Inspection Reports for John Paul II Manor
856 CAMBRIA STREET,, CRESSON, PA, 16630
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
6.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
32% worse than Pennsylvania average
Pennsylvania average: 4.7 deficiencies/year
Deficiencies per year
20
15
10
5
0
Census
Latest occupancy rate
56% occupied
Based on a April 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 28
Capacity: 50
Deficiencies: 0
Apr 8, 2025
Visit Reason
The inspection was conducted as a complaint investigation with an unannounced partial inspection on 04/08/2025.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Complaint Details
The inspection was complaint-related, but no deficiencies or citations were found, indicating no substantiated issues.
Report Facts
License Capacity: 50
Residents Served: 28
Current Hospice Residents: 3
Resident Support Staff Hours: 0
Total Daily Staff Hours: 30
Waking Staff Hours: 23
Inspection Report
Renewal
Census: 31
Capacity: 50
Deficiencies: 8
Aug 8, 2024
Visit Reason
The inspection was conducted as a full, unannounced renewal inspection with an incident review on 08/08/2024.
Findings
The inspection identified multiple deficiencies including an expired boiler certificate, hot water temperature exceeding 120°F, lack of annual fire drill by a fire safety expert, missing annual medical evaluation documentation for a resident, invalid vehicle registration for a transport vehicle, improper medication storage labeling, and a privacy violation involving resident names posted publicly. All deficiencies had plans of correction with specified completion dates and were implemented by 10/01/2024.
Deficiencies (8)
| Description |
|---|
| Expired Certificate of Boiler or Pressure Vessel Operation; boiler certificate expired on 7/19/24. |
| Hot water temperature in room #15 measured 126°F, exceeding the 120°F limit. |
| The home had not completed an annual supervised fire drill by a fire safety expert. |
| Fire drill during sleeping hours not conducted every 6 months as required. |
| Resident #1’s most recent annual medical evaluation documentation was missing. |
| The home’s vehicle used to transport residents did not have a valid PA registration. |
| Resident #1's Humalog KwikPen and Lantus SoloStar injection pen lacked date markings indicating when opened. |
| Privacy coding document containing resident names was posted publicly on a bulletin board. |
Report Facts
License Capacity: 50
Residents Served: 31
Current Hospice Residents: 4
Residents 60 Years or Older: 30
Residents Diagnosed with Mental Illness: 3
Residents Diagnosed with Intellectual Disability: 1
Residents with Mobility Need: 1
Residents with Physical Disability: 0
Total Daily Staff: 32
Waking Staff: 24
Inspection Report
Renewal
Census: 32
Capacity: 50
Deficiencies: 20
Jun 7, 2023
Visit Reason
The inspection was conducted as a renewal inspection of the facility license.
Findings
The inspection found multiple deficiencies including failure to post current license documents, lack of written incident policies, unsigned resident contracts, absence of a quality management plan, hot water temperature exceeding limits, incomplete first aid kits, unlabeled soap, improper refrigerator/freezer temperatures, insufficient emergency water supply, incomplete fire drill records, failure to evacuate residents properly during fire drills, incomplete medical evaluations, medication administration and storage issues, and lack of policies for managing records. Plans of correction were submitted and implemented for all deficiencies.
Deficiencies (20)
| Description |
|---|
| The home’s current violation report, dated 2/15/2022, was not posted in a public place in the home. |
| The home does not have a written policy on the prevention, reporting, notification, investigation and management of reportable incidents. |
| Resident home contracts for Resident #1 and Resident #2 were not signed by the residents; no notation indicated opportunity to sign. |
| The home does not have a policy in place to implement a quality management plan and lacks documentation of annual completion. |
| Hot water temperature in resident room #9 measured 126°F, exceeding the 120°F limit. |
| First aid kits in the nurse's station and welcome desk lacked thermometer, adhesive tape, scissors, and eye coverings. |
| An unlabeled used bar of soap was found in resident room #4, occupied by 2 residents. |
| Temperature in the walk-in freezer was 12°F, exceeding the required 0°F or below. |
| The home served 32 residents requiring 96 gallons of emergency drinking water but had only 72 gallons and no water supplier contract. |
| The home lacks documentation that written emergency procedures were reviewed, updated, and submitted annually to the local emergency management agency. |
| Fire drill record for 5/10/2023 indicated 33 residents evacuated but only 32 evacuated as Resident #3 remained in bed. |
| Resident #3 did not evacuate to a designated meeting place during the fire drill on 5/10/2023. |
| Resident #4's medical evaluation did not include special health or dietary needs, immunization history, body positioning and movement. |
| Resident #5's medical evaluation did not include the date the resident was evaluated. |
| Resident #5 has not been assessed by a physician, physician's assistant, or certified registered nurse practitioner regarding ability to self-administer medications. |
| Resident #2's prescribed medication via nebulizer was not available in the home. |
| Blood glucose checks on the glucometer did not match the numbers documented on the home's June 2023 Monthly Blood Sugar sheet for Resident #1. |
| Resident #5's medication record did not include the amount of units given on the Monthly Blood Sugar record. |
| Resident #5's blood glucose was low and incorrect units of Humalog were administered; per physician's orders, 2 units should have been given. |
| The home does not have policies and procedures for managing records. |
Report Facts
License Capacity: 50
Residents Served: 32
Hot Water Temperature: 126
Walk-in Freezer Temperature: 12
Emergency Drinking Water Required: 96
Emergency Drinking Water Available: 72
Residents Evacuated: 32
Residents Present During Fire Drill: 33
Inspection Report
Renewal
Census: 24
Capacity: 50
Deficiencies: 3
Feb 15, 2022
Visit Reason
The inspection was conducted as a renewal inspection of the facility license.
Findings
The submitted plan of correction was determined to be fully implemented. Deficiencies were related to medication record documentation, staff medication administration training, and support plan signature documentation, all of which were corrected with directed completion dates and verified implementation.
Deficiencies (3)
| Description |
|---|
| Medication Administration Record did not indicate a diagnosis for a prescribed medication for Resident #2. |
| Staff persons administering medications had outdated or incomplete medication administration course reviews and observations. |
| The most recent support plan was not signed by Resident #1 and no notation was made regarding inability or refusal to sign. |
Report Facts
License Capacity: 50
Residents Served: 24
Current Residents in Hospice: 1
Residents Receiving Supplemental Security Income: 2
Residents Age 60 or Older: 24
Residents Diagnosed with Intellectual Disability: 1
Notice
Capacity: 50
Deficiencies: 0
Sep 14, 2021
Visit Reason
The document serves as a renewal notification and issuance of a regular license for John Paul II Manor, a Personal Care Home, following receipt of the renewal application dated September 7, 2021.
Findings
The Department has issued a regular license in response to the renewal application and advises that an onsite inspection will be conducted within the next twelve months to ensure compliance with applicable regulations.
Report Facts
Maximum capacity: 50
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary | Signed the renewal notification letter and certificate of compliance. |
Loading inspection reports...
