| Medical evaluations for Residents 1, 2, and 3 were not completed within 60 days prior to admission or within 30 days after admission. |
| Resident 1's medical evaluation did not include special health or dietary needs; Resident 3's medical evaluation lacked a general physical exam, allergies, and body positioning/movement stimulation details. |
| Resident 3's annual medical evaluation was not completed within the required timeframe. |
| Staff person A administered medications without completing required medication administration training. |
| Resident 1 did not have a preadmission screening form completed within 30 days prior to admission. |
| Resident 1's chart lacked a discharge record documenting previous discharge and return to the facility. |
Report Facts
License Capacity: 65
Residents Served: 37
Current Hospice Residents: 4
Residents with Mental Illness: 13
Residents with Intellectual Disability: 2
Residents with Mobility Need: 5
Residents 60 Years or Older: 37
Total Daily Staff: 42
Waking Staff: 32
Inspection Report
Complaint Investigation
Census: 39
Capacity: 65
Deficiencies: 3
Feb 19, 2025
Visit Reason
The inspection was conducted as a complaint investigation triggered by an incident involving a resident fall during a power outage on February 16, 2025.
Findings
The inspection found multiple violations including abuse related to neglect during a power outage that left hallways dark, resulting in a resident fall and death; unsanitary conditions in a resident's room after their death; and inadequate emergency lighting on the second and third floors contributing to unsafe conditions. The facility was issued a provisional license due to these violations and required to implement corrective actions.
Complaint Details
The complaint investigation was triggered by an incident on 2/16/2025 where a resident with mobility and vision impairments fell down a darkened stairwell during a power outage and later died. The investigation substantiated neglect and abuse related to inadequate emergency lighting and supervision during the outage.
Deficiencies (3)
| Description |
|---|
| Failure to provide sufficient emergency lighting during a power outage, resulting in a resident falling down stairs and dying. |
| Neglect and abuse due to inadequate supervision and emergency response during power outage, leading to resident injury and death. |
| Unsanitary conditions found in a resident's room after their death, including food remnants and toothpaste residue. |
Report Facts
License Capacity: 65
Residents Served: 39
Current Residents in Hospice: 3
Residents 60 Years or Older: 38
Residents Diagnosed with Mental Illness: 17
Residents Diagnosed with Intellectual Disability: 2
Staffing Hours: 41
Waking Staff: 31
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Juliet Marsala | Deputy Secretary | Signed the provisional license letter and correspondence regarding the inspection. |
Inspection Report
Renewal
Census: 39
Capacity: 65
Deficiencies: 3
Oct 31, 2024
Visit Reason
The inspection was conducted as a renewal review of the facility's license by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing on 10/31/2024.
Findings
The report found violations related to outdated food storage, improper medication storage, and medication administration documentation errors. The facility submitted a plan of correction which was accepted and fully implemented by 12/10/2024.
Deficiencies (3)
| Description |
|---|
| Unlabeled, undated green and red peppers and incorrectly labeled and undated red tomatoes in the freezer. |
| Unopened medication belonging to a resident was not stored according to manufacturer’s instructions requiring refrigeration until opening. |
| Medication prescribed as needed was not available in the home and glucometer readings were inaccurately documented on the Resident Medication Administration Record. |
Report Facts
Residents Served: 39
License Capacity: 65
Total Daily Staff: 41
Waking Staff: 31
Residents Receiving Supplemental Security Income: 5
Residents Diagnosed with Mental Illness: 17
Residents Aged 60 or Older: 39
Residents Diagnosed with Intellectual Disability: 2
Residents with Mobility Need: 2
Inspection Report
Renewal
Census: 37
Capacity: 65
Deficiencies: 8
Sep 6, 2023
Visit Reason
The inspection was conducted as a renewal inspection of Hayes Manor to review compliance with licensing requirements and verify the implementation of the submitted plan of correction.
Findings
The inspection identified multiple deficiencies including failure to provide ambulating assistance as per resident support plans, incomplete staff training in required topics, improper scheduling of fire drills, incomplete medical evaluations, medication administration errors, failure to follow prescriber's orders, and medication error reporting deficiencies. Plans of correction were accepted and verified as implemented by November 2, 2023.
Deficiencies (8)
| Description |
|---|
| Resident #1 did not receive ambulating assistance or bed-to-bed transfers as specified in the support plan. |
| Direct care staff persons A and B did not receive required annual training in medication self-administration, care for residents with dementia, infection control, safe management techniques, and falls and accident prevention during training year 2022. |
| Fire drills were routinely conducted during the first week of the month rather than on different days and times as required. |
| Resident #2's medical evaluation was incomplete, missing page two including special diet, special instructions, and medication regimen. |
| Staff member C did not place medication in resident #3's hand, mouth, or other route as ordered by the prescriber. |
| Resident #2 was not administered sliding scale insulin doses as prescribed and documentation was incomplete. |
| Resident #4 was without prescribed medication for 6 days due to medication not being available in the home. |
| Resident #4's medication error was not immediately reported to the resident, designated person, and prescriber as required. |
Report Facts
Residents served: 37
License capacity: 65
Staffing hours: 39
Staffing hours: 29
Residents receiving Supplemental Security Income: 3
Residents diagnosed with mental illness: 11
Residents diagnosed with intellectual disability: 4
Residents aged 60 or older: 37
Residents with mobility need: 2
Residents with physical disability: 0
Fire drills documented: 5
Medication administration refresher date: Sep 11, 2023
Plan of correction completion date: Sep 26, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff Member C | Named in medication administration violation and subsequent retraining | |
| Staff person A | Named in training deficiencies and subsequent retraining | |
| Staff person B | Named in training deficiencies and subsequent retraining | |
| Nurse Manager | Provided training, audits, and oversight related to multiple deficiencies | |
| Human Resources Manager | Responsible for training audits and compliance | |
| Administrator | Reviewed violations and ensured corrective actions |
Inspection Report
Monitoring
Census: 34
Capacity: 65
Deficiencies: 6
Feb 22, 2023
Visit Reason
The visit was a partial, unannounced monitoring inspection conducted to review compliance and the implementation of a previously submitted plan of correction.
Findings
The inspection found multiple medication management deficiencies including expired medications, incorrect glucometer times, unavailable PRN medications, incomplete medication records, failure to follow prescriber's orders, and medication error reporting issues. All deficiencies had corrective plans accepted and were implemented by May 23, 2023.
Deficiencies (6)
| Description |
|---|
| Expired medication belonging to resident #1 was present in the medication cart. |
| Resident #1's glucometer did not have the correct time. |
| Resident #2's prescribed PRN medication was not available in the home on the inspection date. |
| Resident #1's medication administration record did not include a prescribed medication. |
| Resident #1 was not administered prescribed medication as ordered and the medication error was not reported to the resident, designated person, or prescriber. |
| Resident #2's initial assessment did not include a plan to meet medical needs as required. |
Report Facts
Residents Served: 34
License Capacity: 65
Total Daily Staff: 38
Waking Staff: 29
Residents Diagnosed with Mental Illness: 7
Residents 60 Years or Older: 34
Residents Diagnosed with Intellectual Disability: 3
Residents with Mobility Need: 4
Residents with Physical Disability: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nurse Manager | Named in multiple medication management deficiencies and corrective actions | |
| Administrator | Involved in review and monitoring of medication orders and audits |
Inspection Report
Complaint Investigation
Census: 35
Capacity: 65
Deficiencies: 20
Jan 4, 2023
Visit Reason
The inspection was a complaint investigation conducted as an unannounced partial review to assess compliance with regulations following a complaint.
Findings
The inspection identified multiple deficiencies including failure to timely report incidents, inadequate assistance with activities of daily living, incomplete criminal background checks, medication management issues, safety hazards such as rotting porch railings and blocked egress, and incomplete resident assessments and support plans. Plans of correction were accepted and implemented by April 26, 2023.
Complaint Details
The inspection was conducted as a complaint investigation triggered by concerns including resident refusal to eat or drink, failure to report incidents timely, and other care and safety issues. The complaint was substantiated with multiple violations found.
Deficiencies (20)
| Description |
|---|
| Failure to report an incident of resident dehydration and COVID infection to the Department within 24 hours. |
| Failure to submit a final incident report to the Department after resident's death. |
| Resident did not receive required assistance with toileting and bladder management; use of adult briefs not documented in support plan. |
| Criminal background checks not completed timely for certain staff members. |
| Resident #2 did not receive assistance with toileting or bladder management due to lack of available direct care staff. |
| Porch railing was rotting and poorly secured. |
| Thermostats in resident rooms and hallways were not working properly, causing high temperatures. |
| Hole in porch floor approximately eight inches in length. |
| No system to safeguard resident laundry from loss; clothing not returned within 24 hours. |
| Yellow tape blocked egress from left wing of building. |
| Failure to notify resident's primary care physician and designated person promptly when resident refused to eat or drink. |
| Discontinued medication remained in medication cart and was not removed timely. |
| Resident #3's prescribed PRN medications were not available in the home. |
| Resident #4's glucometer readings were not recorded on Medication Administration Record or glucose flow sheet. |
| Medication administration records lacked initials of staff administering medications and completing glucometer checks. |
| No written procedures for delivery and management of services from admission to discharge; resident requiring one-on-one supervision not properly documented. |
| Resident #5's preadmission screening form missing date of prescreening completion. |
| Resident #4's initial assessment was not completed within 15 days of admission. |
| Resident #4's assessment did not include need for one-on-one supervision and elopement risk. |
| Resident #2's support plan did not document bowel management needs or how they would be met. |
Report Facts
Residents Served: 35
License Capacity: 65
Staffing Hours: 40
Waking Staff: 30
Residents with Supplemental Security Income: 2
Residents 60 Years or Older: 35
Residents Diagnosed with Mental Illness: 4
Residents Diagnosed with Intellectual Disability: 3
Residents with Mobility Need: 5
Inspection Report
Renewal
Census: 32
Capacity: 65
Deficiencies: 2
Aug 17, 2022
Visit Reason
The inspection was conducted as a renewal inspection of the facility license.
Findings
The report found deficiencies related to incomplete medical evaluations and missing completion dates on preadmission screening forms. The facility submitted a plan of correction which was determined to be fully implemented.
Deficiencies (2)
| Description |
|---|
| Resident #1's medical evaluation did not include the completion of section 7 or the medication addendum; the form referenced an attachment that was missing. |
| Resident #2's preadmission screening form did not have a completion date, so it was unclear if the determination was made within 30 days prior to admission. |
Report Facts
License Capacity: 65
Residents Served: 32
Total Daily Staff: 37
Waking Staff: 28
Residents Receiving Supplemental Security Income: 2
Residents 60 Years or Older: 32
Residents Diagnosed with Mental Illness: 4
Residents Diagnosed with Intellectual Disability: 3
Residents with Mobility Need: 5
Residents with Physical Disability: 0
Hospice Residents: 1
Inspection Report
Complaint Investigation
Census: 29
Capacity: 65
Deficiencies: 1
Jul 8, 2022
Visit Reason
The inspection was conducted as a complaint investigation with unannounced partial inspections on 07/08/2022 and 07/11/2022 to assess compliance with applicable regulations at Hayes Manor.
Findings
Areas of non-compliance were found related to contract signatures, specifically that a resident was admitted with a boarding agreement rather than a Personal Care Home agreement as required by regulation.
Complaint Details
The inspection was complaint-related and the reason for the visit was a complaint. Substantiation status is not stated.
Deficiencies (1)
| Description |
|---|
| The contract was not properly signed as the resident was admitted with a boarding agreement rather than a Personal Care Home agreement. |
Report Facts
License Capacity: 65
Residents Served: 29
Total Daily Staff: 32
Waking Staff: 24
Residents Receiving Supplemental Security Income: 2
Residents 60 Years or Older: 29
Residents Diagnosed with Mental Illness: 6
Residents Diagnosed with Intellectual Disability: 2
Residents with Mobility Need: 3
Residents with Physical Disability: 1
Inspection Report
Follow-Up
Census: 24
Capacity: 65
Deficiencies: 10
Mar 16, 2022
Visit Reason
The inspection was a partial, unannounced follow-up visit triggered by an incident to verify the implementation of a submitted plan of correction.
Findings
Multiple deficiencies were identified including abuse of a resident, failure to complete timely criminal background checks, lack of required qualifications and training for direct care staff, missing annual medical evaluations, improper medication record keeping, and failure to follow safe equipment usage procedures. Plans of correction were accepted and fully implemented by the facility.
Deficiencies (10)
| Description |
|---|
| Resident #1 was verbally abused and physically mishandled during transfer, causing pain and mental anguish. |
| Criminal background check for Staff A was not requested until after employment started. |
| Direct care staff person B lacked documentation of required education or registry status. |
| No staff trained in first aid and CPR was present during the night shift on 03/06/2022. |
| Direct care staff person B provided unsupervised ADL services before completing required training and competency testing. |
| Resident #1’s annual medical evaluation was delayed and not completed timely. |
| Staff A operated the Sit-to-Stand Lift alone contrary to manufacturer instructions requiring two staff. |
| Resident #1’s March medication administration record did not include prescribed insulin injections. |
| Staff person B administered insulin without completing a Department-approved diabetes education program. |
| Resident #1's support plan lacked assessor information and was signed but not dated. |
Report Facts
Residents served: 24
License capacity: 65
Total daily staff: 28
Waking staff: 21
Supplemental Security Income recipients: 2
Residents 60 years or older: 24
Residents diagnosed with mental illness: 3
Residents diagnosed with intellectual disability: 1
Residents with mobility needs: 4
Residents with physical disability: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Named in abuse incident and improper use of Sit-to-Stand Lift; removed from work schedule and dismissed. | |
| Staff person B | Direct care staff lacking required education and training; removed from direct care duties; involved in medication administration violations. | |
| Claire Mendez | Human Services Licensing Supervisor | Signed the initial letter confirming plan of correction implementation. |
Inspection Report
Complaint Investigation
Census: 29
Capacity: 65
Deficiencies: 4
Jul 28, 2021
Visit Reason
The inspection was conducted as a complaint investigation with an unannounced partial inspection on July 28 and 29, 2021.
Findings
The report found multiple deficiencies including lack of immediate access to resident records, physical facility issues such as cracks and water leaks in the restroom, incomplete medical evaluations for residents, and missing recent photographs in resident records. The submitted plan of correction was later determined to be fully implemented.
Complaint Details
The inspection was triggered by a complaint, as indicated by the inspection reason 'Complaint' and the unannounced partial inspection type.
Deficiencies (4)
| Description |
|---|
| Failure to provide immediate access to residents' records including contracts and financial information upon request. |
| Restroom located on the first floor next to the nurse's office had cracks on the wall and water was dripping from the ceiling. |
| Medical evaluations for residents #1, #2, and #3 did not include required assessments for medication self-administration and body positioning/movement. |
| Residents #2's and #4's records did not include a photograph taken within the last two years. |
Report Facts
Residents Served: 29
License Capacity: 65
Current Hospice Residents: 1
Total Daily Staff: 33
Waking Staff: 25
Residents with Supplemental Security Income: 2
Residents Age 60 or Older: 29
Residents with Mobility Need: 4
Residents with Physical Disability: 2
Inspection Report
Renewal
Census: 29
Capacity: 65
Deficiencies: 11
Jun 29, 2021
Visit Reason
The inspection was conducted as a renewal visit to review compliance with licensing requirements and verify the implementation of the submitted plan of correction.
Findings
The inspection identified multiple deficiencies including staff qualification documentation, training plan content, bathroom ventilation, bedroom furnishings and lighting, refrigerator thermometer absence, emergency procedure submissions and postings, fire department notification, menu posting, and resident record content. All deficiencies had plans of correction accepted and were implemented by specified dates.
Deficiencies (11)
| Description |
|---|
| Direct care staff person A does not have a high school diploma, GED, or active registry status on file. |
| The home's staff training plan does not include name, position and duties of each staff person. |
| The bathroom in bedroom does not have a window or an operable ventilation fan. |
| There is no bedside table or shelf beside resident #1’s bed in bedroom. |
| Resident #1 does not have access to a source of light that can be turned on/off at bedside. |
| There was no thermometer found in the refrigerator known as Box 1 to measure temperature. |
| The home’s written emergency procedures have not been submitted to the local emergency management agency since 2/28/2019. |
| The home’s emergency procedures posted in a conspicuous and public place did not include the local municipality's emergency procedure. |
| The home does not have documentation of written notification to the local fire department of the address, bedroom locations, and assistance needed to evacuate in an emergency. |
| The home's menu for the week of 6/25/21-7/4/2021 was posted, but the following week menu was not posted 1 week in advance. |
| Resident #2's record does not include a photograph taken no more than 2 years ago; last photo dated 1/15/19. |
Report Facts
Residents Served: 29
License Capacity: 65
Total Daily Staff: 33
Waking Staff: 25
Document
Capacity: 65
Deficiencies: 0
Sep 27, 2021
Visit Reason
The document includes a Certificate of Compliance issued to Hayes Manor for operation as a Personal Care Home and a renewal letter acknowledging receipt of the renewal application and advising of an upcoming annual inspection within the next twelve months.
Findings
No inspection findings are reported in this document. It confirms issuance of a regular license and states that the Department will conduct an inspection within the next twelve months to ensure compliance.
Report Facts
Maximum licensed capacity: 65
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Robyn Burns | Administrator | Named as legal entity representative on the renewal application |
| Jamie L. Buchenauer | Deputy Secretary, Office of Long-term Living | Signed the renewal letter |
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