Inspection Report
Complaint Investigation
Census: 44
Capacity: 124
Deficiencies: 14
Jun 18, 2025
Visit Reason
The inspection was a complaint investigation and fine related to regulatory compliance issues at the facility, conducted on June 18, 2025, with a follow-up document submission on August 5, 2025.
Findings
The inspection identified multiple deficiencies including failure to post the current license, delayed incident reporting, lack of dignity and respect in resident care, incomplete criminal background checks, unqualified direct care staff, inadequate fire safety orientation, incomplete rights and abuse training, failure to maintain clean and safe surfaces, hazardous exterior deck conditions, inadequate bedding, and multiple medication administration record deficiencies including missing diagnosis, missing staff initials, and failure to follow prescriber's orders.
Complaint Details
The inspection was complaint-related with a fine. The report notes a complaint and fine as the reason for the inspection on 06/18/2025.
Deficiencies (14)
| Description |
|---|
| The home's current license was not posted in a conspicuous and public place. |
| Incident of water damage and unlocked exit doors in the Memory Care Unit was not reported to the department timely. |
| Resident was not treated with dignity and respect; toilet paper was kept out of reach. |
| Several staff members did not have criminal background checks in accordance with regulations. |
| Direct care staff persons C, D, E, F, and G lacked required educational qualifications. |
| Staff persons B and G did not receive required fire safety orientation on their first day. |
| Staff persons B, G, and H did not complete required 40-hour training within the required timeframe. |
| Staff person I did not receive required annual training in multiple areas including fire safety and resident rights. |
| Floors, walls, ceilings, windows, doors and other surfaces were not clean, in good repair, and free of hazards; multiple ceiling openings and leaks observed. |
| The exterior deck was in poor repair with a large dip and broken column, posing a hazard. |
| Resident 2's bed lacked bedsheets and blankets. |
| Medication administration records for multiple residents lacked required diagnosis or purpose for prescribed medications. |
| Medication administration records lacked initials of staff administering medications on multiple dates for several residents. |
| Resident 2's prescribed treatment with TED stockings was not completed on multiple dates. |
Report Facts
License Capacity: 124
Residents Served: 44
Memory Care Unit Capacity: 30
Memory Care Unit Residents Served: 18
Hospice Residents: 4
Staff Total Daily: 64
Staff Waking: 48
Inspection Report
Follow-Up
Census: 48
Capacity: 124
Deficiencies: 14
Apr 30, 2025
Visit Reason
The visit was a follow-up review conducted on June 10 and 20, 2025, to assess the implementation of the plan of correction submitted for the April 30, 2025 inspection.
Findings
The facility was found to have multiple deficiencies including incomplete criminal background checks for staff, inadequate staff orientation and training in fire safety, resident rights, and medication administration, failure to provide fans when indoor temperatures exceeded 80°F due to malfunctioning air conditioning, open ceiling tiles with water leaks, insufficient water pressure in some areas, torn window screens, expired medication storage, and incomplete medication administration records. None of the plans of correction submitted by the facility were implemented as of the follow-up date.
Deficiencies (14)
| Description |
|---|
| Staff persons lacked completed criminal background checks as required. |
| Direct care staff did not receive required orientation on fire safety and emergency preparedness on their first day. |
| Direct care staff did not complete required training within 40 scheduled working hours on resident rights, emergency medical plan, mandatory reporting of abuse and neglect, and reporting of reportable incidents. |
| Direct care staff provided unsupervised ADL services without documented completion and passing of Department-approved direct care training and competency test. |
| Direct care staff did not receive the required 12 hours of annual training related to their job duties during training year 2024. |
| Direct care staff did not receive required annual training topics including medication self-administration, care for residents with dementia, infection control, and safe management techniques during training year 2024. |
| Direct care staff did not receive training in fire safety completed by a fire safety expert or equivalent during training year 2024. |
| Fans were not made available to residents when indoor temperature exceeded 80°F due to malfunctioning air conditioning. |
| Multiple open ceiling tiles and holes with water leaks were observed in various areas of the facility. |
| Insufficient hot and cold water pressure was noted in the bathroom shower and kitchen sink in room 318. |
| A torn window screen was observed in the Terrace Level Dining Room. |
| Expired medication (Latanoprost Ophthalmic eye drops) was found in the medication cart beyond the discard date. |
| Medication administration records for multiple residents lacked initials of staff who administered medications on various dates. |
| Direct care staff working in the Secure Dementia Care Unit had zero hours of required dementia care training during the 2024 training year. |
Report Facts
License Capacity: 124
Residents Served: 48
Secured Dementia Care Unit Capacity: 30
Residents Served in Dementia Unit: 15
Current Hospice Residents: 5
Staff Total Daily: 65
Waking Staff: 49
Indoor Temperature: 82
Indoor Temperature: 80.2
Expired Medication Date: Feb 26, 2025
Training Hours: 4.65
Training Hours: 2.9
Inspection Report
Follow-Up
Census: 49
Capacity: 124
Deficiencies: 14
Mar 20, 2025
Visit Reason
The inspection was a complaint investigation conducted on March 20, 2025, with a follow-up review on May 8 and June 9, 2025, to verify the implementation of the plan of correction from the March 20, 2025 inspection.
Findings
The facility was found to have multiple deficiencies including incomplete criminal background checks, inadequate fire safety orientation, insufficient annual staff training, unsecured poisonous materials accessible to residents, inoperable bathroom ventilation, missing emergency telephone numbers, furniture and equipment hazards, lack of operable bedside lamps, missing soap dispensers, improper medication storage, unavailable prescribed medications, and insufficient dementia care training for staff. The submitted plan of correction was not fully implemented as of the follow-up dates.
Complaint Details
The inspection was complaint-related, triggered by a complaint with an exit conference on 03/20/2025. The follow-up review found that the plan of correction from the March 20, 2025 inspection was not implemented as required.
Deficiencies (14)
| Description |
|---|
| Staff person A did not have a background check requested until after hire. |
| Staff person A did not receive required fire safety orientation on first day of work. |
| Direct care staff persons B and C received 0 hours of annual training in 2024. |
| Direct care staff persons B, C, and D did not receive required annual training topics including medication self-administration and infection control. |
| Staff persons B, C, and D did not receive required annual training in fire safety, emergency preparedness, resident rights, and other topics. |
| Poisonous materials were unlocked and accessible to residents in multiple rooms; not all residents assessed capable of safe use. |
| Bathrooms in rooms 305, 308, and 314 lacked operable windows or ventilation fans. |
| Emergency telephone numbers were missing on or by telephones in rooms 314 and 325. |
| Ceiling light in shower of bathroom in room 314 continuously flickers. |
| Residents 3 and 4 did not have access to operable bedside lamps. |
| No soap dispenser within reach of bathroom sinks in rooms 305, 306, 308, and 318. |
| Five loose pills were observed in the medication cart. |
| PRN medications prescribed to resident 5 were not available in the home. |
| Direct care staff persons B and C working in the Secure Dementia Care Unit had 0 hours of dementia care training during 2024. |
Report Facts
License Capacity: 124
Residents Served: 49
Secured Dementia Care Unit Capacity: 30
Secured Dementia Care Unit Residents Served: 18
Hospice Residents: 6
Staffing Hours: 68
Waking Staff: 51
Mobility Need Residents: 19
Loose Pills: 5
Inspection Report
Complaint Investigation
Census: 55
Capacity: 124
Deficiencies: 68
Sep 17, 2024
Visit Reason
The inspection was conducted as a complaint investigation to assess compliance with regulations following allegations and concerns raised about the facility.
Findings
Multiple deficiencies were identified including lack of staff certifications, incomplete resident contracts, inadequate staff training, medication management issues, environmental hazards, and failure to maintain proper documentation and resident care standards.
Complaint Details
The complaint investigation was triggered by concerns including inadequate staff training, medication management errors, environmental hazards, and failure to maintain proper resident documentation and care standards. The investigation identified multiple repeat violations and ongoing deficiencies.
Deficiencies (68)
| Description |
|---|
| No staff present in the kitchen were ServSafe certified during specified hours. |
| Resident-home contracts for residents #2 and #3 were not signed by the residents. |
| Resident #2 and #3's records did not contain signed statements acknowledging receipt of resident rights and complaint procedures. |
| Insufficient staff certified in first aid, obstructed airway techniques, and CPR during specified times. |
| Staff person A did not receive required fire safety orientation on first day of work. |
| Staff person A did not complete mandatory orientation training within 40 scheduled work hours including resident rights and abuse reporting. |
| Direct care staff person D did not receive required annual training in medication administration, dementia care, infection control, and other topics during 2023. |
| Leak and water damage in 'Paoli Local' room and main dining room requiring repair. |
| Urinal in public men's room covered with plastic and dishwasher inoperable since 09/01/24. |
| First aid kit in memory care nurse's station missing thermometer, breathing shield, and eye coverings. |
| Resident in room #213 lacks operable bedside lamp or lighting. |
| No thermometer in ice cream freezer in main kitchen. |
| Dishwasher broken since 09/01/24; disposable plates and utensils used regularly. |
| Written emergency procedures not submitted to local emergency management agency since 06/07/23. |
| Fire extinguisher in facility bus not inspected since 08/2022. |
| Fire drill records missing exit route used and number of residents evacuated for multiple drills. |
| Fire drill during sleeping hours not conducted within required 6 month interval. |
| Resident #3's initial medical evaluation not completed within required timeframe. |
| Resident #4's initial medical evaluation missing body positioning and movement stimulation assessment. |
| Resident #2 and #5's most recent medical evaluations not completed timely or missing. |
| Expired or discontinued medications not removed timely from medication storage. |
| Medication storage not compliant with sanitation, temperature, moisture, and light requirements; loose pills found. |
| Prescription medications not properly labeled with pharmacy labels including resident name and instructions. |
| Medication administration records missing required documentation including diagnosis, administration times, and staff initials. |
| Medications not administered according to prescriber's orders including insulin dosing errors. |
| Residents #2 and #3 not educated on right to refuse medication if medication error suspected. |
| Resident #2's preadmission screening form completed after admission date. |
| Resident #2 and #5's assessments not completed annually or as required. |
| Resident #4's initial support plan for Secure Dementia Care Unit not completed within required timeframe. |
| Resident #6 not assessed annually for continuing need for Secure Dementia Care Unit. |
| Resident #6's support plan missing documentation of bed rails use including need, risks, and safety. |
| Resident #4's cognitive preadmission screening for Secure Dementia Care Unit not completed within 72 hours prior to admission. |
| Resident #1 and #2's records missing required personal information including religion and eye color. |
| Resident #2's support plan not signed by resident. |
| Resident #8's medication cart contained medications for deceased resident. |
| Resident #8's prescribed Albuterol Sulfate as needed was not available in the home. |
| Resident #8's Cephalexin medication count discrepancy; one tablet missing. |
| Resident #10 and #11's glucometers not calibrated to correct date and time; glucometer readings inaccurately documented. |
| Portable space heater found in use in resident room 15. |
| Resident #1's record missing photograph no more than 2 years old. |
| Resident #8's medication administration record missing diagnosis or purpose for medications. |
| Resident #10's medication administration record missing diagnosis or purpose for medications. |
| Resident #8's medication administration record missing staff initials for administration of multiple medications. |
| Resident #12's medication administration record missing staff initials for administration of Acetaminophen on multiple dates. |
| Resident #10 administered insulin doses inconsistent with sliding scale orders. |
| Resident #12 administered Acetaminophen twice daily instead of prescribed three times daily. |
| Resident #6 does not have operable bedside lamp or lighting. |
| Resident #4's bed linens stained with dried urine; resident #5's bed lacks bed sheets. |
| Resident #2's bedside mobility device not securely attached to bed. |
| Poisonous materials accessible to residents in bathroom cabinet in room 310. |
| Strong odor of urine in room 202. |
| Trash cans in bathrooms of rooms 202 and 213 uncovered and filled with used incontinence products. |
| Bathrooms in multiple rooms lack operable windows or ventilation fans; vents covered with lint and inoperable. |
| Ceiling tiles in stairwell A/3 water stained. |
| Garbage disposal in main kitchen inoperable over a month; bathroom cabinet door broken in room 310. |
| First aid kit in Terrace Level medication room missing breathing shield. |
| Resident rooms 217, 308, and 309 lack bathroom doors to provide privacy. |
| Designated acting administrator unfamiliar with emergency preparedness plan; emergency procedures not activated. |
| Written emergency procedures submitted to county emergency management agency for 2024 were illegible and not approved. |
| No smoke detector within 15 feet of resident room 213. |
| Medication cart contained medications for deceased resident #7. |
| Medication carts contained loose pills and damaged bubble packs. |
| Pill organizer in medication cart lacked resident name and pharmacy label. |
| Resident 10's glucometer not calibrated; glucometer readings inaccurately documented in MAR. |
| Resident 11's medication administration record missing initials of administering staff for multiple medications. |
| Resident 6's preadmission screening form missing determination that home can meet resident's needs. |
| Resident 2 participated in support plan development but did not sign the support plan. |
| Resident 1's record missing photograph no more than 2 years old. |
Report Facts
License Capacity: 124
Residents Served: 55
Secured Dementia Care Unit Capacity: 30
Residents Served in Secured Dementia Care Unit: 21
Total Daily Staff: 79
Waking Staff: 59
Staff Certified in First Aid/CPR: 1
Number of Residents with Mobility Need: 24
Number of Residents 60 Years or Older: 55
Number of Residents Diagnosed with Mental Illness: 1
Number of Residents Diagnosed with Intellectual Disability: 1
Inspection Report
Complaint Investigation
Census: 54
Capacity: 124
Deficiencies: 46
Sep 17, 2024
Visit Reason
The inspection was conducted due to a combination of renewal, complaint, and incident reasons as indicated in the inspection summary.
Findings
Multiple deficiencies were identified including lack of ServSafe certified kitchen staff, unsigned resident contracts, missing signed statements of resident rights, insufficient first aid/CPR trained staff, inadequate fire safety orientation, incomplete staff training on resident rights and abuse reporting, medication administration and storage issues, environmental hazards such as leaks and inoperable equipment, and deficiencies in resident records and support plans.
Complaint Details
The inspection was complaint-related as indicated by the inspection reason and the presence of multiple cited violations related to resident care, safety, and facility conditions.
Deficiencies (46)
| Description |
|---|
| No staff present in the kitchen were ServSafe certified during specified hours. |
| Resident-home contracts for residents #2 and #3 were not signed by the residents. |
| Resident #2 and #3's records did not contain signed statements acknowledging receipt of resident rights and complaint procedures. |
| Insufficient staff certified in first aid, obstructed airway techniques and CPR during specified times. |
| Staff person A did not receive required fire safety orientation on first day of work. |
| Staff person D did not receive required annual training in medication administration, resident needs, infection control, and safe management techniques during 2023. |
| Leak and water damage above 'Paoli Local' room and main dining room with disrepair and need for painting. |
| Urinal in public men's room covered with plastic and dishwasher inoperable since 09/01/24. |
| First aid kit in memory care nurse's station missing thermometer, breathing shield, and eye coverings. |
| Resident in room #213 lacks operable bedside lamp or lighting source. |
| No thermometer in ice cream freezer in main kitchen. |
| Dishwasher broken since 09/01/24; disposable plates, bowls, and cups used regularly. |
| Written emergency procedures not submitted to local emergency management agency since 06/07/23. |
| Fire extinguisher on home's bus not inspected since 08/2022. |
| Fire drill records missing exit route used and number of residents evacuated for drills on 08/20/24, 07/19/24, and 06/13/24. |
| Fire drill during sleeping hours not conducted within required 6 month interval. |
| Resident #3's initial medical evaluation not completed within required timeframe. |
| Resident #4's initial medical evaluation missing body positioning and movement stimulation assessment. |
| Resident #2 and #5's most recent medical evaluations and assessments not completed timely or missing. |
| Prescription medication for deceased resident #7 found in medication refrigerator; medication for resident #8 on med cart not on current order summary. |
| Lorazepam Intensol prescribed to resident #9 not stored at required temperature; two insulin pens for resident #10 open and undated. |
| Resident #4's Clonazepam medication label inconsistent with prescriber's order; resident #8's Lorazepam label inconsistent with MAR; insulin pens for resident #10 missing pharmacy labels. |
| Resident #8's Albuterol Sulfate medication not available in the home. |
| Medication count discrepancy for resident #8; one tablet missing. |
| Resident #10 and #11's glucometers not calibrated to correct date and time. |
| Medication administration records missing required information including diagnosis or purpose, date/time of administration, and administering staff initials for multiple residents and medications. |
| Resident #10 not administered insulin as prescribed on sliding scale on multiple occasions; resident #12 administered acetaminophen twice daily instead of prescribed three times daily. |
| Resident #2 participated in support plan development but did not sign the support plan. |
| Resident #1's record missing photograph no more than 2 years old; resident #2's record missing eye color. |
| Resident #2's bedside mobility device not securely attached to bed. |
| Poisonous materials accessible to residents in bathroom cabinet in room 310. |
| Strong odor of urine in room 202; uncovered trash cans with used incontinence products in bathrooms of rooms 202 and 213. |
| Bathrooms in multiple rooms lack operable windows or ventilation fans; vents covered with lint and inoperable. |
| Ceiling tiles water stained in stairwell A/3. |
| Garbage disposal in main kitchen inoperable over a month; bathroom cabinet door broken in room 310. |
| First aid kit in Terrace Level medication room missing breathing shield. |
| Bedsheets stained with dried urine on resident 4's bed; resident 5's bed missing sheets. |
| Portable space heater in use in room 15. |
| Resident #1 and #3 not educated on right to refuse medication if medication error suspected. |
| Resident #2's preadmission screening form completed after admission date. |
| Resident #2 not assessed annually for continuing need for secured dementia care unit. |
| Resident #4 admitted to secured dementia care unit with cognitive preadmission screening completed after admission. |
| Resident #4 admitted to secured dementia care unit with initial support plan completed after admission. |
| Resident rooms 217, 308, and 309 lack bathroom doors to provide privacy. |
| Designated acting administrator not familiar with emergency preparedness plan; emergency procedures not activated. |
| Smoke detector missing within 15 feet of resident room 213. |
Report Facts
License Capacity: 124
Residents Served: 54
Secured Dementia Care Unit Capacity: 30
Residents Served in Secured Dementia Care Unit: 21
Staffing Hours: 101
Waking Staff: 76
Number of Residents Who Are 60 Years or Older: 53
Number of Residents Diagnosed with Mental Illness: 5
Number of Residents with Mobility Need: 47
Number of Residents with Physical Disability: 2
Inspection Dates: Array
Number of Violations with Fine Potential: 5
Fine Amount Per Day: 275
Inspection Report
Complaint Investigation
Census: 54
Capacity: 124
Deficiencies: 44
Sep 17, 2024
Visit Reason
The inspection was conducted as a complaint investigation with additional renewal and incident review components.
Findings
Multiple deficiencies were identified including lack of ServSafe certified kitchen staff, unsigned resident contracts, incomplete resident medical evaluations, medication administration errors, inadequate staff training, environmental hazards such as inoperable heating and ventilation, and privacy violations due to unauthorized cameras.
Complaint Details
The inspection was complaint-related with substantiated violations including inadequate staff training, medication errors, environmental hazards, and resident rights violations.
Deficiencies (44)
| Description |
|---|
| No staff present in the kitchen were ServSafe certified during specified hours. |
| Resident-home contracts for residents #2 and #3 were not signed by the residents. |
| Resident #2 and #3's records did not contain signed statements acknowledging receipt of resident rights and complaint procedures. |
| Insufficient staff certified in first aid, obstructed airway techniques, and CPR during specified times. |
| Staff person A did not receive required fire safety and emergency preparedness orientation on first day. |
| Direct care staff person D did not receive required annual training in multiple topics during 2023. |
| Leak and water damage in dining and adjacent rooms with disrepair and need for painting. |
| Urinal in public men's room covered with plastic and dishwasher inoperable since 09/01/24. |
| First aid kit in memory care nurse's station missing thermometer, breathing shield, and eye coverings. |
| Resident in room #213 lacks operable bedside lamp or lighting source. |
| No thermometer in ice cream freezer in main kitchen. |
| Home using disposable plates, bowls, and cups on a regular basis due to dishwasher breakdown. |
| Written emergency procedures not submitted to local emergency management agency since 06/07/23. |
| Fire extinguisher on home's bus not inspected since 08/2022. |
| Fire drill records missing exit route used and number of residents evacuated for multiple drills. |
| Fire drill during sleeping hours not conducted within required 6-month interval. |
| Resident #3's initial medical evaluation not completed within required timeframe. |
| Resident #4's initial medical evaluation missing body positioning and movement stimulation assessment. |
| Resident #2 and #5's most recent medical evaluations not completed timely or missing. |
| Medications for deceased resident #7 not removed; medication on med cart not on current order summary. |
| Temperature-sensitive medication not stored at proper temperature; open undated insulin pens found. |
| Medication labeling discrepancies including missing pharmacy labels on insulin pens. |
| Medication prescribed as needed not available in the home. |
| Medication count discrepancy for resident #8; missing tablet. |
| Glucometers for residents #10 and #11 not calibrated to correct date and time; glucometer readings inaccurately documented. |
| Resident #2's bedside mobility device not securely attached to bed. |
| Poisonous materials accessible to residents in bathroom cabinet. |
| Strong odor of urine and uncovered trash receptacles with used incontinence products in resident bathrooms. |
| Bathrooms without operable windows or ventilation fans; vents covered with lint and inoperable. |
| Water-stained ceiling tiles in stairwell A/3. |
| Bed linens stained with dried urine and missing bed sheets for residents. |
| Resident #6 lacks operable bedside lamp or lighting source. |
| Ceiling cracked in bedroom of room 211. |
| Resident rooms 217, 308, and 309 lack bathroom doors for privacy. |
| Resident #4 admitted to Secure Dementia Care Unit without timely cognitive preadmission screening. |
| Resident #2 not assessed annually for continuing need for secured dementia care unit. |
| Resident #4 admitted to Secure Dementia Care Unit without timely initial support plan. |
| Resident #2 participated in support plan development but did not sign the plan. |
| Resident #1's record missing photograph no more than 2 years old; Resident #2's record missing eye color. |
| Resident #1 and #3 not educated on right to refuse medication if medication error suspected. |
| Resident #2's preadmission screening form missing determination that home can meet resident's needs. |
| Resident #2's most recent assessment not completed timely; multiple assessments for resident #5 inconsistent. |
| Resident #1 requires assistance with ADLs per support plan but did not receive timely assistance with toileting and ambulating. |
| Direct care staff person C lacks required educational qualifications. |
Report Facts
License Capacity: 124
Residents Served: 54
Secured Dementia Care Unit Capacity: 30
Residents Served in Secured Dementia Care Unit: 21
Staffing Hours: 101
Waking Staff: 76
Number of Residents with Mobility Need: 47
Number of Residents 60 Years or Older: 53
Number of Residents Diagnosed with Mental Illness: 5
Number of Residents Diagnosed with Intellectual Disability: 0
Number of Residents with Physical Disability: 2
Number of Residents Receiving Hospice: 5
Number of Residents Receiving Supplemental Security Income: 0
Inspection Report
Complaint Investigation
Census: 47
Capacity: 124
Deficiencies: 19
Jul 2, 2024
Visit Reason
The inspection was conducted as a complaint investigation with unannounced partial inspections on 07/02/2024, 07/10/2024, and 07/11/2024 to review compliance and the submitted plan of correction.
Findings
The facility was found to have multiple deficiencies including failure to report suspected resident abuse, unqualified direct care staff, incomplete staff orientation and training, unlocked poisonous materials accessible to residents, unsanitary conditions, maintenance issues such as water damage and leaks, failure to follow prescriber's orders, and missing documentation for support plans and key-locking device instructions. The submitted plan of correction was accepted and fully implemented by 09/12/2024.
Complaint Details
The inspection was complaint-driven as indicated by the reason 'Complaint' and the unannounced partial inspection dates. The report documents multiple violations related to resident abuse reporting, staff qualifications, training deficiencies, safety hazards, and care plan documentation.
Deficiencies (19)
| Description |
|---|
| Failure to immediately report suspected resident abuse to the local area agency on aging. |
| Direct care staff person did not have a high school diploma, GED, or active registry status on the Pennsylvania nurse aide registry. |
| Direct care staff persons did not receive required orientation on fire safety and emergency preparedness topics on their first day. |
| Direct care staff person did not complete required training within 40 scheduled work hours including resident rights and mandatory reporting of abuse. |
| Direct care staff person provided unsupervised ADL services without completing required training and competency testing. |
| Direct care staff person did not receive at least 12 hours of annual training relating to job duties in 2023. |
| Direct care staff person did not receive training in medication self-administration, care for residents with dementia, infection control, and other required topics during 2023 training year. |
| Direct care staff person did not receive training in fire safety, emergency preparedness, resident rights, and other required annual topics during 2023 training year. |
| Poisonous materials were unlocked and accessible to residents in memory care areas despite not all residents being assessed as capable of safe use. |
| Unsanitary conditions observed including strong smell of feces and urine in resident rooms and hallways, and lack of hand drying methods. |
| Multiple ceiling tiles missing with water damage and active leaks throughout the building. |
| Cooling system malfunction causing leaks and damage to building infrastructure. |
| Resident lacked access to a closet or wardrobe with clothing racks or shelves in bedroom. |
| Egress routes blocked by patio chairs in private dining room. |
| Menus not posted one week in advance as required. |
| Failure to properly document and follow orders for resident compression sock application and removal. |
| Support plans for residents lacked required signatures from accessors. |
| Directions for operating key-locking devices not conspicuously posted near stairwell doors in Secure Dementia Care Unit. |
| Direct care staff working in Secure Dementia Care Unit lacked required dementia care training hours. |
Report Facts
License Capacity: 124
Residents Served: 47
Secured Dementia Care Unit Capacity: 30
Secured Dementia Care Unit Residents Served: 17
Current Hospice Residents: 5
Direct Care Staff Total Daily: 89
Waking Staff: 67
Deficiency Repeat Violation Dates: 3
Audit Frequency: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff person B | Named in multiple findings related to lack of qualifications, incomplete orientation and training, failure to follow prescriber's orders, and documentation issues | |
| Staff person C | Named in finding related to incomplete fire safety orientation; no longer employed | |
| Staff person D | Named in findings related to lack of annual training and dementia care training | |
| Staff person E | Named in finding related to inadequate handwashing practices | |
| Staff member F | Maintenance Director | Named in findings related to building leaks, ceiling tile damage, and cooling system failure |
| Staff member G | Named in findings related to improper medication administration and failure to follow prescriber's orders for compression socks |
Inspection Report
Complaint Investigation
Census: 48
Capacity: 124
Deficiencies: 0
Apr 18, 2024
Visit Reason
The inspection was conducted as a complaint and incident investigation during an unannounced partial inspection on 04/18/2024.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Complaint Details
The inspection was complaint-related and incident-related; no deficiencies were found and follow-up was not required.
Report Facts
License Capacity: 124
Residents Served: 48
Secured Dementia Care Unit Capacity: 30
Secured Dementia Care Unit Residents Served: 16
Hospice Residents: 8
Resident Support Staff: 0
Total Daily Staff: 74
Waking Staff: 56
Residents Age 60 or Older: 48
Residents Diagnosed with Mental Illness: 4
Residents with Mobility Need: 26
Residents with Physical Disability: 1
Inspection Report
Complaint Investigation
Census: 50
Capacity: 124
Deficiencies: 15
Feb 26, 2024
Visit Reason
The inspection was a partial, unannounced complaint and incident investigation conducted on 02/26/2024 to review allegations and compliance with care standards at the facility.
Findings
Multiple deficiencies were identified including abuse due to inadequate staff assistance, insufficient waking hours of care, unsanitary bathroom conditions, missing or broken equipment, incomplete medical evaluations, lack of posted menus, failure to implement positive interventions for resident behaviors, improper use of restraints, incomplete resident assessments and support plans, and missing incident reports in resident records.
Complaint Details
The inspection was complaint-related, triggered by allegations of abuse, neglect, and inadequate care. The complaint was substantiated based on findings of resident injury due to insufficient staff assistance and other care deficiencies.
Deficiencies (15)
| Description |
|---|
| Resident fell and hit head due to only one staff member assisting when two-person assist was required. |
| Only 68 and 63 of the required 72 direct care hours were provided during waking hours on two occasions. |
| Sticky substance resembling urine and yellow/brown feces stains found on bathroom floors in resident rooms. |
| Missing floor tiles at bathroom entry for a resident's room. |
| Broken lamp cover in a resident's bedroom. |
| Resident did not have access to an operable lamp or source of lighting at bedside. |
| Resident medical evaluations lacked medication lists and emergency pertinent medical information. |
| Menus for current and upcoming week were not posted in a conspicuous place in the memory care unit. |
| Resident exhibited hitting and biting behaviors without implementation of positive interventions. |
| Resident was restrained manually causing bruising; no resolution taken to stop this practice. |
| Resident support plan did not document need for two-person assistance despite significant change in condition. |
| Resident support plan did not specify dietary needs as indicated in medical evaluation. |
| Resident support plan did not document how various assessed needs will be met, including behaviors and ADLs. |
| Resident medical evaluation did not specify behaviors exhibited by resident admitted to secured dementia care unit. |
| Resident records lacked incident reports and face sheets with required demographic and medical information. |
Report Facts
License Capacity: 124
Residents Served: 50
Secured Dementia Care Unit Capacity: 30
Residents Served in Dementia Unit: 16
Hospice Residents: 4
Waking Staff Hours Required: 72
Waking Staff Hours Provided: 68
Waking Staff Hours Provided: 63
Inspection Report
Complaint Investigation
Census: 46
Capacity: 124
Deficiencies: 10
Nov 27, 2023
Visit Reason
The inspection was conducted as a complaint and incident investigation with an unannounced partial inspection on 11/27/2023.
Findings
The facility was found to have multiple deficiencies including failure to report medication errors and financial exploitation incidents, inadequate staff orientation and training, failure to maintain a current staff contact list, unsanitary conditions, and failure to follow prescriber's medication orders. Plans of correction were accepted and implemented by early 2024.
Complaint Details
The inspection was complaint-driven, investigating incidents including medication errors, financial exploitation by staff, rough handling of residents, and failure to maintain proper staff records and training. The complaint was substantiated with multiple deficiencies identified.
Deficiencies (10)
| Description |
|---|
| Failure to report a medication error to the Department within 24 hours. |
| Failure to complete, document, or keep a record of an internal investigation of financial exploitation and failure to submit it to the Department. |
| Failure to inform other residents or their designated persons about financial exploitation incidents. |
| Resident was financially exploited by a staff member; missing checks and forged signature noted. |
| Rough handling of a resident in the Secure Dementia Care Unit by agency staff. |
| Failure to maintain a current list of all staff including agency staff. |
| New staff member did not receive required orientation on fire safety and emergency preparedness topics. |
| New staff member did not complete required orientation training within 40 scheduled working hours on resident rights, emergency medical plan, and mandatory reporting of abuse and neglect. |
| Sanitary conditions not maintained; pungent urine odor detected on fabric chairs in the Terrace area. |
| Failure to administer prescribed medications due to omission and unavailability. |
Report Facts
License Capacity: 124
Residents Served: 46
Secured Dementia Care Unit Capacity: 30
Residents Served in Dementia Unit: 16
Hospice Residents: 7
Resident Mobility Need: 36
Total Daily Staff: 82
Waking Staff: 62
Inspection Report
Complaint Investigation
Census: 79
Capacity: 124
Deficiencies: 0
Mar 8, 2023
Visit Reason
The inspection was conducted as a complaint investigation with a partial, unannounced visit on 03/08/2023.
Findings
No regulatory citations or deficiencies were identified during this inspection.
Complaint Details
The inspection was complaint-related, but no deficiencies were found and the follow-up type was noted as not required.
Report Facts
Resident Support Staff: 107
Waking Staff: 80
Residents Served: 79
License Capacity: 124
Secured Dementia Care Unit Capacity: 30
Secured Dementia Care Unit Residents Served: 22
Residents Age 60 or Older: 79
Residents Diagnosed with Intellectual Disability: 1
Residents with Mobility Need: 28
Inspection Report
Complaint Investigation
Census: 79
Capacity: 124
Deficiencies: 1
Feb 9, 2023
Visit Reason
The inspection was conducted as a complaint investigation to review compliance and verify the submitted plan of correction.
Findings
The submitted plan of correction was determined to be fully implemented. The main deficiency involved a resident's annual medical evaluation not being completed within the required 12 months, which has since been addressed with audits and staff in-service training.
Complaint Details
The visit was complaint-related, and the submitted plan of correction was accepted and fully implemented as of 02/27/2023.
Deficiencies (1)
| Description |
|---|
| Resident 1's most recent medical evaluation was not completed within the required 12 months. |
Report Facts
Residents Served: 79
License Capacity: 124
Memory Care Unit Capacity: 30
Memory Care Unit Residents Served: 22
Hospice Current Residents: 6
Residents Age 60 or Older: 79
Residents Diagnosed with Intellectual Disability: 1
Residents with Mobility Need: 6
Inspection Report
Follow-Up
Census: 64
Capacity: 124
Deficiencies: 5
Nov 16, 2022
Visit Reason
The inspection was a partial, unannounced follow-up visit triggered by an incident to review the submitted plan of correction related to previous deficiencies.
Findings
The facility was found to have fully implemented the submitted plan of correction addressing abuse, additional staffing, positive interventions, additional assessments, and support plan needs. Continued compliance must be maintained.
Deficiencies (5)
| Description |
|---|
| A resident was forcefully pushed to the floor by another resident resulting in a bleeding head wound; the home failed to ensure safety on the memory support unit. |
| Inadequate staffing on the memory support unit allowed an assault to occur; staff person B was left alone caring for 27 residents. |
| Failure to use positive interventions to modify or eliminate behavior that endangers residents, resulting in a resident being pushed and injured. |
| Resident #1's assessment did not address significant changes in agitation, falls, intrusive behaviors, and mobility concerns. |
| Resident #1's support plan did not address agitation for behavioral concerns and frequent falls with mobility concerns. |
Report Facts
License Capacity: 124
Residents Served: 64
Memory Support Unit Capacity: 30
Memory Support Unit Residents Served: 27
Current Hospice Residents: 4
Residents with Mobility Need: 33
Total Daily Staff: 97
Waking Staff: 73
Inspection Report
Renewal
Census: 56
Capacity: 124
Deficiencies: 17
Mar 15, 2022
Visit Reason
The inspection was conducted as a renewal and incident review of the facility Highgate at Paoli Pointe on 03/15/2022 through 03/17/2022.
Findings
Multiple deficiencies were identified including failure to post current license inspection summary, delayed refunds after resident deaths, unqualified direct care staff, incomplete staff training, unsafe storage of trash and combustible materials, improper food storage temperatures, medication administration errors, incomplete resident records, and obstructed egress routes. Plans of correction were accepted and implemented with ongoing audits scheduled.
Deficiencies (17)
| Description |
|---|
| The home's current license inspection summary and copy of the 2600 regulation book were not posted in a conspicuous and public place. |
| Refunds for residents who passed away were issued late, beyond the required 30 days after removal of personal belongings. |
| Direct care staff persons A and B did not have a high school diploma, GED, or active registry status on the Pennsylvania nurse aide registry. |
| Staff persons A, B, C, D, E, and F did not complete required training within 40 scheduled work hours on resident rights, emergency medical plan, mandatory reporting of abuse and neglect, and reporting of reportable incidents. |
| Direct care staff persons B and F began providing unsupervised ADL services without completing required training including demonstration of job duties, supervised practice, and passing the competency test. |
| Broken chair was found outside the trash dumpster, violating trash storage requirements. |
| No toilet paper was provided for the toilet in a bathroom. |
| Temperature in the ice cream freezer was 18 degrees Fahrenheit, above the required 0°F for frozen food. |
| A dented can of Marinara Sauce was found in the main kitchen food storage for daily use. |
| Two chairs were blocking the egress from the home's exit on the Terrace Unit. |
| Highly flammable plastic pipe primer and pipe cement were stored inside the boiler room approximately 10 feet from boilers. |
| Medication carts contained loose pills in drawers and an override error was found on resident 6's MAR record. |
| Resident 7's medication administration record showed a count discrepancy for Lorazepam 0.5 mg. |
| Resident 6's glucometer reading did not match the documented medication administration record. |
| Resident 8 was administered 9 units of Novolog Flex Pen insulin instead of 6 units as per sliding scale order. |
| Resident 8's preadmission screening form was missing the date when the screening was completed. |
| Resident 6's record was missing multiple demographic and identifying information; Residents 9 and 10's records lacked incident reports. |
Report Facts
License Capacity: 124
Residents Served: 56
Memory Care Unit Capacity: 30
Memory Care Residents Served: 25
Hospice Residents: 4
Staff: 89
Waking Staff: 67
Loose Pills: 3
Dented Can Weight: 6.56
Temperature: 18
Medication Count Discrepancy: 1
Insulin Units Administered: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mia Johnson | Executive Director | Named in multiple findings related to education, audits, and plan of correction implementation. |
| Business Office Manager | Named in relation to education on refunds, medication storage, and medication administration. | |
| Human Resources Manager | Named in relation to education on staff qualifications, training, and medication administration. | |
| Maintenance Director | Named in relation to education on trash storage, combustible materials, and unobstructed egress. | |
| Environmental Services Director | Named in relation to education on trash storage and toilet paper provision. | |
| Dining Services Account Manager | Named in relation to education on food storage temperatures and dented cans. | |
| Sales and Marketing Director | Named in relation to education on required demographic information in resident records. |
Inspection Report
Complaint Investigation
Census: 55
Capacity: 124
Deficiencies: 1
Feb 2, 2022
Visit Reason
The inspection was conducted as a complaint and incident investigation with unannounced partial on-site and off-site reviews between 02/02/2022 and 02/10/2022.
Findings
The facility was found to have a deficiency related to the failure to complete a required written cognitive preadmission screening for a resident admitted to the Secure Dementia Care Unit within the regulatory timeframe. The submitted plan of correction was fully implemented and compliance was maintained.
Complaint Details
The visit was complaint-related and incident-driven. The deficiency involved failure to complete required preadmission screening documentation. The plan of correction was accepted and implemented with follow-up dates scheduled.
Deficiencies (1)
| Description |
|---|
| Resident 1 was admitted to the Secure Dementia Care Unit without a completed written cognitive preadmission screening within 72 hours prior to admission as required. |
Report Facts
License Capacity: 124
Residents Served: 55
Memory Care Unit Capacity: 30
Residents Served in Memory Care Unit: 23
Hospice Residents: 6
Residents Age 60 or Older: 55
Residents with Intellectual Disability: 2
Residents with Mobility Need: 32
Total Daily Staff: 87
Waking Staff: 65
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mia Johnson | Signed letter regarding plan of correction implementation | |
| Memory Support Director | Named in plan of correction for re-education and completion of preadmission screening | |
| Executive Director | Re-educated Memory Support Director on admission criteria and regulatory timeframes |
Inspection Report
Routine
Deficiencies: 0
Jan 19, 2022
Visit Reason
The inspection was conducted as a licensing inspection by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing.
Findings
No regulatory citations were identified as a result of this inspection.
Inspection Report
Census: 53
Capacity: 124
Deficiencies: 0
Jan 5, 2022
Visit Reason
The inspection was a partial, unannounced licensing inspection conducted due to an incident.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Residents Served: 53
License Capacity: 124
Memory Care Capacity: 28
Memory Care Residents Served: 25
Total Daily Staff: 86
Waking Staff: 65
Residents Age 60 or Older: 53
Residents with Intellectual Disability: 2
Residents with Mobility Need: 33
Inspection Report
Renewal
Census: 48
Capacity: 124
Deficiencies: 12
Feb 24, 2021
Visit Reason
The inspection was a renewal visit to assess compliance with licensing requirements and regulations at the facility.
Findings
The inspection identified multiple deficiencies including missing carbon monoxide alarms, unsigned resident contracts, lack of privacy due to missing bathroom doors, incomplete criminal background checks for staff and contractors, sanitation issues, medication administration errors, incomplete resident education on medication refusal rights, and unsecured resident records. Plans of correction were accepted and implemented for all deficiencies.
Deficiencies (12)
| Description |
|---|
| Carbon monoxide alarms were not installed as required near fossil-fuel burning devices. |
| Resident #1's contract was not signed by the resident. |
| Resident #1's record lacked a signed statement acknowledging receipt of resident rights and complaint procedures. |
| Resident #1's bathroom lacked a door to provide privacy; a curtain was installed instead. |
| Staff person A did not have a valid criminal background check; contractors were onsite without background checks. |
| Sanitary conditions were compromised: clogged sink and improper handling of medication during observation. |
| Lint accumulation in lint traps of dryers in memory care and commercial laundry rooms. |
| Medication administration errors for resident #2 including mismatched glucometer readings and missed insulin dose. |
| Resident #1 was not educated on the right to refuse medication if a medication error is suspected. |
| Resident #2's preadmission screening form was completed late. |
| Resident #3's cognitive preadmission screening was completed after admission to the secured dementia care unit. |
| Records for multiple residents were unlocked, unattended, and accessible in the rehabilitation room. |
Report Facts
License Capacity: 124
Residents Served: 48
Secured Dementia Care Unit Capacity: 30
Residents Served in SCDU: 19
Current Hospice Residents: 6
Residents with Mobility Need: 29
Total Daily Staff: 77
Waking Staff: 58
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