Deficiencies (last 5 years)
Deficiencies (over 5 years)
18.6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
296% worse than Pennsylvania average
Pennsylvania average: 4.7 deficiencies/yearDeficiencies per year
40
30
20
10
0
Census
Latest occupancy rate
83% occupied
Based on a March 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Monitoring
Census: 67
Capacity: 81
Deficiencies: 0
Mar 27, 2025
Visit Reason
The inspection was a partial, unannounced monitoring visit conducted by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing on 03/27/2025.
Findings
No regulatory citations or deficiencies were identified during this inspection.
Report Facts
Total Daily Staff: 77
Waking Staff: 58
Resident Support Staff: 0
License Capacity: 81
Residents Served: 67
Receive Supplemental Security Income: 54
Diagnosed with Mental Illness: 67
Are 60 Years of Age or Older: 37
Have Mobility Need: 10
Diagnosed with Intellectual Disability: 0
Have Physical Disability: 0
Current Hospice Residents: 0
Inspection Report
Renewal
Census: 67
Capacity: 81
Deficiencies: 38
Oct 2, 2024
Visit Reason
The inspection was an unannounced full renewal inspection conducted on October 2 and 3, 2024, to assess compliance with licensing requirements.
Findings
The inspection identified multiple deficiencies including failure to post current violation reports, lack of carbon monoxide detectors near gas appliances, improper tobacco sales practices, inadequate quality management plan, abuse and compensation violations related to resident labor, privacy issues, incomplete criminal background checks, insufficient direct care staffing hours, lack of trained medication technicians, incomplete staff training and orientation, maintenance issues, medication storage and administration violations, and emergency preparedness deficiencies.
Deficiencies (38)
| Description |
|---|
| The home's current violation report dated 6/27/2023 was not posted in a conspicuous and public place. |
| No carbon monoxide detector installed within 15 feet of the gas range in the kitchen. |
| The home does not have signs at the entrance indicating smoking is only permitted in designated areas and lacks signs at the designated smoking area. |
| Resident 1 rolling cigarettes for the home and residents paying an undetermined amount, violating tobacco sales laws. |
| Quality management meetings do not address resident concerns and resident council meetings are not held regularly. |
| Resident 1 is not compensated in accordance with Federal wage and hour requirements for labor performed on behalf of the home. |
| Public restroom lacked blinds or curtains for privacy. |
| Staff person A did not have a criminal background check through Pennsylvania State Police. |
| Direct care staff hours were insufficient to provide at least 1 hour per day of personal care services to each mobile resident on specified dates. |
| Less than 75% of personal care service hours were available during waking hours on specified dates. |
| No trained medication technicians present during overnight shifts on multiple dates. |
| Staff persons A and C did not receive required fire safety and emergency preparedness orientation on their first work day. |
| Staff person A did not complete required training within 40 scheduled working hours including resident rights and mandatory reporting. |
| Staff person A provided unsupervised ADL services without completing and passing the Department-approved direct care training course and competency test. |
| Staff person D did not receive required annual training including medication self-administration, infection control, and care for residents with dementia during training year 2023. |
| Staff person D did not receive training in fire safety by a fire safety expert and other required annual training during 2023-2024. |
| Staff person D's training record lacks documentation of annual training and medication trainer's certificate. |
| Trash cans in public restroom and hallway were full, uncovered, and unattended. |
| Loose floor tiles near emergency exit door on third floor. |
| Hot water temperature exceeded 120°F in shared bathroom. |
| Torn screen in hall window off courtyard. |
| Broken radiator cover in second-floor bathroom next to room 204. |
| First aid kit in office missing tweezers, thermometer, and breathing shield. |
| Fire escape stairs from third to second floor missing steps and rusted. |
| Bedroom 102 occupied by 2 residents but lacks chairs. |
| Residents in room 102 lack access to operable bedside lighting. |
| Second-floor bathroom next to room 204 lacked soap in dispenser. |
| Home lacked a 3-day supply of emergency drinking water and food for residents. |
| Home's written emergency procedures not submitted to Philadelphia Emergency Management Agency. |
| No documentation of written notification to local fire department regarding home address, bedroom locations, and evacuation assistance. |
| No documentation of annual fire safety inspection and fire drill by a fire safety expert. |
| No maximum safe evacuation time specified in writing by a fire safety expert; evacuation drill exceeded 2 minutes 30 seconds. |
| Annual medical evaluations missing for residents 2, 3, 4, 5, 6, and 7. |
| Resident 8 self-administers medications stored unlocked and unattended in bedroom. |
| Expired and improperly stored medications found in medication cart. |
| Home not tracking counts on controlled substances; no narcotic count sheets or shift change counts. |
| Medication prescribed for resident 5 not available in home. |
| Staff person D administered medications without completing Department-approved medication administration course. |
Report Facts
Residents served: 67
License capacity: 81
Staffing hours: 58.5
Required direct care hours: 67
Waking hours provided: 35.5
Waking hours required: 50.25
Resident labor compensation: 2.5
Resident labor hours: 7
Rent reduction: 75
Medication dosages: 19445
Medication dosages: 500
Medication dosages: 16
Inspection Report
Renewal
Census: 50
Capacity: 81
Deficiencies: 15
Jun 27, 2023
Visit Reason
The inspection was an unannounced full renewal inspection conducted to review compliance with licensing regulations.
Findings
The inspection identified multiple deficiencies including staff qualification documentation, inadequate hot water temperature, missing window coverings, improper refrigerator temperatures, lack of current rabies vaccination for a cat, incomplete medical evaluations, medication storage and administration issues, and incomplete resident assessments. Plans of correction were accepted and implemented by 11/02/2023.
Deficiencies (15)
| Description |
|---|
| Direct care staff person does not have a high school diploma, GED, or active registry status on the Pennsylvania nurse aide registry. |
| Insufficient hot water to bathroom in hallway D with water temperature peaking at 75 degrees Fahrenheit. |
| Hot water temperature at bathroom in hallway A measured 142 degrees Fahrenheit, exceeding 120°F limit. |
| First aid kit does not include a thermometer. |
| Window in bedroom 110 does not have shades, blinds, or shutters. |
| Main kitchen refrigerator temperature was 55 degrees Fahrenheit, exceeding the required 40°F or below. |
| A cat present at the home does not have a current certificate of rabies vaccination. |
| Resident 1's medical evaluation did not include mobility assessment and special health or dietary needs. |
| Resident 2's most recent medical evaluation was not completed as required. |
| Loose round white pill found in medication cart and a bottle of ibuprofen without a cap or cover. |
| Resident 2 prescribed medication was not available in the home during inspection. |
| Controlled substance count for Resident 4 was inaccurate; 19 pills documented but 20 pills present. |
| Resident 2's medication administration was documented on MAR but not on the controlled substance log. |
| Resident 2's medication was not administered at prescribed times. |
| Resident 1’s annual assessment was not completed within a year. |
Report Facts
License Capacity: 81
Residents Served: 50
Staffing Hours: 50
Waking Staff: 38
Supplemental Security Income Recipients: 33
Residents Diagnosed with Mental Illness: 41
Residents Aged 60 or Older: 30
Residents Diagnosed with Intellectual Disability: 2
Residents with Physical Disability: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Marlo Evans | Held responsible for medication cart audits and ensuring medication bottles have tops. |
Inspection Report
Renewal
Census: 50
Capacity: 81
Deficiencies: 6
Apr 19, 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. Several deficiencies were identified related to staff qualifications, fire safety, medication disposal, and support plan documentation, all of which were addressed with accepted plans of correction.
Deficiencies (6)
| Description |
|---|
| Direct care staff person A does not have a high school diploma, GED, or active registry status on the Pennsylvania nurse aide registry. |
| The fire exit door located on the third floor of building 5919 fell off the hinges upon opening. |
| An unannounced fire drill was not held in 2022. |
| The home has not had a fire safety inspection and fire drill conducted by a fire safety expert. |
| Medication belonging to resident #1 expired and was observed in the medication cart, which is not an approved method of destroying medications. |
| Resident #2's support plan dated 2022 does not include a marking or circle for each level of degree for all sections. |
Report Facts
License Capacity: 81
Residents Served: 50
Total Daily Staff: 50
Waking Staff: 38
Residents Receiving Supplemental Security Income: 41
Residents Diagnosed with Mental Illness: 43
Residents Aged 60 or Older: 25
Residents Diagnosed with Intellectual Disability: 2
Inspection Report
Renewal
Census: 52
Capacity: 81
Deficiencies: 17
Feb 22, 2021
Visit Reason
The inspection was an unannounced full renewal inspection conducted on February 22 and 23, 2021 to review compliance with licensing regulations.
Findings
The inspection identified multiple deficiencies including failure to post the current license inspection summary, incomplete criminal background checks, direct care staff qualifications not met, uncovered trash receptacles, hot water temperature exceeding limits, furniture hazards, snow removal issues, inoperable bedside lamp, insufficient showers, lack of soap and hand drying means in bathrooms, outdated emergency management submission, overdue furnace inspection, repeated use of same fire drill exits, incomplete medication course certifications, and incomplete resident assessments.
Deficiencies (17)
| Description |
|---|
| License Inspection Summary not posted in a conspicuous and public place. |
| Criminal background check for a direct care staff member was not completed timely. |
| Direct care staff person does not have a high school diploma, GED, or active registry status. |
| Dumpsters behind the home were not covered and overflowing with trash. |
| Hot water temperature in 2nd floor 2nd bathroom measured 136.5°F, exceeding 120°F limit. |
| Cushions on large sofa in day room sunken in, posing hazard. |
| Approximately 5 inch accumulation of snow and ice on front steps. |
| Light at bed B in bedroom 207 was not operable (unplugged). |
| Only 3 showers available for 52 residents, ratio below required 1:10 users. |
| No soap in soap dispenser in 2nd floor 2nd bathroom. |
| No paper towels, mechanical hand dryer or other sanitary means of hand drying in 2nd floor 2nd bathroom. |
| Written emergency procedures not submitted to local emergency management agency since 2017. |
| Last furnace inspection conducted on 4/23/19, overdue for annual inspection. |
| Same exits used for all three fire drills on 8/22/19, 9/7/19, and 10/1/19, not alternating exits. |
| Staff person A did not complete annual medication administration practicum; staff persons C and D also overdue. |
| Resident #1's initial assessment incomplete, missing some personal care needs and degree. |
| Resident #2's additional assessment incomplete, missing short term memory, long term memory, and ability to use and avoid poisonous materials. |
Report Facts
License Capacity: 81
Residents Served: 52
Staffing Hours: 52
Waking Staff: 39
Hot Water Temperature: 136.5
Snow Accumulation: 5
Number of Showers: 3
Inspection Report
Renewal
Census: 52
Capacity: 81
Deficiencies: 17
Feb 22, 2021
Visit Reason
The inspection was a renewal inspection conducted on 02/22/2021 and 02/23/2021 to assess compliance with licensing requirements for KAYSIM-COURT MANOR.
Findings
The inspection identified multiple violations including failure to post the current license inspection summary, delayed criminal background checks, unqualified direct care staff, uncovered trash receptacles, excessive hot water temperature, furniture hazards, snow and ice obstructions, inoperable bedside lamp, insufficient showers, lack of soap and hand drying means in bathrooms, outdated emergency procedure submission, overdue furnace inspection, repeated use of same fire drill exits, incomplete resident assessments, and incomplete medication administration certification for staff.
Deficiencies (17)
| Description |
|---|
| The home's current License Inspection Summary was not posted in a conspicuous and public place. |
| Staff Person A's criminal background check was not completed until after employment start date. |
| Direct care staff person B does not have a high school diploma, GED, or active registry status on the Pennsylvania nurse aide registry. |
| Dumpsters behind the home were not covered and overflowing with trash, with discarded mattresses nearby. |
| Hot water temperature in the 2nd floor 2nd bathroom measured 136.5 degrees Fahrenheit, exceeding the 120°F limit. |
| Cushions on the large sofa in the day room were sunken in, posing a hazard. |
| Approximately 5 inch accumulation of snow and ice on the front steps of the home. |
| Light at bed B in bedroom 207 was not operable because it was unplugged. |
| The home had only 3 showers for 52 residents, not meeting the required ratio of one shower per 10 users. |
| No soap in the soap dispenser in the 2nd floor 2nd bathroom. |
| No paper towels, mechanical hand dryer, or other sanitary means of hand drying in the 2nd floor 2nd bathroom. |
| The home's written emergency procedures have not been submitted to the local emergency management agency since 2017. |
| The last inspection of the furnace was conducted on 4/23/19, overdue for annual inspection. |
| The same exits were used for all three fire drills conducted on 8/22/19, 9/7/19, and 10/1/19, not using alternate exit routes. |
| Staff person A did not complete the annual medication administration practicum; staff persons C and D last practicum was 10/10/19. |
| Resident #1's initial assessment was incomplete and did not include all factors of personal care needs and degree. |
| Resident #2's additional assessment was incomplete and did not include assessment for short term memory, long term memory, and ability to use and avoid poisonous materials. |
Report Facts
Inspection Dates: 2
Total Daily Staff: 52
Waking Staff: 39
License Capacity: 81
Residents Served: 52
Hot Water Temperature: 136.5
Snow Accumulation: 5
Number of Showers: 3
Furniture Cost: 800
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