Inspection Reports for Impressions Memory Care at Bryn Mawr Village
PA, 19010
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Inspection Report
Monitoring
Census: 10
Capacity: 25
Deficiencies: 8
Jul 2, 2025
Visit Reason
The visit was an unannounced partial inspection conducted for monitoring purposes to review compliance with licensing requirements and the submitted plan of correction.
Findings
The inspection found multiple deficiencies including untimely criminal background checks, incomplete emergency preparedness training, broken mirror hazards, medication management issues, missing support plan signatures, and late cognitive preadmission screenings. Plans of correction were accepted and implemented by 08/29/2025 with ongoing audits scheduled to ensure compliance.
Deficiencies (8)
| Description |
|---|
| Staff person A's criminal background check was not processed timely. |
| Staff person B did not receive emergency preparedness training during the training year. |
| Broken mirror on medicine cabinet in resident room posed a hazard. |
| Medication found in the medication cart without a current order. |
| Medications prescribed as needed were not available in the home at the required times. |
| Medication was not administered as prescribed due to unavailability. |
| Family member who participated in support plan development did not sign the support plan. |
| Cognitive preadmission screenings were completed late for residents admitted to the Secure Dementia Care Unit. |
Report Facts
License Capacity: 25
Residents Served: 10
Current Hospice Residents: 2
Residents Age 60 or Older: 10
Residents with Mobility Need: 10
Total Daily Staff: 20
Waking Staff: 15
Inspection Report
Follow-Up
Census: 10
Capacity: 25
Deficiencies: 21
Mar 17, 2025
Visit Reason
The inspection was an unannounced partial review conducted due to an incident at the facility, with follow-up on previously submitted plans of correction.
Findings
The facility was found to have multiple deficiencies including incomplete staff lists, lack of first aid/CPR trained staff during shifts, missing contract signatures, incomplete criminal background checks for hospice workers, improper storage of poisonous materials and food, missing medical evaluations and assessments for residents, medication labeling and storage issues, and incomplete support plan documentation. Plans of correction were accepted and implemented with proposed completion dates mostly in April and May 2025.
Deficiencies (21)
| Description |
|---|
| Resident-home contract was not signed by the resident, responsible party, administrator or designee. |
| The home does not have criminal background checks for hospice workers providing services to the resident. |
| The home did not have a complete staff list including agency staff. |
| No staff person trained in first aid and certified in obstructed airway techniques and CPR was present during shifts when residents were present. |
| Staff person completed CPR training with a non-certified trainer. |
| Staff person did not receive orientation on fire safety and emergency preparedness topics on first day of work. |
| Staff training records did not include date, source, content, length of course or certificates. |
| Poisonous materials were not stored in original labeled containers and were accessible to residents. |
| Poisonous materials were unlocked and accessible to residents not assessed capable of safe use. |
| Resident did not have a toilet paper holder in bathroom. |
| Food was stored in unsealed containers. |
| Outdated or spoiled food was found in refrigerator. |
| Initial medical evaluation was not completed for a resident. |
| Annual medical evaluation did not include required components such as general physical exam and cognitive functioning. |
| Medication was present on medication cart but not listed on medication order or administration record. |
| Medication blister pack had a tear with pill still in pack. |
| Medication label had incorrect directions without direction change sticker. |
| Preadmission screening form was not completed for a resident. |
| Initial assessment was not completed within 15 days of admission for a resident. |
| Resident or assessor did not sign the support plan. |
| Support plan did not address diagnosis of dementia for a resident. |
Report Facts
Residents Served: 10
License Capacity: 25
Current Residents in Hospice: 2
Total Daily Staff: 20
Waking Staff: 15
Inspection Report
Monitoring
Census: 13
Capacity: 25
Deficiencies: 6
Sep 9, 2024
Visit Reason
The visit was a monitoring review conducted by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing on 09/09/2024 and 09/10/2024 to verify continued compliance and implementation of the submitted plan of correction.
Findings
The inspection identified multiple deficiencies including delayed staff orientation on fire safety and emergency preparedness, incomplete training on resident rights and abuse reporting, unlocked poisonous materials accessible to residents, failure to post weekly menus in a timely manner, medication storage and documentation errors, and failure to follow prescriber's medication orders. Plans of correction were accepted and implemented with ongoing audits scheduled.
Deficiencies (6)
| Description |
|---|
| Staff person did not receive orientation on fire safety and emergency preparedness topics until after first work day. |
| Staff person did not complete required training on resident rights, emergency medical plan, and abuse reporting within 40 scheduled work hours. |
| Poisonous materials were unlocked, unattended, and accessible to residents who were not assessed capable of safely using or avoiding them. |
| Weekly menu for upcoming week was not posted in a conspicuous and public place in the home. |
| Medication missing from blister pack and improper documentation on medication administration record. |
| Medications prescribed for residents were not available in the home as required by prescriber's orders. |
Report Facts
License Capacity: 25
Residents Served: 13
Total Daily Staff: 26
Waking Staff: 20
Inspection Report
Renewal
Census: 23
Capacity: 33
Deficiencies: 16
Jun 24, 2024
Visit Reason
The inspection was conducted as a licensing inspection with reasons including renewal, complaint, and incident review.
Findings
The facility was found to be in compliance overall, but several deficiencies were identified including issues with resident confidentiality, activities of daily living assistance, rent rebate information, abuse and neglect, privacy violations, staff orientation and training deficiencies, medication storage, sanitary conditions, emergency procedures, and documentation such as preadmission screening and support plan signatures. Plans of correction were accepted and implemented with specified completion dates.
Deficiencies (16)
| Description |
|---|
| Resident records were not kept confidential, with a resident task list visible on a resident's window ledge. |
| Resident 1 did not receive required assistance with toileting, bladder, and bowel management during the overnight shift. |
| Resident 2's contract lacked information regarding the Senior Citizens Rebate and Assistance Act. |
| Resident 1 was found lying in urine and feces, indicating neglect and abuse. |
| Staff recorded video of a resident in a state violating privacy rights. |
| Staff person C did not have a current list of staff for the home. |
| Several staff members did not receive required fire safety and emergency preparedness orientation on their first day. |
| Staff persons B, C, and D did not complete required training within 40 scheduled work hours on emergency medical plan and reporting of incidents. |
| Direct care staff person D did not receive required annual training on multiple topics including medication self-administration and care for residents with dementia. |
| Direct care staff person D did not receive required annual training on fire safety, emergency preparedness, resident rights, and other topics. |
| Poisonous materials were unlocked and accessible to residents in Resident 2's room. |
| Blood stains and heavy dust accumulation were found in Resident 2's bathroom. |
| A small round pill was found loose on the floor near the medication cart. |
| Two small round orange pills were loose in the medication cart. |
| Resident 1's preadmission screening form was incomplete and missing required signatures. |
| Resident 1's support plan lacked signatures from the assessor and resident. |
Report Facts
License Capacity: 33
Residents Served: 23
Secured Dementia Care Unit Capacity: 25
Residents Served in Dementia Unit: 17
Current Hospice Residents: 2
Total Daily Staff: 40
Waking Staff: 30
Inspection Report
Monitoring
Census: 22
Capacity: 33
Deficiencies: 43
Apr 15, 2024
Visit Reason
The visit was a provisional monitoring inspection conducted by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing, to review compliance with licensing requirements and the submitted plan of correction for Bryn Mawr Village.
Findings
The inspection identified multiple deficiencies including failure to post current licenses, medication errors and reporting failures, incomplete resident contracts, privacy violations, inadequate staff training and orientation, unsafe storage of poisonous materials, sanitary and safety hazards, incomplete medical evaluations and assessments, and deficiencies in fire safety procedures. Plans of correction were accepted with proposed completion dates mostly in mid to late 2024.
Deficiencies (43)
| Description |
|---|
| Current license was not posted in a conspicuous and public place in the secured dementia care unit. |
| Medication errors including missed blood sugar checks and missed prescribed medications were not reported to the Department. |
| Resident home contracts were not reviewed and explained to residents prior to signature. |
| Resident home contracts lacked required signatures from administrator, resident, or guardian. |
| Resident home contracts did not include resident rights or complaint procedures. |
| Resident home contracts did not indicate whether the home collects a portion of the resident’s rent rebate benefit. |
| The home had not implemented a quality management plan. |
| Resident records lacked signed statements acknowledging receipt of resident rights and complaint procedures. |
| Video recording camera was noted in a resident area without signage or contract language informing residents. |
| Criminal background checks were not completed timely for some staff members. |
| The home was unable to provide an accurate and current list of staff personnel. |
| 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 orientation within 40 scheduled working hours on resident rights, emergency medical plan, and mandatory reporting. |
| Ancillary staff did not have general orientation to their specific job functions prior to working in that capacity. |
| The home did not have records of completed staff training or orientation for some staff. |
| The staff training plan did not include names, positions, duties, required training courses, or scheduled training dates for staff. |
| Poisonous materials were unlocked and accessible to residents in the secured memory care unit. |
| Sanitary conditions were not maintained; a glucometer labeled 'HOUSE' was found in medication cart. |
| Trash receptacles in kitchens and bathrooms were uncovered and unattended. |
| Furniture on the patio was worn, dirty, and hazardous. |
| Staff could not locate the first aid kit on the personal care side of the home. |
| Exterior building grounds were not free of hazards; patio walkway was blocked and littered. |
| Refrigerator and freezer temperatures exceeded required limits; thermometers were missing or not functioning. |
| Outdated or unlabeled food items were found in the kitchen freezer. |
| Egress routes were blocked by items including a cooler and garden bench. |
| The home lacked documentation of written notification to the local fire department regarding address, bedroom locations, and evacuation assistance. |
| Unannounced fire drills were not held monthly as required; records were incomplete. |
| Fire drill records lacked evacuation time and clarity on units evacuated. |
| Resident medical evaluations were missing or outdated for resident #4. |
| Menus posted lacked dates, causing confusion for residents with memory impairments. |
| Prescription medications were not kept in original labeled containers and lacked pharmacy labels. |
| Over-the-counter medications and CAM were not labeled with resident's name and house stock was used improperly. |
| Prescribed medications were not available in the home for residents #3 and #5. |
| Errors in recording blood glucose levels and insulin administration for resident #1 were noted. |
| The home did not follow prescriber's orders; residents missed prescribed medications on multiple occasions. |
| Residents #4 and #5 were not educated on their right to refuse medication if they believe there is a medication error. |
| Resident #4's preadmission screening form was not completed. |
| Initial assessments were not completed within 15 days of admission for residents #2, #3, and #4. |
| Resident #4 had not had an initial or annual additional assessment completed since admission. |
| Directions for operating key-locking devices were not conspicuously posted or were incorrectly posted near certain doors. |
| Resident #2 and #4 were admitted to the secured dementia care unit without completed initial support plans. |
| Resident #4's record lacked a resident-home contract signed by the resident or guardian and no medical file was available. |
| Resident #2's record did not include admission date, Social Security number, identifying marks, communication means, or other required information. |
Report Facts
License Capacity: 33
Residents Served: 22
Residents Served in Secured Dementia Care Unit: 16
Current Residents in Hospice: 1
Residents Age 60 or Older: 22
Residents with Mobility Need: 16
Total Daily Staff: 38
Waking Staff: 29
Deficiencies Cited: 36
Inspection Report
Follow-Up
Census: 21
Capacity: 33
Deficiencies: 12
Mar 13, 2024
Visit Reason
The inspection was a partial, unannounced follow-up visit conducted on 03/13/2024 to review the submitted plan of correction and verify compliance following a prior fine.
Findings
The facility was found to have implemented the submitted plan of correction fully. Deficiencies related to staff records, criminal background checks, direct care staff qualifications, orientation, first aid kits, exit signage, unobstructed egress, prescription medication storage, and key-locking device directions were addressed with corrective actions and ongoing monitoring plans.
Deficiencies (12)
| Description |
|---|
| Failure to provide immediate access to staff records upon request. |
| Staff persons hired without required criminal background checks. |
| Direct care staff lacking high school diploma, GED, or active registry status. |
| Contact list did not include substitute personnel. |
| Direct care staff did not receive required fire safety and emergency preparedness orientation on first day. |
| Direct care staff did not complete required training within 40 scheduled hours on resident rights, emergency medical plan, mandatory abuse reporting, and reportable incidents. |
| Direct care staff provided unsupervised ADL services without completing required training and competency testing. |
| First aid kits missing required items such as breathing shield, tape, antiseptic, eye covering, and thermometer. |
| Manual lock blocked egress from the home's Impression's dining room. |
| No exit sign over the Impression dining room exit door. |
| Non-resident medication found in the home's first aid kit. |
| Directions for operating key-locking devices not conspicuously posted near the gate in the courtyard on the Secure Dementia Care Unit. |
Report Facts
License Capacity: 33
Residents Served: 21
Residents Served in Secured Dementia Care Unit: 16
Current Hospice Residents: 1
Total Daily Staff: 37
Waking Staff: 28
Residents 60 Years or Older: 21
Residents with Mobility Need: 16
Inspection Report
Renewal
Census: 17
Capacity: 33
Deficiencies: 43
May 18, 2023
Visit Reason
The inspection was a renewal visit conducted to assess compliance with 55 Pa. Code Chapter 2600 relating to Personal Care Homes.
Findings
The inspection identified multiple deficiencies including lack of written policies, medication errors, incomplete resident contracts, missing training and orientation for staff, unsafe storage of poisonous materials, sanitary issues, fire safety violations, and incomplete resident medical and admission documentation.
Deficiencies (43)
| Description |
|---|
| The home does not have a written policy on the prevention, reporting, notification, investigation and management of reportable incidents. |
| Residents 1 and 2 did not receive any prescribed medications on the evening of 5/14/23 and the home did not report these medication errors to the department. |
| The resident-home contract for resident 1 was not signed by the resident. |
| The resident-home contract for Resident 1 does not indicate whether the home collects a portion of the resident’s rent rebate benefit. |
| The home does not have a quality management plan. |
| Resident 1's record did not contain a statement signed by the resident acknowledging receipt of a copy of the resident rights and complaint procedures. |
| There is a camera in the common area on the personal care side with no sign indicating video surveillance. |
| Staff person A was hired without a completed criminal background check prior to start date; Staff person B does not have a criminal background check. |
| Staff persons A, B, and C did not receive orientation on fire safety and emergency preparedness topics including evacuation procedures, fire extinguisher use, and emergency notification. |
| Staff persons A, B, and C did not complete training on resident rights, emergency medical plan, mandatory abuse reporting, and reporting of reportable incidents within 40 scheduled working hours. |
| Direct care staff person B did not complete and pass the Department-approved direct care training course and competency test. |
| Direct care staff person B did not complete required initial direct care training topics including safe management techniques, ADLs/IADLs, personal hygiene, care of residents with dementia, infection control, and other required subjects. |
| The home's record of direct care staff training does not include the name, date, source, content, and length of training. |
| The home does not have a staff training plan for 2023. |
| Poisonous materials including hand sanitizers and personal care products were unlocked, unattended, and accessible to residents who have not been assessed capable of recognizing and using poisons safely. |
| Sanitary conditions were not maintained including shared unlabeled glucometers, spills in freezer and refrigerator, and lack of hand drying methods in bathrooms. |
| Trash receptacles in the main kitchen were uncovered. |
| Missing ceiling tile with water damage stain in bathroom ceiling. |
| Emergency telephone numbers were not posted by telephones with outside lines in the personal care kitchenette. |
| First aid kits were missing required items including scissors, gauze, eye coverings, and tape. |
| Leftover food items in refrigerators and freezers were not labeled or dated. |
| Refrigerator and freezer temperatures exceeded regulatory limits and thermometers were missing or outdated. |
| Food items were not stored in closed or sealed containers. |
| Written emergency procedures were not submitted annually to the local emergency management agency. |
| Exits were obstructed by furniture and equipment. |
| The home lacked documentation of written notification to the local fire department regarding address, bedroom locations, and evacuation assistance. |
| Unannounced fire drills were not held during several months and fire safety inspection and supervised fire drills were not completed annually for all areas. |
| Fire drill records were incomplete missing year, number of residents present, and location of drill. |
| The home exceeded the maximum safe evacuation time of 3 minutes 30 seconds during multiple fire drills. |
| Resident 4 did not have a medical evaluation documented on a Department specified form within required timeframe. |
| Resident 1's medical evaluation did not include a list of the resident's medications. |
| Menus were not prepared and posted one week in advance in a conspicuous and public place. |
| Admelog insulin pen belonging to resident 2 was not dated upon opening as required by manufacturer. |
| Glucometer on the Impressions med cart was not labeled with anyone’s name. |
| Resident 1 was prescribed Milk of Magnesia as needed but medication was not available in the home. |
| Residents 1 and 2 did not receive prescribed medications on the evening of 5/14/23 and medication errors were not reported to residents, designated persons, or prescribers. |
| Resident 1 has not been educated on the right to refuse medication if a medication error is suspected. |
| Residents 1 and 4 do not have preadmission screening forms. |
| Residents 1 and 4 did not have written initial assessments completed within 15 days of admission. |
| Resident 1 did not have a written cognitive preadmission screening completed within 72 hours prior to admission to the secured dementia care unit. |
| The home does not have a statement from the lock manufacturer verifying that the electronic or magnetic locking system will release upon fire alarm activation, power failure, or override. |
| Directions for operating locking mechanisms are not conspicuously posted near the patio exit door and gate in the Secure Dementia Care Unit. |
| Resident 1's initial support plan was not completed within 72 hours of admission to the Secure Dementia Care Unit. |
Report Facts
License Capacity: 33
Residents Served: 17
Residents Served in Secured Dementia Care Unit: 12
Staffing Hours: 30
Waking Staff: 23
Number of Deficiencies Cited: 43
Fine Per Resident Per Day: 5
Census at Inspection: 23
Total Daily Staff: 41
Waking Staff: 31
Residents Served: 23
Residents Served in Secured Dementia Care Unit: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff person A | Named in relation to criminal background check deficiency and training deficiencies | |
| Staff person B | Named in relation to criminal background check deficiency and training deficiencies | |
| LPN Supervisor | Licensed Practical Nurse Supervisor | Named in relation to medication error findings, training, and audits |
| Maintenance Director | Named in relation to fire safety, emergency procedures, and facility maintenance deficiencies | |
| Dietary Manager | Named in relation to food safety and sanitation deficiencies | |
| PCHA | Personal Care Home Administrator | Named in relation to multiple deficiencies and corrective actions |
Inspection Report
Renewal
Census: 17
Capacity: 33
Deficiencies: 46
May 18, 2023
Visit Reason
The inspection visit was a renewal inspection conducted to assess compliance with 55 Pa. Code Chapter 2600 relating to Personal Care Homes.
Findings
The inspection identified multiple deficiencies including lack of written policies, medication errors, incomplete resident contracts, missing training and orientation for staff, unsafe storage of poisonous materials, sanitary issues, fire safety violations, and incomplete resident medical and admission documentation.
Deficiencies (46)
| Description |
|---|
| The home does not have a written policy on the prevention, reporting, notification, investigation and management of reportable incidents. |
| Residents 1 and 2 did not receive any prescribed medications on the evening of 5/14/23 and the home did not report these medication errors to the department. |
| The resident-home contract for resident 1 was not signed by the resident. |
| The resident-home contract for Resident 1 does not indicate whether the home collects a portion of the resident’s rent rebate benefit. |
| The home does not have a quality management plan. |
| Resident 1's record did not contain a statement signed by the resident acknowledging receipt of a copy of the resident rights and complaint procedures. |
| There is a camera in the common area on the personal care side with no sign indicating video surveillance. |
| Staff person A was hired without a completed criminal background check prior to their first day of work; Staff person B does not have a criminal background check. |
| The home does not have a complete list of staff, including substitute personnel. |
| Staff persons A, B, and C did not receive orientation on fire safety and emergency preparedness topics on their first day. |
| Staff persons A, B, and C did not complete training within 40 scheduled working hours on resident rights, emergency medical plan, mandatory reporting of abuse and neglect, and reporting of reportable incidents and conditions. |
| Direct care staff person B did not complete and pass the Department-approved direct care training course and competency test. |
| Direct care staff person B did not complete required initial direct care staff person training on multiple required topics including safe management techniques, ADLs, personal hygiene, care of residents with dementia, infection control, and others. |
| The home's record of direct care staff training does not include the name, date, source, content, and length of training. |
| The home does not have a staff training plan for 2023. |
| Poisonous materials including hand sanitizers and personal care products were unlocked, unattended, and accessible to residents who have not been assessed capable of recognizing and using poisons safely. |
| Sanitary conditions were not maintained including shared unlabeled glucometers, spills in freezer and refrigerator, and lack of hand drying methods in bathrooms. |
| Trash receptacles in the main kitchen were uncovered. |
| Missing ceiling tile and water damage stain in bathroom ceiling. |
| Emergency telephone numbers were not posted by the telephone in the personal care kitchenette. |
| First aid kits were missing required items including scissors, gauze, eye coverings, and tape. |
| Leftover food in refrigerators and freezers was not labeled or dated. |
| Food requiring refrigeration was stored above required temperatures and thermometers were missing or inaccurate. |
| Food was not stored in closed or sealed containers. |
| Written emergency procedures were not submitted to the local emergency management agency. |
| Exits were obstructed by furniture and equipment. |
| No documentation of written notification to the local fire department of the address, bedroom locations, and evacuation assistance needed. |
| Unannounced fire drills were not held during July 2022, August 2022, and April 2023. |
| No fire safety inspection and no supervised fire drill for the Impressions area. |
| Fire drill records were incomplete missing year, number of residents present, and location of drill. |
| Evacuation times exceeded the maximum safe evacuation time of 3 minutes and 30 seconds during multiple fire drills. |
| Resident 4 did not have a medical evaluation documented on a form specified by the Department within required timeframe. |
| Resident 1's medical evaluation did not include a list of the resident's medications. |
| Weekly menus were not posted in advance and no future weekly menu was posted. |
| Admelog insulin pen belonging to resident 2 was not dated upon opening as required by manufacturer. |
| Glucometer on the Impressions med cart was not labeled with anyone’s name. |
| Resident 1 was prescribed Milk of Magnesia as needed but medication was not available in the home. |
| Residents 1 and 2 did not receive prescribed medications on the evening of 5/14/23. |
| Medication errors were not immediately reported to residents, designated persons, and prescribers. |
| Resident 1 was not educated on the right to refuse medication if a medication error is suspected. |
| Residents 1 and 4 do not have preadmission screening forms. |
| Assessments were not completed within 15 days of admission for residents 1 and 4. |
| Resident 1 does not have a written cognitive preadmission screening completed within 72 hours prior to admission to the secured dementia care unit. |
| The home does not have a statement from the lock manufacturer verifying that the electronic or magnetic locking system will release upon fire alarm activation, power failure, or use of lock-releasing device. |
| Directions for operating the home's locking mechanism are not conspicuously posted near the door to the patio exit in the Secure Dementia Care Unit. |
| Resident 1 was admitted to the Secure Dementia Care Unit but the initial support plan was not completed within 72 hours. |
Report Facts
License Capacity: 33
Residents Served: 17
Residents Served in Secured Dementia Care Unit: 12
Staffing Hours: 30
Waking Staff: 23
Deficiencies cited: 43
Fine Per Resident Per Day: 5
Calculated Fine Per Day: 115
Census at Inspection: 23
Total Daily Staff: 41
Waking Staff: 31
Residents Served: 23
Residents Served in Secured Dementia Care Unit: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff person A | Named in relation to criminal background check and training deficiencies | |
| Staff person B | Named in relation to criminal background check and training deficiencies | |
| LPN Supervisor | Licensed Practical Nurse Supervisor | Named in relation to medication error findings, training, and audits |
| Maintenance Director | Named in relation to fire safety, emergency procedures, and facility maintenance | |
| Dietary Manager | Named in relation to food storage and labeling deficiencies | |
| PCHA | Personal Care Home Administrator | Named in relation to multiple plan of correction activities and oversight |
| HR Director | Named in relation to staff training, background checks, and compliance audits | |
| Admissions Coordinator | Named in relation to resident contract and admission documentation |
Inspection Report
Renewal
Census: 17
Capacity: 33
Deficiencies: 46
May 18, 2023
Visit Reason
The inspection was a renewal visit to assess compliance with 55 Pa. Code Chapter 2600 relating to Personal Care Homes.
Findings
The inspection identified multiple deficiencies including lack of written policies, medication errors, incomplete resident contracts, missing staff training, unsecured poisonous materials, sanitary issues, fire safety violations, and incomplete resident medical and admission documentation.
Deficiencies (46)
| Description |
|---|
| The home does not have a written policy on the prevention, reporting, notification, investigation and management of reportable incidents. |
| Residents 1 and 2 did not receive any prescribed medications on the evening of 5/14/23 and the home did not report these medication errors to the department. |
| The resident-home contract for resident 1 was not signed by the resident. |
| The resident-home contract for Resident 1 does not indicate whether the home collects a portion of the resident’s rent rebate benefit. |
| The home does not have a quality management plan. |
| Resident 1's record did not contain a statement signed by the resident acknowledging receipt of a copy of the resident rights and complaint procedures. |
| There is a camera in the common area on the personal care side with no sign indicating video surveillance. |
| Staff person A was hired without a completed criminal background check prior to their first day of work. Staff person B does not have a criminal background check. |
| The home does not have a complete list of staff, including substitute personnel. |
| The home's administrator has not completed required orientation, training course, and competency test. |
| Staff persons A, B, and C did not receive orientation on fire safety and emergency preparedness topics on their first day. |
| Staff persons A, B, and C did not complete training on resident rights, emergency medical plan, abuse reporting, and incident reporting within 40 scheduled working hours. |
| Direct care staff person B did not complete and pass the Department-approved direct care training course and competency test. |
| Direct care staff person B did not complete required initial direct care staff training on multiple topics including safe management techniques, ADLs, personal hygiene, dementia care, nutrition, infection control, and others. |
| The home's record of direct care staff training does not include the name, date, source, content, and length of training. |
| The home does not have a staff training plan for 2023. |
| Poisonous materials including hand sanitizers, antiperspirants, and toothpaste were unlocked, unattended, and accessible to residents who have not been assessed capable of recognizing and using poisons safely. |
| Sanitary conditions were not maintained including shared unlabeled glucometers, spills in freezer and refrigerator, and lack of hand drying methods in bathrooms. |
| Trash receptacles in the main kitchen were uncovered during inspection. |
| Missing ceiling tile with water damage stain in bathroom ceiling. |
| Emergency telephone numbers were not posted by the telephone in the personal care kitchenette. |
| First aid kits were missing required items including scissors, gauze, eye coverings, and tape. |
| Leftover food items in refrigerators and freezer were unlabeled and undated. |
| Food requiring refrigeration was stored above required temperatures and thermometers were missing or inaccurate. |
| Food items were not stored in closed or sealed containers. |
| Written emergency procedures were not submitted annually to the local emergency management agency. |
| Exit from Impressions was obstructed by furniture and patio chair. |
| The home lacks documentation of written notification to the local fire department of the address, bedroom locations, and evacuation assistance needed. |
| Unannounced fire drills were not held during July 2022, August 2022, and April 2023. |
| No fire safety inspection and no supervised fire drill were conducted for the Impressions area. |
| Fire drill records were incomplete missing year, number of residents present, and location of drill. |
| The home exceeded the maximum safe evacuation time of 3 minutes 30 seconds during multiple fire drills. |
| Resident 4 did not have a medical evaluation documented on a form specified by the Department within required timeframe. |
| Resident 1's medical evaluation did not include a list of the resident's medications. |
| Weekly menus were not posted one week in advance in a conspicuous and public place. |
| Admelog insulin pen belonging to resident 2 was not dated upon opening as required by manufacturer. |
| Glucometer on the Impressions med cart was not labeled with anyone’s name. |
| Resident 1 was prescribed Milk of Magnesia as needed but medication was locked and not accessible. |
| Residents 1 and 2 did not receive prescribed medications on the evening of 5/14/23. |
| Medication errors were not immediately reported to residents, designated persons, and prescribers. |
| Resident 1 has not been educated on the right to refuse medication if a medication error is suspected. |
| Residents 1 and 4 do not have preadmission screening forms. |
| Resident 1 was admitted to the Secure Dementia Care Unit without a written cognitive preadmission screening completed within 72 hours prior to admission. |
| The home does not have a statement from the lock manufacturer verifying that the electronic or magnetic locking system will release upon fire alarm activation, power failure, or override. |
| Directions for operating the home's locking mechanism are not conspicuously posted near the patio exit door and gate in the Secure Dementia Care Unit. |
| Resident 1 was admitted to the Secure Dementia Care Unit without an initial support plan completed within 72 hours of admission. |
Report Facts
License Capacity: 33
Residents Served: 17
Residents Served in Secure Dementia Care Unit: 12
Staffing Hours: 30
Waking Staff: 23
Number of Deficiencies Cited: 33
Fine Per Resident Per Day: 5
Calculated Fine Per Day: 115
Correction Dates: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Juliet Marsala | Deputy Secretary | Signed licensing letters and enforcement notices |
Inspection Report
Follow-Up
Census: 25
Capacity: 33
Deficiencies: 6
Feb 7, 2023
Visit Reason
The inspection visit on 02/07/2023 was a partial, unannounced follow-up to review the submitted plan of correction related to an incident at the facility.
Findings
The facility was found to have multiple deficiencies related to resident abuse reporting, assistance with activities of daily living, abuse incidents, staff contact list maintenance, staff training content, and support plan needs. The submitted plan of correction was accepted and fully implemented by 03/24/2023.
Deficiencies (6)
| Description |
|---|
| Failure to immediately report suspected abuse of a resident to the Department of Aging. |
| Resident did not receive required assistance with reminders to use walker as indicated in the support plan. |
| Resident was physically abused by staff resulting in injury requiring staples to the scalp. |
| Licensed Practical Nurse was not listed on the staff contact list provided by the administrator. |
| Staff training plan did not include de-escalation techniques for caring for residents with aggressive behaviors. |
| Support plan did not address resident's behaviors regarding boundaries concerning food and verbal aggression towards staff. |
Report Facts
License Capacity: 33
Residents Served: 25
Residents Served in Secured Dementia Care Unit: 15
Current Hospice Residents: 1
Residents 60 Years or Older: 15
Residents with Mobility Need: 13
Total Daily Staff: 38
Waking Staff: 29
Inspection Report
Follow-Up
Census: 18
Capacity: 33
Deficiencies: 13
Jul 25, 2022
Visit Reason
The visit was an unannounced partial inspection conducted as an interim review to assess the implementation status of a previously submitted plan of correction.
Findings
The inspection identified multiple deficiencies including lack of required qualifications and training documentation for direct care staff, sanitary issues, missing items in the first aid kit, non-functioning bedside lamp, missing emergency procedure postings, medication order and administration documentation errors, missing resident photo in records, and lack of conspicuous posting of key-locking device instructions. Some deficiencies were accepted with corrective actions and directed completion dates.
Deficiencies (13)
| Description |
|---|
| Direct care staff person A did not have a high school diploma, GED, or active registry status on the Pennsylvania nurse aide registry. |
| Staff person A did not receive documentation of direct care worker orientation on the first day. |
| Staff person A did not complete 40 hours of training in resident rights, abuse reporting, or emergency medical plan. |
| Staff person A did not complete initial direct care staff person trainings. |
| The freezer on the Impressions Unit was soiled and dirty. |
| The first aid kit on the Impressions Unit did not include gloves or scissors. |
| Resident #1's bedside lamp was not working at the time of inspection. |
| The home’s emergency procedures were not posted in a conspicuous and public place. |
| Resident #2 did not have an order for certain medications found on the med-cart. |
| Medication administration record did not document administration, refusal, or unavailability for resident #2 at a scheduled time. |
| Resident #3 did not sign their support plan and the home did not document inability or refusal to sign. |
| Directions for operating the home's locking mechanism were not conspicuously posted near the Secure Dementia Care Unit door. |
| Resident #3's record did not include a photo of the resident. |
Report Facts
Residents Served: 18
License Capacity: 33
Total Daily Staff: 32
Waking Staff: 24
Secured Dementia Care Unit Capacity: 25
Residents Served in Secured Dementia Care Unit: 14
Residents 60 Years or Older: 18
Residents with Mobility Need: 14
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