Inspection Report
Renewal
Census: 49
Capacity: 60
Deficiencies: 13
May 12, 2025
Visit Reason
The inspection was conducted as a renewal visit to assess compliance with licensing requirements for Hidden Meadows on the Ridge.
Findings
The inspection identified multiple deficiencies related to staff training, medication storage and administration, food storage, emergency procedures, and resident support plans. Plans of correction were accepted and many deficiencies were implemented by follow-up dates.
Severity Breakdown
Repeat Violation: 2
Deficiencies (13)
| Description | Severity |
|---|---|
| Staff member A did not receive training on meeting the needs of residents as described in the preadmission screening form, assessment tool, medical evaluation, and support plan, and personal care service needs during training year 2024. | — |
| Staff persons A and B did not receive training in fire safety completed by a fire safety expert and resident rights during training year 2024. | Repeat Violation |
| The first aid kit located in the third-floor nurse’s office did not include scissors. | — |
| Opened food items (baking powder and sugar) were not tightly sealed in the main kitchen dry storage. | — |
| Outdated or unlabeled food items (stuffed shells and chicken cordon bleu) were found in the walk-in freezer not in original containers and unlabeled. | — |
| The home’s written emergency procedures had not been reviewed, updated, and submitted since March 14, 2024, to the local emergency management agency. | — |
| A loose pill was found on the first drawer of the medication cart on the 2nd floor. | — |
| Resident 1's Hydrocodone-Acetaminophen medication card had an opening on the back of pill #8. | — |
| Expired Lorazepam 2 mg medications for residents 2 and 3 were observed in the medication station locked refrigerator. | — |
| Resident 4's medication administration record did not indicate the number of units of insulin administered from May 1 through May 12 as prescribed. | — |
| Staff person C administered medications without successfully completing the Department-approved medications administration course in 2024. | — |
| Resident 5's assessment and support plan did not address the use of a bedside mobility device to assist with transfer. | Repeat Violation |
| Resident 6's assessment form and support plan did not document how the resident's need for a heart-healthy diet would be met. | — |
Report Facts
License Capacity: 60
Residents Served: 49
Current Hospice Residents: 3
Residents 60 Years or Older: 49
Residents with Mobility Need: 11
Residents with Physical Disability: 1
Total Daily Staff: 60
Waking Staff: 45
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff member A | Named in training deficiency for missing required training in 2024 | |
| Staff member B | Named in training deficiency for missing required training in 2024 | |
| Staff member C | Named in medication administration deficiency for not completing required medication administration course | |
| Health and Wellness Director | Responsible for correcting medication and training deficiencies, conducting audits, and education | |
| Executive Director | Provided education, reviewed audits, and oversaw corrective actions | |
| Director of Culinary | Involved in food storage violations and corrective actions |
Inspection Report
Monitoring
Census: 52
Capacity: 60
Deficiencies: 0
Aug 14, 2024
Visit Reason
The inspection was an unannounced monitoring visit conducted by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing on 08/14/2024.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Total Daily Staff: 63
Waking Staff: 47
Resident Support Staff: 0
License Capacity: 60
Residents Served: 52
Have Mobility Need: 11
Are 60 Years of Age or Older: 52
Diagnosed with Intellectual Disability: 1
Have Physical Disability: 2
Diagnosed with Mental Illness: 0
Receive Supplemental Security Income: 0
Current Hospice Residents: 0
Inspection Report
Renewal
Census: 51
Capacity: 60
Deficiencies: 29
May 21, 2024
Visit Reason
The inspection was conducted as a full, unannounced renewal inspection with reasons including renewal, complaint, and incident review.
Findings
Multiple deficiencies were identified across various regulatory areas including resident confidentiality, treatment of residents, staff qualifications and training, sanitary conditions, medication management, fire safety, and resident records. Plans of correction were accepted with proposed completion dates mostly in July 2024 and implementation by December 2024.
Deficiencies (29)
| Description |
|---|
| The 2nd floor narcotic book was left unlocked and unattended on the medication cart, accessible to anyone. |
| Refunds for deceased residents were not issued timely according to regulations. |
| Refunds for residents who moved out were delayed beyond the required 30 days. |
| Resident #3 was treated without dignity and respect; staff was verbally and physically inappropriate. |
| Direct care staff person lacked required high school diploma, GED, or active registry status. |
| Direct care staff did not receive the required 12 hours of annual training. |
| Direct care staff did not receive required training on medication self-administration, dementia care, safe management, and care for residents with mental illness or intellectual disability. |
| Direct care staff did not receive training on emergency preparedness, resident rights, and falls prevention. |
| Resident #3's bedside mobility device was not securely attached to the bed frame, creating entrapment hazards. |
| Medication refrigerator was unsanitary with food and beverages stored alongside medications. |
| Dumpster outside the home was missing a top covering and had trash improperly disposed near it. |
| First aid kit in the facility bus was missing eye coverings and breathing shield. |
| Outdated food items were found in the emergency food storage. |
| Emergency exit door had inappropriate signage obstructing egress. |
| Fire extinguisher inside the front entrance was undercharged. |
| Fire drill records lacked required details including exact location, exit routes, and evacuation times. |
| During fire drill, only 29 of 50 residents evacuated to designated meeting place. |
| Resident #4's medical evaluation was incomplete regarding body positioning and movement stimulation. |
| Resident #4's most recent medical evaluation was overdue. |
| Resident #6 had medication in the cart not listed on current orders. |
| Medication refrigerator temperature was above recommended range for insulin pens and eye drops. |
| Expired medication was found in the medication cart. |
| Resident #6's medication label required a direction change sticker. |
| Resident #3's prescribed medication was not available in the home. |
| Resident #6's medication administration record lacked staff initials for administered medication. |
| Resident #8's preadmission screening form did not include determination that the resident's needs can be met by the home. |
| Resident #5's support plan did not address use of bedside mobility device. |
| Resident #5's support plan was not signed by the assessor and was signed but not dated by the resident. |
| Resident #5's record did not include the preadmission screening form. |
Report Facts
License Capacity: 60
Residents Served: 51
Total Daily Staff: 60
Waking Staff: 45
Direct Care Staff Training Hours: 4.5
Direct Care Staff Training Hours: 10.25
Expired Food Items: 6
Fire Drill Residents Evacuated: 29
Fire Drill Residents Present: 50
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff person A | Named in findings related to treatment of residents, staff qualifications, training deficiencies, and termination | |
| Staff person C | Named in findings related to training deficiencies and supplemental training | |
| Staff person D | Named in medication administration record deficiency | |
| Administrator | Administrator/Executive Director | Named in multiple findings and plans of correction including training, audits, and policy updates |
| Director of Health and Wellness | Named in multiple findings and plans of correction including training, audits, and policy updates | |
| Business Office Manager | Named in plans of correction related to refunds and onboarding | |
| Assistant Business Office Manager | Named in plans of correction related to onboarding |
Inspection Report
Complaint Investigation
Census: 51
Capacity: 60
Deficiencies: 0
Oct 11, 2023
Visit Reason
The inspection was conducted as a complaint and incident investigation at the facility.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Complaint Details
The inspection was complaint-related; no deficiencies were found and no follow-up was required.
Report Facts
License Capacity: 60
Residents Served: 51
Total Daily Staff: 64
Waking Staff: 48
Residents Age 60 or Older: 51
Residents Diagnosed with Mental Illness: 1
Residents with Mobility Need: 13
Residents with Physical Disability: 1
Inspection Report
Renewal
Census: 56
Capacity: 60
Deficiencies: 10
Jan 4, 2023
Visit Reason
The inspection was conducted as a renewal inspection with an incident review, unannounced, on 01/04/2023 and 01/05/2023.
Findings
The facility was found to have multiple deficiencies including failure to immediately report suspected resident abuse to the local area agency on aging, lack of a supervisory plan for a staff member involved in an abuse allegation, missing documentation of food safety certification for kitchen staff, hazards in food serving areas, missing emergency telephone numbers in a resident room, outdated food items in the kitchen, lack of timely fire safety inspections and drills, medication storage and prescription issues, and incomplete resident support plans. All deficiencies had plans of correction accepted and were implemented by 02/09/2023.
Deficiencies (10)
| Description |
|---|
| Failure to immediately report suspected resident abuse to the local area agency on aging. |
| Failure to develop and implement a plan of supervision or suspend staff person involved in alleged abuse incident. |
| Only one staff member had ServSafe certification with no documentation available to verify. |
| Hazardous peeling/chipped paint behind steam table in 2nd floor dining room food serving area. |
| No emergency telephone numbers posted on or by telephone in resident room #322. |
| Outdated or unlabeled food items found in main kitchen refrigerator. |
| No fire safety inspection and drill completed in 2021; last inspection on 02/10/22. |
| Discontinued medications found with resident #2's current medications. |
| Loose unidentified pills found in 2nd floor medication cart. |
| Resident #3's support plan did not document how mechanical soft diet and shower chair needs would be met. |
Report Facts
License Capacity: 60
Residents Served: 56
Current Hospice Residents: 3
Residents Age 60 or Older: 56
Residents Diagnosed with Mental Illness: 2
Residents with Mobility Need: 13
Residents with Physical Disability: 1
Total Daily Staff: 69
Waking Staff: 52
Inspection Report
Renewal
Census: 40
Capacity: 60
Deficiencies: 11
Dec 28, 2021
Visit Reason
The inspection was conducted as a renewal licensing inspection of the facility Hidden Meadows on the Ridge on 12/28/2021.
Findings
The inspection identified multiple deficiencies including unsigned resident contracts, safety hazards with uncovered enablers, improper soap dispenser labeling, refrigerator temperature violations, medication administration errors, incomplete resident assessments, and missing signatures on support plans. Plans of correction were accepted for all deficiencies with specified completion dates.
Deficiencies (11)
| Description |
|---|
| Resident #1's home contract was not signed by the resident. |
| Resident #2's bed was equipped with an uncovered enabler posing a safety hazard. |
| An unlabeled used bar of soap was found in a shared bathroom. |
| Walk-in refrigerator temperature was 45°F, exceeding the required 40°F limit. |
| Medication administration errors for Resident #3 including incorrect dosing times and failure to follow medication administration procedures. |
| Pharmacy label on Resident #4's medication blister pack did not reflect updated dosing instructions. |
| Missing staff initials on medication administration records for Resident #3 and Resident #5. |
| Resident #6's initial assessment was not completed within 15 days of admission. |
| Resident #7's support plan was not updated to reflect change in medication administration status. |
| Resident #6's and Resident #8's support plans were not signed by the assessor. |
| Resident #6's photograph on file was outdated by more than 2 years. |
Report Facts
License Capacity: 60
Residents Served: 40
Staffing Hours: 55
Waking Staff: 41
Hospice Residents: 1
Residents with Mental Illness: 2
Residents with Mobility Need: 15
Residents with Physical Disability: 3
Notice
Capacity: 60
Deficiencies: 0
Jul 7, 2021
Visit Reason
The document serves as a renewal notification and license issuance for the Personal Care Home 'Hidden Meadows on the Ridge' following receipt of the renewal application dated May 13, 2021. It also advises that an annual inspection will be conducted within the next twelve months as required by regulation.
Findings
The Department issued a regular license in response to the renewal application and informed the facility that an onsite inspection will be conducted within the next twelve months to ensure compliance with applicable regulations.
Report Facts
Total licensed capacity: 60
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary, Office of Long-term Living | Signed the renewal notification letter. |
Inspection Report
Renewal
Census: 42
Capacity: 60
Deficiencies: 10
Jan 27, 2021
Visit Reason
The inspection was conducted as a renewal visit to review compliance with licensing requirements at Hidden Meadows on the Ridge.
Findings
The inspection identified multiple deficiencies including lack of carbon monoxide detectors near heating sources, unsigned resident contracts, improper documentation of resident refunds, staff training deficiencies, outdated food in the pantry, combustible storage violations, and medication administration documentation errors. Plans of correction were accepted for most deficiencies with some requiring further follow-up.
Deficiencies (10)
| Description |
|---|
| No carbon monoxide detector near the home's natural gas heating source. |
| Resident-home contract for Resident #1 was not signed by the resident. |
| Home did not provide required refund documentation for Resident #2 after discharge. |
| Direct care staff person A provided unsupervised ADL services without completing required training and competency test. |
| Staff training plan did not include dates, times, and locations of scheduled training for each staff person for the upcoming year. |
| Expired food found in the food pantry including macaroni and cheese and Quaker grits. |
| Flammable washer fluid stored near a heating source. |
| Staff person B transported residents without completing initial new hire direct care staff training. |
| Medication administration record for Resident #3 did not include initials of staff who administered Morphine on 01/22/21 at 11am and 2pm. |
| Resident #1's Midodrine medication was held without proper documentation despite blood pressure readings. |
Report Facts
License Capacity: 60
Residents Served: 42
Total Daily Staff: 54
Waking Staff: 41
Expired Food Items: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff person A | Named in deficiency for providing unsupervised ADL services without required training | |
| Staff person B | Named in deficiency for transporting residents without completing required direct care training | |
| Claire Mendez | Licensing Representative | Signed the cover letter confirming plan of correction implementation |
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