Deficiencies per Year
8
6
4
2
0
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Renewal
Census: 37
Capacity: 48
Deficiencies: 5
Oct 17, 2024
Visit Reason
The inspection was conducted as a renewal visit to assess compliance with licensing requirements at Legacy Place Cottages.
Findings
The inspection identified several deficiencies related to food labeling, medication management, and adherence to prescriber orders. All deficiencies were addressed with plans of correction that were fully implemented by the time of the report.
Deficiencies (5)
| Description |
|---|
| A partially used bag of frozen corn was found in the freezer without a label indicating the date it was opened. |
| A discontinued ointment medication was found in the medication cart for Resident #1. |
| Medication label for Resident #2 did not match the current PRN order and had incorrect administration instructions. |
| Medication administration record for Resident #2 lacked initials indicating medication was administered as scheduled on 10/2/24 at 9pm. |
| Resident #2 was administered a nasal saline spray instead of the prescribed nasal gel as per prescriber’s order. |
Report Facts
License Capacity: 48
Residents Served: 37
Secured Dementia Care Unit Capacity: 18
Secured Dementia Care Unit Residents Served: 16
Current Hospice Residents: 7
Residents with Mobility Need: 16
Residents 60 Years or Older: 37
Total Daily Staff: 53
Waking Staff: 40
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Wellness Director | Wellness Director | Named in medication-related deficiencies and responsible for training and compliance |
| Dining Manager | Dining Manager | Named in food storage deficiency and responsible for compliance audits |
Inspection Report
Follow-Up
Census: 40
Capacity: 48
Deficiencies: 1
Mar 19, 2024
Visit Reason
The inspection was a partial, unannounced follow-up visit triggered by an incident to review the submitted plan of correction.
Findings
The submitted plan of correction was determined to be fully implemented. The incident involved unauthorized use of a resident's credit card by a staffing agency employee, who was blocked from the facility. Measures including staff training, criminal background checks, and resident education on financial safety were implemented.
Deficiencies (1)
| Description |
|---|
| Unauthorized use of a resident's credit card by a staffing agency employee. |
Report Facts
License Capacity: 48
Residents Served: 40
Staffing Hours: 57
Waking Staff: 43
Secured Dementia Care Unit Capacity: 18
Secured Dementia Care Unit Residents Served: 16
Hospice Current Residents: 6
Residents Age 60 or Older: 40
Residents with Mobility Need: 17
Inspection Report
Renewal
Census: 42
Capacity: 48
Deficiencies: 5
Sep 6, 2023
Visit Reason
The inspection was conducted as a renewal inspection with an incident review on 09/06/2023 at Legacy Place Cottages.
Findings
The submitted plan of correction was determined to be fully implemented. Deficiencies were found related to food storage labeling, refrigerator/freezer temperature monitoring, menu posting, medication management, and support plan revisions, all of which had corrective actions planned and implemented.
Deficiencies (5)
| Description |
|---|
| An undated white frozen beverage in an Arby's cup, resembling a milkshake, was found in the freezer of the home's kitchen. |
| The freezer located in the kitchen of the Personal Care Home did not contain a thermometer. |
| On 9-6-23 menus were posted through 9-9-23, not a week in advance as required. |
| Resident 1 had a discontinued prescription medication (Guggul Extract 500 MG) still available in the medication cart on 9-6-23. |
| The Resident Assessment Support Plan for Resident 2 was not updated to include the significant change of multiple rib fractures. |
Report Facts
License Capacity: 48
Residents Served: 42
Secured Dementia Care Unit Capacity: 16
Secured Dementia Care Unit Residents Served: 16
Hospice Current Residents: 7
Total Daily Staff: 58
Waking Staff: 44
Resident with Mobility Need: 16
Residents 60 Years or Older: 42
Inspection Report
Renewal
Census: 38
Capacity: 48
Deficiencies: 2
Jun 15, 2022
Visit Reason
The inspection was an unannounced full renewal inspection conducted on 06/15/2022 to review the facility's compliance with licensing requirements.
Findings
The submitted plan of correction was found to be fully implemented. Two medication-related deficiencies were identified involving incorrect medication administration records and failure to follow prescriber's orders, both of which were immediately remediated with staff training and process improvements.
Deficiencies (2)
| Description |
|---|
| Medication record did not correctly indicate that a tablet should be cut in half and administered once daily. |
| Medication was withheld when it should have been administered due to a med tech misreading the order. |
Report Facts
License Capacity: 48
Residents Served: 38
Resident Support Staff: 15
Total Daily Staff: 68
Waking Staff: 51
Current Hospice Residents: 4
Residents with Mobility Need: 15
Residents 60 Years or Older: 38
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Wellness | Named in relation to medication record deficiency and corrective actions |
Inspection Report
Follow-Up
Census: 40
Capacity: 48
Deficiencies: 2
Mar 28, 2022
Visit Reason
The inspection was a partial, unannounced follow-up visit triggered by an incident at the facility, specifically related to a plan of correction submission and review of compliance with prior deficiencies.
Findings
The facility was found to have fully implemented the submitted plan of correction related to failure to submit a final incident report and failure to update a resident's support plan after a significant incident. Continued compliance was emphasized.
Deficiencies (2)
| Description |
|---|
| Failure to submit a final incident report regarding resident #1's hospitalization, skilled nursing rehabilitation discharge dates, and follow-up medical care. |
| Failure to update resident #1's support plan after a hospital evaluation and subsequent fall resulting in a hip fracture. |
Report Facts
License Capacity: 48
Residents Served: 40
Secured Dementia Care Unit Capacity: 18
Residents Served in Dementia Unit: 16
Hospice Residents: 7
Resident Support Staff Hours: 40
Total Daily Staff: 96
Waking Staff Hours: 72
Notice
Capacity: 48
Deficiencies: 0
Aug 27, 2021
Visit Reason
The document serves as a renewal notification and license issuance for the Personal Care Home 'Legacy Place Cottages' following receipt of the renewal application dated June 4, 2021. It also advises that an annual inspection will be conducted within the next twelve months as required by regulation.
Findings
No inspection findings are reported in this document; it is a license renewal notice and certificate of compliance confirming the facility meets regulatory requirements as of the renewal date.
Report Facts
Maximum licensed capacity: 48
Secure Dementia Care Unit capacity: 18
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary | Signed the renewal notification letter. |
Inspection Report
Renewal
Census: 33
Capacity: 48
Deficiencies: 3
Aug 10, 2021
Visit Reason
The inspection was conducted as a renewal inspection of the facility's license.
Findings
The inspection identified deficiencies related to sanitary conditions, medical evaluation documentation, and medication storage procedures. Plans of correction were submitted and determined to be fully implemented.
Deficiencies (3)
| Description |
|---|
| The strap holding the blood glucose monitor for Resident #1 had dried red material that appeared to be dried blood, creating unsanitary conditions. |
| Resident #2's medical evaluation form had edits made after being signed by non-licensed staff, which is not compliant with regulations. |
| Narcotic count sheets were not signed by the required staff on multiple dates and times, violating medication storage procedures. |
Report Facts
License Capacity: 48
Residents Served: 33
Secured Dementia Care Unit Capacity: 18
Residents Served in Dementia Unit: 14
Current Hospice Residents: 3
Residents with Mobility Need: 17
Staffing Hours - Resident Support Staff: 68
Staffing Hours - Total Daily Staff: 118
Staffing Hours - Waking Staff: 89
Inspection Report
Routine
Deficiencies: 0
Apr 15, 2021
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.
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