Inspection Report
Renewal
Census: 55
Capacity: 72
Deficiencies: 8
Sep 3, 2025
Visit Reason
The inspection was conducted as a renewal visit to review compliance with licensing regulations at Juniper Village at Mount Joy.
Findings
The inspection identified multiple deficiencies including unsecured bedrails posing entrapment hazards, uncovered food items in storage, lint accumulation in dryer lint traps, dietary needs not fully met, presence of discontinued medication in the medication cart, loose medication pills found on the floor, and incomplete resident assessments and support plan signatures. All deficiencies had plans of correction accepted and were implemented by October 14, 2025.
Deficiencies (8)
| Description |
|---|
| Bedrails located on both sides of resident #1's bed were not firmly secured, posing a potential entrapment or injury hazard. |
| Uncovered 3-gallon container of vanilla ice cream and uncovered box of lettuce, carrots and celery stored in walk-in freezer and refrigerator. |
| Approximate 1/2-inch accumulation of lint in the lint trap of the dryer located in the 200-hall laundry room. |
| Resident #1 was prescribed an advanced chopped diet but was served half of a bologna, lettuce and tomato sandwich. |
| Calmoseptine ointment prescribed for resident #1 was in the medication cart but was discontinued on 7/30/25. |
| One loose pink pill was found on the floor in the 400-hallway near resident room #402. |
| Resident #2’s current assessment did not indicate the need for the resident to sleep in a recliner rather than a bed. |
| Resident #2 participated in the development of support plan but neither the resident nor the assessor signed the support plan. |
Report Facts
License Capacity: 72
Residents Served: 55
Current Hospice Residents: 1
Residents 60 Years or Older: 55
Residents Diagnosed with Mental Illness: 1
Residents with Mobility Need: 3
Total Daily Staff: 58
Waking Staff: 44
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Medical Concierge | Reviewed RASP with resident, obtained resident signature and provided assessor signature at time of survey | |
| EVS Director | Tightened bedrails, audited bedrails and dryer lint traps, educated team on regulations | |
| Dining Director | Discarded unprotected food items, audited refrigerators, educated team on food protection and dietary needs | |
| DOW | Removed discontinued medication, educated medication team, audited medication carts and administration | |
| ED | Educated team on dietary needs, medication regulations, additional assessments, and support plan requirements |
Inspection Report
Complaint Investigation
Census: 59
Capacity: 72
Deficiencies: 6
Jun 30, 2025
Visit Reason
The inspection was conducted as a complaint investigation with unannounced partial inspections on 06/30/2025 and 07/02/2025 to review compliance with submitted plans of correction.
Findings
The inspection identified multiple deficiencies including failure to complete required 15-minute safety checks for residents following elopements, incomplete resident contracts lacking required level of care assessments, incidents of resident elopement resulting in injury and hospitalization, unlocked medication cart drawer exposing medications, difficulty unlocking an egress door, and incomplete resident assessments including medication self-administration ability. Plans of correction were accepted and implemented by 09/29/2025.
Complaint Details
The visit was complaint-related, triggered by concerns about resident safety and care following multiple elopement incidents. The complaint was substantiated as deficiencies were found related to supervision, safety checks, and resident assessments.
Deficiencies (6)
| Description |
|---|
| Failure to complete 15-minute safety checks on residents following elopements as required by their assessment and support plans. |
| Resident home contract did not include the level of care assessment required to determine personal care services upon admission. |
| Resident elopement incident resulting in resident being found approximately 1 mile from home, diagnosed with dehydration, heat exhaustion, and acute kidney injury. |
| Left side of doubled-door in 400-Hallway activity room was difficult to unlock and took considerable effort to open. |
| Top drawer of medication cart was unlocked, unattended, and accessible exposing resident medications. |
| Resident assessments did not include critical information such as inability to communicate needs, allergies, financial management, mobility status, and ability to self-administer medications. |
Report Facts
License Capacity: 72
Residents Served: 59
Current Hospice Residents: 5
Total Daily Staff: 60
Waking Staff: 45
Inspection Report
Follow-Up
Census: 58
Capacity: 72
Deficiencies: 2
May 29, 2025
Visit Reason
The inspection was a partial, unannounced incident review conducted on 05/29/2025 to evaluate the facility's compliance with submitted plans of correction.
Findings
The facility was found to have medication administration errors and incomplete resident assessments, but the submitted plan of correction was determined to be fully implemented and compliance maintained.
Deficiencies (2)
| Description |
|---|
| Medication administration errors including missed and mistimed medications for multiple residents. |
| Resident initial assessment did not include an assessment for moderate mobility as indicated on the resident’s initial medical evaluation. |
Report Facts
License Capacity: 72
Residents Served: 58
Total Daily Staff: 59
Waking Staff: 44
Medication Errors: 6
Plan of Correction Completion Date: Jun 25, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Wellness | Provided live training on medication administration and responsible for audits | |
| Executive Director | Responsible for education and audits related to resident assessments and medication administration |
Inspection Report
Follow-Up
Census: 64
Capacity: 72
Deficiencies: 5
Jan 8, 2025
Visit Reason
The inspection was a partial, unannounced follow-up visit conducted due to an incident, to review the submitted plan of correction for the facility.
Findings
The facility was found to have multiple deficiencies related to medication administration and record confidentiality, including an unlocked computer with resident medication records, ungloved medication counting, unlocked medication carts, unlabeled OTC medications, and incomplete medication administration records. All deficiencies had accepted plans of correction and were implemented by early February 2025.
Deficiencies (5)
| Description |
|---|
| The computer on top of the 300-hallway medication cart was unlocked, unattended, and accessible, allowing anyone to view medication and treatment records. |
| Staff was observed using an ungloved hand to count resident tablets. |
| A medication cart containing treatments was unlocked, unattended, and accessible in the corner of the 300-hallway lounge. |
| A tube and two tubs of OTC medications belonging to a resident were not labeled with the resident's name. |
| Resident medication administration record did not include the initials of the staff person who administered medication at 0600. |
Report Facts
License Capacity: 72
Residents Served: 64
Total Daily Staff: 66
Waking Staff: 50
Current Residents in Hospice: 1
Residents Diagnosed with Mental Illness: 3
Residents Age 60 or Older: 64
Residents with Mobility Need: 2
Residents with Physical Disability: 1
Inspection Report
Follow-Up
Census: 61
Capacity: 72
Deficiencies: 3
Dec 4, 2024
Visit Reason
The inspection visit was conducted as a follow-up to verify the correction of previously identified deficiencies related to medication errors and incident reporting.
Findings
The facility was found to have multiple medication administration errors, including missed doses, extra doses, and inaccurate medication records. The facility submitted a plan of correction which was accepted and implemented by January 8, 2025.
Complaint Details
The inspection was complaint-related and incident-related as indicated by the reason for inspection. Specific substantiation status is not stated.
Deficiencies (3)
| Description |
|---|
| Failure to report medication errors to the Department within 24 hours as required. |
| Medication administration record (MAR) inaccurately documented medications as given when they were not administered. |
| Failure to follow prescriber's orders resulting in missed doses and extra doses of medications. |
Report Facts
Residents served: 61
License capacity: 72
Staffing hours: 61
Staffing hours: 46
Current residents in hospice: 2
Residents age 60 or older: 61
Residents with physical disability: 1
Inspection Report
Complaint Investigation
Census: 63
Capacity: 72
Deficiencies: 0
Oct 24, 2024
Visit Reason
The inspection was conducted as a complaint and incident investigation at Juniper Village at Mount Joy.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Complaint Details
The inspection was triggered by a complaint and incident, but no deficiencies or citations were found, indicating no substantiated issues.
Report Facts
Total Daily Staff: 63
Waking Staff: 47
Resident Support Staff: 0
Residents Served: 63
License Capacity: 72
Current Hospice Residents: 2
Residents Age 60 or Older: 63
Residents Diagnosed with Mental Illness: 2
Residents with Physical Disability: 1
Inspection Report
Renewal
Census: 26
Capacity: 40
Deficiencies: 16
Sep 6, 2023
Visit Reason
The inspection was conducted as a renewal review of the assisted living facility license, including a full unannounced inspection from 09/06/2023 to 09/08/2023.
Findings
The inspection identified multiple deficiencies including failure to post the current licensing inspection summary, missing medical evaluations prior to admission, lack of involvement in quality management plans, staff qualification issues, inadequate first aid/CPR coverage, incomplete staff training documentation, missing items in the first aid kit, missed fire drills and incomplete fire drill records, incomplete medical evaluations and assessments, medication storage and usage issues, and failure to conduct quarterly reviews of resident support plans. All deficiencies had plans of correction accepted and were implemented by late November 2023.
Deficiencies (16)
| Description |
|---|
| Failure to post the current Licensing Inspection Summary in a conspicuous and public place. |
| No documentation of a medical evaluation prior to admission for Resident #1. |
| Assisted living portion of the community not involved in quality management plan reviews or meetings. |
| Direct care staff persons A and B lacked required high school diploma, GED, or active nurse aide registry status. |
| No staff trained in first aid and certified in obstructed airway techniques and CPR present during specified shifts. |
| Direct care staff persons A and B providing unsupervised assisted living services without completing required direct care training and competency test. |
| Monthly staff training documentation ceased in April 2023 and was incomplete for required courses. |
| First aid kit at nurse's station missing tweezers. |
| Unannounced fire drills not held during January, July, and August 2023. |
| Fire drill records for 5/9/23 and 6/15/23 missing key information including evacuation time, number of residents and staff evacuated, and exit routes used. |
| Medical evaluations for Residents #2 and #3 missing documentation of tuberculin skin test or chest X-ray results. |
| Resident #1's most recent medical evaluation and previous evaluation dates missing or incomplete. |
| Medication prescribed for Resident #2 was not available in the residence as required. |
| Used tube of medication found in first aid kit belonged to a discharged resident. |
| Resident #1 and #3 assessments were not completed annually as required. |
| Resident #1, #2, and #3 support plans were not reviewed quarterly as required. |
Report Facts
Residents served: 26
License capacity: 40
Total daily staff: 26
Waking staff: 20
Dates of inspection: 3
Fire drills missed: 3
Residents without medical evaluation prior to admission: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Denise Geib | Administrator | Educated staff on posting Licensing Inspection Summary and other regulatory requirements |
| Clinical Coordinator | Responsible for maintaining ADME tracking tool, staff education, medication audits, and training coordination | |
| Human Resource Director | Educated on direct care staff qualification requirements and new hire paperwork | |
| Nursing Assistant | Scheduled staff for CPR/First Aid training and provided tracking sheet to Administrator | |
| Maintenance Director | Reviewed fire drill regulations and coordinated fire drill documentation |
Inspection Report
Renewal
Census: 70
Capacity: 72
Deficiencies: 4
May 4, 2022
Visit Reason
The inspection was conducted as a renewal and complaint-related visit to assess compliance and review the submitted plan of correction.
Findings
The facility was found to have deficiencies related to hospice care physician certification, hot water temperature exceeding 120°F in multiple locations, lack of operable thermometers in the kitchen refrigerator and freezer, and incomplete preadmission screening forms. All plans of correction were accepted and fully implemented by the follow-up dates.
Complaint Details
The inspection included a complaint investigation component, but no substantiation status was explicitly stated.
Deficiencies (4)
| Description |
|---|
| Resident receiving hospice care was not evacuated during a fire drill without a written physician certification that the resident is actively dying and may suffer injury or hastened death. |
| Hot water temperature exceeded 120°F at multiple bathroom sinks and laundry tub. |
| No operable thermometer in the refrigerator or freezer in the 300 hallway kitchen. |
| Preadmission screening form for a resident was incomplete, missing the title of the person completing the screening and other required information. |
Report Facts
License Capacity: 72
Residents Served: 70
Hot Water Temperature: 125.1
Hot Water Temperature: 124.4
Hot Water Temperature: 124.1
Hot Water Temperature: 122.3
Total Daily Staff: 71
Waking Staff: 53
Current Hospice Residents: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Executive Chef | Named in relation to replacing non-operable thermometers in kitchen refrigerator and freezer. | |
| Environmental Services Director (ESD) | Responsible for checking and adjusting hot water temperatures and ensuring compliance. | |
| Medical Concierge or Director of Wellness | Responsible for obtaining physician orders for hospice residents not to evacuate during fire drills. | |
| Administrator | Responsible for ensuring completion of preadmission screening forms. |
Inspection Report
Plan of Correction
Census: 72
Capacity: 72
Deficiencies: 1
Feb 3, 2022
Visit Reason
The inspection was conducted as a follow-up to verify that the submitted plan of correction was fully implemented following a prior incident.
Findings
The facility was found to have fully implemented the submitted plan of correction related to medication refusal documentation. Continued compliance must be maintained.
Deficiencies (1)
| Description |
|---|
| Resident 1 refused to take a scheduled dose of multiple medications and the home did not document this in the resident's record nor notify the prescriber of the refusals. |
Report Facts
License Capacity: 72
Residents Served: 72
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Gloria Emick | Signed the letter confirming plan of correction implementation | |
| Director of Wellness | Provided verbal education to medication technician as part of plan of correction |
Notice
Capacity: 72
Deficiencies: 0
Mar 14, 2021
Visit Reason
This document serves as a renewal notification and license issuance for Juniper Village at Mount Joy, a Personal Care Home, confirming the facility's compliance and informing that an annual onsite inspection will be conducted within the next twelve months.
Findings
The Department has issued a regular license in response to the renewal application and advises that an annual inspection will be conducted to ensure compliance with applicable regulations.
Report Facts
Maximum licensed capacity: 72
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary, Office of Long-term Living | Signed the renewal notification letter. |
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