Deficiencies per Year
20
15
10
5
0
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Complaint Investigation
Census: 58
Capacity: 100
Deficiencies: 1
Sep 9, 2025
Visit Reason
The inspection was conducted as a complaint investigation with an unannounced partial inspection to review compliance related to resident care and support plans.
Findings
The facility was found deficient in providing required assistance with activities of daily living (ADLs) for a resident, resulting in an injury. The submitted plan of correction was fully implemented and compliance was maintained.
Complaint Details
The visit was complaint-related as indicated by the inspection reason. The plan of correction was accepted and fully implemented, indicating the complaint was addressed.
Deficiencies (1)
| Description |
|---|
| Resident did not receive required assistance with transferring in and out of bed/chair, resulting in injury to nose. |
Report Facts
License Capacity: 100
Residents Served: 58
Secured Dementia Care Unit Capacity: 40
Secured Dementia Care Unit Residents Served: 18
Hospice Current Residents: 5
Residents Diagnosed with Mental Illness: 1
Residents with Mobility Need: 19
Residents Age 60 or Older: 58
Inspection Report
Complaint Investigation
Census: 55
Capacity: 100
Deficiencies: 5
Jul 2, 2025
Visit Reason
The inspection was conducted as a complaint, incident, and interim review to investigate issues related to resident care, staff access to records, staffing adequacy, fire drill records, evacuation procedures, and support plan revisions.
Findings
The inspection identified multiple deficiencies including denial of immediate access to records for the Long-Term Care Ombudsman, inadequate staffing on the third shift to safely evacuate residents, inaccurate fire drill records, failure of some residents to evacuate to designated meeting places during drills, and incomplete support plans regarding hospice services.
Complaint Details
The visit was complaint-related as indicated by the inspection information section stating Reason: Complaint, Incident, Interim. The complaint involved issues such as denial of access to records by the Ombudsman and staffing inadequacies.
Deficiencies (5)
| Description |
|---|
| Denial of immediate access to Resident's Electronic Medication Record to the Long-Term Care Ombudsman. |
| Inadequate staffing on 3rd shift to safely evacuate all residents in the event of an emergency. |
| Fire drill records contained inaccurate information regarding staff participation and number of residents evacuated. |
| Two residents did not evacuate to a designated meeting place during a fire drill. |
| Resident support plan did not indicate hospice services provided despite resident receiving hospice care. |
Report Facts
License Capacity: 100
Residents Served: 55
Residents in Secured Dementia Care Unit: 17
Current Hospice Residents: 3
Residents Age 60 or Older: 55
Residents with Mobility Need: 20
Staff on 3rd Shift: 3
Residents Requiring Assist of 2 for Transfer: 4
Residents Requiring Assist of 1 for Transfer: 21
Staff Participating in Fire Drill: 4
Staff Participating in Fire Drill: 12
Residents Present During Fire Drill: 51
Residents Evacuated During Fire Drill: 49
Residents Evacuated During Fire Drill: 6
Residents Not Evacuated to Designated Meeting Place: 2
Inspection Report
Follow-Up
Census: 61
Capacity: 100
Deficiencies: 6
Apr 22, 2025
Visit Reason
The inspection was a partial, unannounced visit conducted due to a complaint and incident. It included a review of submitted plans of correction and compliance with medication administration and reporting regulations.
Findings
The facility had multiple deficiencies related to medication administration errors, late or missing documentation of medication administration, refusal of medication not properly documented or reported, failure to follow prescriber's orders, medication error reporting delays, and missing resident signatures on support plans. The submitted plan of correction was fully implemented as of the follow-up review.
Complaint Details
The inspection was triggered by a complaint and incident, as noted in the inspection information section.
Deficiencies (6)
| Description |
|---|
| Failure to report medication errors to the Department within 24 hours as required. |
| Medication Administration Records were not initialed by staff to indicate medications were administered. |
| Refusals of medication were not documented or reported to the prescriber as required. |
| Failure to follow prescriber's orders regarding medication administration times. |
| Medication errors were not immediately reported to the resident's family or physician. |
| Resident support plan was not signed by the resident. |
Report Facts
Residents Served: 61
License Capacity: 100
Resident Support Staff: 1
Total Daily Staff: 85
Waking Staff: 64
Residents Served in Memory Care Unit: 19
Current Hospice Residents: 8
Residents Age 60 or Older: 61
Residents with Mobility Need: 23
Inspection Report
Follow-Up
Census: 62
Capacity: 100
Deficiencies: 2
Apr 8, 2025
Visit Reason
The inspection was a partial, unannounced visit conducted due to an incident at the facility.
Findings
The facility was found to have deficiencies related to delayed incident reporting and inadequate measures to prevent resident falls, including repeated falls of a resident without sufficient interventions. The submitted plan of correction was determined to be fully implemented.
Deficiencies (2)
| Description |
|---|
| Incident report for a resident's unwitnessed fall was not sent to DHS within the required 24 hours. |
| Resident experienced multiple falls over two months with insufficient safety measures in place to prevent further falls, resulting in injury. |
Report Facts
License Capacity: 100
Residents Served: 62
Secured Dementia Care Unit Capacity: 40
Secured Dementia Care Unit Residents Served: 20
Resident Falls: 8
Waking Staff: 65
Total Daily Staff: 86
Inspection Report
Complaint Investigation
Census: 59
Capacity: 100
Deficiencies: 3
Mar 18, 2025
Visit Reason
The inspection was conducted as a partial, unannounced visit due to a complaint and incident at the facility.
Findings
The inspection identified deficiencies including improper use of seclusion by putting a resident to bed against their wishes, failure to update resident assessment plans after significant changes, and incomplete medical evaluations missing key information such as dementia diagnosis and vital signs.
Complaint Details
The visit was complaint-related and incident-driven, with the complaint substantiated by findings of resident rights violations and care deficiencies.
Deficiencies (3)
| Description |
|---|
| Resident was put into bed against their wishes by staff, constituting prohibited seclusion. |
| Resident assessment plan was not updated to reflect significant changes in resident's condition requiring additional assistance. |
| Medical evaluation form lacked documentation of dementia diagnosis, need for secured dementia care, and vital signs. |
Report Facts
License Capacity: 100
Residents Served: 59
Secured Dementia Care Unit Capacity: 40
Residents Served in Secured Dementia Care Unit: 17
Current Residents in Hospice: 8
Residents Age 60 or Older: 59
Residents with Mobility Need: 26
Residents with Physical Disability: 3
Total Daily Staff: 85
Waking Staff: 64
Inspection Report
Follow-Up
Census: 64
Capacity: 100
Deficiencies: 4
Nov 5, 2024
Visit Reason
The inspection was conducted as a partial, unannounced incident investigation to review compliance following reported incidents and a submitted plan of correction.
Findings
The facility was found to have multiple violations related to failure to report incidents timely, abuse, treatment of residents with dignity and respect, and incomplete support plans. The plan of correction was accepted and implemented, with retraining and audits scheduled to ensure compliance.
Deficiencies (4)
| Description |
|---|
| Incidents were not reported to the Department within the mandatory 24-hour timeframe. |
| Resident was physically abused by Staff A who grabbed and pinched the resident's fingers and arm during care. |
| Resident was threatened and verbally abused by Staff A using vulgar language and disrespectful statements. |
| Resident's support plan was not updated to reflect involvement of hospice services. |
Report Facts
License Capacity: 100
Residents Served: 64
Secured Dementia Care Unit Capacity: 40
Secured Dementia Care Unit Residents Served: 17
Current Hospice Residents: 7
Staffing Hours - Total Daily Staff: 88
Staffing Hours - Waking Staff: 66
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Named in multiple findings related to physical abuse, verbal abuse, and disrespectful treatment of residents. | |
| Staff B | Witnessed incidents involving Staff A and residents. | |
| Administrator | Administrator | Reported incidents late, accepted plan of correction, retrained staff, conducted audits, and took disciplinary action including suspension and termination of Staff A. |
| Healthcare Director | Healthcare Director | Conducted resident safety checks, interviews, chart audits, and participated in retraining and compliance monitoring. |
| Assistant Healthcare Director | Assistant Healthcare Director | Assisted in resident safety checks and interviews. |
Inspection Report
Renewal
Census: 67
Capacity: 100
Deficiencies: 6
Oct 1, 2024
Visit Reason
The inspection was conducted as part of licensing inspections on October 1 and 2, 2024, to assess compliance with 55 Pa. Code Chapter 2600 relating to Personal Care Homes, including complaint, provisional, incident, and interim reasons.
Findings
The facility was found to be in compliance with applicable regulations after corrections were made. Several deficiencies were identified related to emergency procedures, menu posting, medication administration, prescription labeling, following prescriber's orders, and support plan documentation, all of which had plans of correction accepted and implemented.
Complaint Details
The inspection included complaint, provisional, incident, and interim reasons as stated in the inspection information.
Deficiencies (6)
| Description |
|---|
| Failure to manually trigger fire alarm during a small kitchen fire as per home’s policy. |
| Menus were not posted one week in advance as required. |
| Medication administration steps were not properly followed; medication was removed from blister pack and taped back after blood pressure check was too low to administer medication. |
| Medication (Latanoprost eye drops) lacked date of first use or expiration date on label. |
| Resident's blood sugar checks were performed earlier than prescribed times. |
| Resident support plans did not include required verbiage regarding use of enabler bars and medication assistance. |
Report Facts
License Capacity: 100
Residents Served: 67
Secured Dementia Care Unit Capacity: 40
Residents Served in Dementia Unit: 20
Current Hospice Residents: 7
Total Daily Staff: 94
Waking Staff: 71
Residents with Mobility Need: 27
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Juliet Marsala | Deputy Secretary | Signed licensing letter and certificate of compliance. |
Inspection Report
Complaint Investigation
Census: 68
Capacity: 100
Deficiencies: 1
Aug 28, 2024
Visit Reason
The inspection was conducted as a complaint investigation following information received about a malfunctioning door keypad between the personal care and memory care units.
Findings
The inspection found that the door leading from personal care to the memory care unit was not functioning properly for about two weeks, preventing staff and family members from exiting the memory care unit through this door. The keypad was replaced prior to the inspection and a monitoring plan was implemented to ensure ongoing functionality.
Complaint Details
The complaint was substantiated based on staff interviews confirming the keypad malfunction. The department verified the issue through interviews but not functionality testing.
Deficiencies (1)
| Description |
|---|
| Door leading from personal care to memory care unit was not functioning properly for around two weeks, preventing exit through the door. |
Report Facts
License Capacity: 100
Residents Served: 68
Secured Dementia Care Unit Capacity: 40
Residents Served in Dementia Unit: 20
Current Hospice Residents: 10
Total Daily Staff: 88
Waking Staff: 66
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Carhart | Administrator | Named as facility administrator |
| Amy Deluca | Lead Inspector | Conducted the on-site inspection |
| Jason Harvey | Human Services Licensing Supervisor | Reviewer and signatory of the inspection summary |
| Andrea DiOttavio | Submitted plan of correction and document submissions |
Inspection Report
Complaint Investigation
Census: 67
Capacity: 100
Deficiencies: 3
Aug 15, 2024
Visit Reason
The inspection was conducted as a complaint and incident investigation to review compliance with care and treatment regulations at the facility.
Findings
The inspection found multiple deficiencies including failure to provide assistance with activities of daily living as required by resident support plans, mistreatment and abuse by staff towards residents, and unsanitary conditions in resident rooms. Corrective actions and staff re-education were implemented.
Complaint Details
The visit was complaint-related, triggered by allegations of neglect and mistreatment. The complaint was substantiated as the facility failed to protect residents from abuse and neglect, and failed to provide required assistance and sanitary conditions.
Deficiencies (3)
| Description |
|---|
| Failure to consistently follow the support plan for bladder management and assistance changing soiled undergarments for a resident. |
| Resident was scolded and handled roughly by staff, including being changed in the living room instead of the bathroom, causing fear of staff. |
| Unsanitary conditions observed including soiled depends on the floor and urine-like substance on carpet with no staff response to resident calls for assistance. |
Report Facts
License Capacity: 100
Residents Served: 67
Secured Dementia Care Unit Capacity: 32
Residents Served in Dementia Unit: 21
Residents with Mobility Need: 21
Total Daily Staff: 88
Waking Staff: 66
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff Person A | Named in mistreatment and abuse findings; suspended and terminated following investigation | |
| Healthcare Director | Involved in re-education of staff and review of audits related to deficiencies | |
| Assistant Healthcare Director | Involved in re-education of staff and review of audits related to deficiencies | |
| Maintenance Director | Responsible for cleaning and auditing resident rooms for sanitary conditions | |
| Administrator | Interviewed residents, took immediate action suspending and terminating Staff Person A, and reviewed resident council minutes |
Inspection Report
Complaint Investigation
Census: 68
Capacity: 100
Deficiencies: 4
Jul 17, 2024
Visit Reason
The inspection was conducted as a complaint and incident investigation to review compliance with regulations and assess the facility's response to reported issues.
Findings
The inspection identified multiple deficiencies including delayed response to call bells, inadequate medication administration training, failure to follow prescriber orders, and inaccurate resident support plans. Plans of correction were accepted and implemented with ongoing monitoring.
Complaint Details
The visit was complaint-related with substantiation of issues including delayed call bell responses, medication administration errors, and inaccurate resident support plans.
Deficiencies (4)
| Description |
|---|
| Delayed response to call bells with some unanswered for over 15 minutes and up to several hours, resulting in unmet resident needs. |
| No staff present who were trained in medication administration on several days, despite residents requiring PRN medications. |
| Failure to follow prescriber orders for medication administration, including administering medication when it should have been held based on vital sign parameters. |
| Resident support plan contained contradictory information regarding resident's care needs and cognitive status. |
Report Facts
Residents Served: 68
License Capacity: 100
Secured Dementia Care Unit Capacity: 25
Secured Dementia Care Unit Residents Served: 23
Hospice Current Residents: 6
Residents Age 60 or Older: 26
Residents with Mobility Need: 23
Call Bell Response Times: 16
Call Bell Unanswered Duration: 805
Inspection Report
Plan of Correction
Census: 72
Capacity: 100
Deficiencies: 1
Jun 18, 2024
Visit Reason
The inspection was a follow-up visit to verify the implementation of a previously submitted plan of correction related to medication administration errors.
Findings
The submitted plan of correction was determined to be fully implemented. The original deficiency involved failure to follow prescriber's orders regarding medication administration based on residents' heart rates, with no documentation to indicate medication was held as ordered.
Deficiencies (1)
| Description |
|---|
| Failure to follow prescriber's instructions for holding medication based on residents' systolic blood pressure and heart rate, with no documentation of medication being held accordingly. |
Report Facts
License Capacity: 100
Residents Served: 72
Secured Dementia Care Unit Capacity: 32
Residents Served in Dementia Unit: 26
Hospice Residents: 8
Total Daily Staff: 98
Waking Staff: 74
Resident with Mobility Need: 26
Plan of Correction Completion Date: 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Healthcare Director | Identified medication error during inspection and took swift action | |
| Assistant Health Care Director (EMT) | Provided on-the-spot training to medication technician responsible for error | |
| Regional Healthcare Specialist | Conducted comprehensive retraining of medication technicians | |
| Administrator/Designee | Responsible for auditing MARs weekly for six weeks to ensure compliance |
Inspection Report
Complaint Investigation
Census: 71
Capacity: 100
Deficiencies: 8
Apr 18, 2024
Visit Reason
The inspection was conducted as a complaint investigation and interim exit conference to address violations found during multiple licensing inspections on December 13, 2023, February 1, 2024, March 5, 2024, and April 18, 2024.
Findings
The facility was found to have multiple violations including failure to report incidents timely, inadequate assistance with activities of daily living, improper fire drill documentation, medication administration errors, and deficiencies in resident assessments and support plans. A provisional license was issued with a requirement to correct all violations by specified dates.
Complaint Details
The complaint involved allegations of neglect and inadequate care, including a resident found in unsanitary conditions after a fall and failure to report incidents timely. The complaint investigation confirmed multiple violations related to resident care and reporting.
Deficiencies (8)
| Description |
|---|
| Failure to report missed medication administration and incidents to the Department within required timeframes. |
| Resident left in unsanitary and unsafe conditions after a fall, with inadequate assistance and care. |
| Fire drill records lacked required details such as number of residents and staff participating. |
| Residents self-administering medications were not properly assessed or monitored. |
| Medication administration errors including incorrect insulin dosing and missed medications. |
| Inaccurate documentation of blood glucose readings and glucometer calibration issues. |
| Failure to complete cognitive preadmission screening within required timeframe. |
| Resident support plans and assessments were incomplete or not updated timely. |
Report Facts
Deficiencies cited: 8
Resident census: 71
Total licensed capacity: 100
Staffing hours: 98
Waking staff hours: 74
Correction deadlines: 5
Fine amount per day: 355
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Juliet Marsala | Deputy Secretary | Signed the letter issuing the provisional license and enforcement actions. |
| Unnamed Administrator | Administrator | Named in relation to failure to follow procedures and staff training deficiencies. |
| Unnamed Health Care Director | Health Care Director | Named in relation to medication errors, staff training, and compliance monitoring. |
| Unnamed Assistant Health Care Director | Assistant Health Care Director | Named in relation to medication errors, staff training, and compliance monitoring. |
| Unnamed Maintenance Director | Maintenance Director | Named in relation to fire drill deficiencies and corrective actions. |
| Unnamed Residence Director | Residence Director | Named in relation to quality management meetings and staff training. |
Inspection Report
Complaint Investigation
Census: 71
Capacity: 100
Deficiencies: 7
Apr 18, 2024
Visit Reason
The inspection was conducted as a complaint investigation with interim exit conference on 04/26/2024, triggered by complaints and incidents reported at the facility.
Findings
Multiple deficiencies were found including failure to report incidents timely, inadequate assistance with activities of daily living, improper fire drill documentation, medication administration errors, and failure to follow prescriber's orders. The facility was issued a provisional license due to these violations and required to submit plans of correction.
Complaint Details
The complaint involved allegations of inadequate care following a resident's fall and hospitalization, including failure to report incidents timely and leaving the resident in unsanitary conditions. The complaint was substantiated with findings of multiple violations.
Deficiencies (7)
| Description |
|---|
| Failure to report missed medication administration and incidents to the Department within required timeframes. |
| Resident left in soiled bed with inadequate assistance with activities of daily living after a fall and hospitalization. |
| Fire drill records lacked required details including number of residents and staff participating. |
| Resident self-administration assessment not properly followed; resident had unauthorized medication in room. |
| Medication administration errors including incorrect insulin dosing and missed medications due to unavailability. |
| Medication storage procedures not properly followed; glucometer calibration and documentation errors. |
| Failure to conduct cognitive preadmission screening within required 72-hour window for secured dementia care unit admission. |
Report Facts
Deficiencies cited: 7
Resident census: 71
Total licensed capacity: 100
Fine amount per violation: 355
Correction timeframe: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Juliet Marsala | Deputy Secretary | Signed the letter issuing the provisional license and enforcement actions. |
| Directed [Name Redacted] | Administrator or Designee | Named in multiple plans of correction related to incident reporting, medication administration, and staff training. |
Inspection Report
Enforcement
Census: 71
Capacity: 100
Deficiencies: 19
Apr 18, 2024
Visit Reason
The inspection was conducted as a complaint investigation and interim exit conference to address multiple violations found during prior inspections and to review the facility's plan of correction submissions.
Findings
The facility was found to have multiple deficiencies including failure to report incidents timely, inadequate assistance with activities of daily living, improper fire drill documentation, medication administration errors, and incomplete resident assessments and support plans. Several repeat violations were noted. The facility submitted plans of correction and was issued a provisional license with fines pending if corrections are not made.
Complaint Details
The visit was complaint-related, triggered by allegations including missed medication administration, resident neglect, and failure to report incidents. The complaint was substantiated based on findings of multiple violations including failure to report incidents timely and inadequate resident care.
Deficiencies (19)
| Description |
|---|
| Failure to report missed medication administration and incidents to the Department within required timeframes. |
| Resident left in soiled conditions and inadequate assistance with activities of daily living. |
| Fire drill records lacked required details such as number of residents and staff participating. |
| Residents self-administering medications were not properly assessed or monitored. |
| Medication administration errors including incorrect insulin dosing and missed medications. |
| Medication storage and glucometer calibration deficiencies. |
| Incomplete or inaccurate resident assessments, support plans, and preadmission screenings. |
| Inadequate staffing levels to meet resident mobility and care needs during certain shifts. |
| Failure to maintain proper food labeling and menu posting. |
| Failure to immediately report suspected resident abuse and incidents to the Area Agency on Aging and Department. |
| Resident funds accounting errors and failure to provide accurate itemized accounts upon discharge. |
| Failure to post current license inspection summaries in a conspicuous public place. |
| Failure to maintain adequate first aid and CPR trained staff coverage. |
| Failure to properly document medication administration records and follow prescriber's orders. |
| Failure to report medication errors to residents, designated persons, and prescribers. |
| Failure to document medical evaluations within required timeframes and with complete information. |
| Failure to maintain current prescription medications and discard expired medications. |
| Failure to implement safe management techniques to address resident aggression. |
| Failure to document required information regarding use of bedside mobility devices in resident support plans. |
Report Facts
Resident census: 71
Total licensed capacity: 100
Fines calculated: 355
Correction timeframe: 5
Staffing hours: 98
Waking staff hours: 74
Residents with mobility needs: 27
Residents served in secured dementia care unit: 25
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Juliet Marsala | Deputy Secretary | Signed enforcement and licensing letters |
| Unnamed Administrator | Administrator | Named in relation to failure to follow reporting procedures and oversight of plan of correction |
| Unnamed Health Care Director | Health Care Director | Named in multiple findings related to medication errors, incident reporting, staff education, and resident care |
| Unnamed Assistant Health Care Director | Assistant Health Care Director | Named in multiple findings related to medication errors, incident reporting, staff education, and resident care |
| Unnamed Maintenance Director | Maintenance Director | Named in relation to fire drill deficiencies and corrective actions |
| Unnamed Residence Director | Residence Director | Named in relation to quality management meetings, staff training, and compliance monitoring |
| Unnamed Customer Service Associate | Customer Service Associate | Named in relation to staff training audits and record access |
| Unnamed Dining Director | Dining Director | Named in relation to food storage and menu posting deficiencies |
Inspection Report
Enforcement
Census: 71
Capacity: 100
Deficiencies: 16
Apr 18, 2024
Visit Reason
The inspection was conducted as a complaint and interim visit to investigate allegations and verify compliance with regulations.
Findings
Multiple violations were found including failure to report incidents timely, inadequate assistance with activities of daily living, improper fire drill documentation, medication administration errors, and deficiencies in staff training and record keeping. The facility was issued a provisional license due to these violations and required to submit plans of correction.
Complaint Details
The complaint involved allegations of neglect and inadequate care including a resident found in soiled bedding after a fall, missed medication administration, and failure to report incidents timely. The complaint was substantiated with multiple violations found during the inspection.
Deficiencies (16)
| Description |
|---|
| Failure to report missed medication administration and incidents to the Department within required timeframes. |
| Resident left in soiled bed with inadequate assistance after a fall, violating care plan requirements. |
| Fire drill records lacked required details such as number of residents and staff participating. |
| Residents self-administering medications were not properly assessed or monitored. |
| Medication administration errors including incorrect insulin dosing and missed medications. |
| Expired medications found in medication carts. |
| Inadequate staffing levels to meet residents' mobility needs and emergency evacuation requirements. |
| Failure to maintain confidentiality of resident records. |
| Food storage violations including unlabeled and undated food items. |
| Resident support plans and assessments not completed or updated timely to reflect resident needs. |
| Failure to post required licensing inspection summaries and menus in a conspicuous place. |
| Resident funds accounting not accurately provided upon discharge. |
| Failure to follow prescriber's orders and medication record documentation errors. |
| Failure to immediately report medication errors to resident, designated person, and prescriber. |
| Preadmission screening forms incomplete or not properly documented. |
| Support plans missing required medical, dental, vision, hearing, mental health or behavioral care service documentation. |
Report Facts
Deficiencies cited: 16
Resident census: 71
Licensed capacity: 100
Staffing hours: 98
Waking staff hours: 74
Fine amount: 355
Correction timeframe: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Juliet Marsala | Deputy Secretary | Signed enforcement and licensing letters. |
| Unnamed Administrator | Administrator | Named in relation to failure to follow procedures and staff training deficiencies. |
| Unnamed Health Care Director | Health Care Director | Named in relation to medication errors, incident reporting, staff training, and corrective actions. |
| Unnamed Assistant Health Care Director | Assistant Health Care Director | Named in relation to medication errors, incident reporting, staff training, and corrective actions. |
| Unnamed Maintenance Director | Maintenance Director | Named in relation to fire drill deficiencies and corrective actions. |
| Unnamed Residence Director | Residence Director | Named in relation to quality management meetings and staff training. |
| Unnamed Customer Service Associate | Customer Service Associate | Named in relation to staff training audits and record access. |
Inspection Report
Complaint Investigation
Census: 81
Capacity: 100
Deficiencies: 0
Apr 4, 2024
Visit Reason
The inspection was conducted as a complaint and incident investigation at the facility.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Complaint Details
The inspection was complaint-related with no deficiencies found and no follow-up required.
Report Facts
License Capacity: 100
Residents Served: 81
Secured Dementia Care Unit Capacity: 40
Residents Served in Dementia Unit: 26
Hospice Residents: 6
Resident Support Staff: 0
Total Daily Staff: 112
Waking Staff: 84
Residents Age 60 or Older: 81
Residents with Mobility Need: 31
Inspection Report
Census: 81
Capacity: 100
Deficiencies: 0
Nov 21, 2023
Visit Reason
The inspection was conducted as a licensing inspection by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing, triggered by an incident.
Findings
No regulatory citations or deficiencies were identified during this unannounced partial inspection.
Report Facts
Residents Served: 81
License Capacity: 100
Secured Dementia Care Unit Capacity: 40
Residents Served in Secured Dementia Care Unit: 28
Current Residents in Hospice: 8
Residents Age 60 or Older: 81
Residents with Mobility Need: 30
Inspection Report
Complaint Investigation
Census: 81
Capacity: 100
Deficiencies: 3
Sep 5, 2023
Visit Reason
The inspection was conducted as a complaint and incident investigation at the facility.
Findings
The inspection found neglect related to unexplained bruises and injuries to Resident #1, inadequate supervision during an incident where Resident #1 was pushed by Resident #2, and failure to update the resident's support plan to reflect changes in medical needs such as incontinence and use of compression stockings. Plans of correction were accepted and implemented.
Complaint Details
The visit was complaint-related with substantiated neglect and inadequate supervision findings involving Resident #1 and Resident #2. The facility was cited for failure to protect Resident #1 from injury and failure to update support plans accordingly.
Deficiencies (3)
| Description |
|---|
| Resident #1 suffered unexplained bruises and injuries due to neglect and lack of supervision during an incident where Resident #2 pushed Resident #1. |
| Resident #1's support plan was not revised within 30 days to address changes in needs such as incontinence and use of compression stockings. |
| Resident #1's support plan did not document current medical and behavioral care needs including more frequent safety checks and use of compression stockings. |
Report Facts
License Capacity: 100
Residents Served: 81
Residents in Secured Dementia Care Unit: 28
Capacity of Secured Dementia Care Unit: 40
Current Hospice Residents: 8
Residents 60 Years or Older: 81
Residents with Mobility Need: 30
Total Daily Staff: 111
Waking Staff: 83
Inspection Report
Complaint Investigation
Census: 88
Capacity: 100
Deficiencies: 2
Jun 8, 2023
Visit Reason
The inspection was conducted as a complaint investigation following a complaint survey regarding medication administration and blood glucose monitoring at the facility.
Findings
The inspection found deficiencies related to inaccurate documentation of blood glucose readings and failure to administer prescribed insulin doses on specified dates. The errors were attributed to a medication technician no longer employed by the facility. The facility submitted and implemented a plan of correction to address these issues.
Complaint Details
The complaint investigation found that on March 4 and 8, insulin was not administered as ordered. The responsible medication technician is no longer employed by the facility. The facility plans to educate current medication technicians on medication administration safety and auditing procedures.
Deficiencies (2)
| Description |
|---|
| Inaccurate documentation of blood glucose readings on multiple dates. |
| Failure to test blood glucose and administer insulin as ordered on specified dates. |
Report Facts
Residents Served: 88
License Capacity: 100
Blood Glucose Documentation Errors: 3
Missed Blood Glucose Tests: 4
Missed Insulin Administrations: 2
Inspection Report
Complaint Investigation
Census: 79
Capacity: 100
Deficiencies: 0
May 12, 2023
Visit Reason
The inspection was conducted as a complaint investigation at the facility.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Complaint Details
The inspection was complaint-driven and partial in nature, with an unannounced notice. No deficiencies or citations were found.
Report Facts
License Capacity: 100
Residents Served: 79
Secured Dementia Care Unit Capacity: 40
Secured Dementia Care Unit Residents Served: 33
Current Hospice Residents: 6
Residents with Mobility Need: 33
Residents Age 60 or Older: 79
Inspection Report
Follow-Up
Census: 79
Capacity: 100
Deficiencies: 5
Feb 15, 2023
Visit Reason
The inspection visit on 02/15/2023 was conducted as a follow-up to verify the implementation of a previously submitted plan of correction related to an incident.
Findings
The facility was found to have fully implemented the plan of correction addressing sanitary conditions, emergency telephone postings, refrigerator thermometer placement, fire extinguisher accessibility, and key-locking device code posting. Continued compliance is required.
Deficiencies (5)
| Description |
|---|
| The glucometer of Resident 1 was used in error on Resident 2, violating sanitary conditions. |
| No emergency telephone numbers were posted by the landline telephone in the Reminiscence parlor. |
| No thermometer was present in the refrigerator located in the bistro. |
| Fire extinguishers in the reflection unit were locked and inaccessible in the event of an emergency. |
| Incorrect code was posted near the keypad to operate the magnetic lock exiting the building from the dining room in the reflection’s unit. |
Report Facts
License Capacity: 100
Residents Served: 79
Secured Dementia Care Unit Capacity: 40
Residents Served in Dementia Unit: 33
Hospice Residents: 6
Residents Age 60 or Older: 79
Residents with Mobility Need: 33
Total Daily Staff: 112
Waking Staff: 84
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Named in relation to corrections and monitoring of fire extinguisher accessibility and keypad code posting | |
| Director of Culinary Services | Named in relation to correction and monitoring of refrigerator thermometer placement | |
| Health Care Director | Named in relation to monitoring sanitary conditions and glucometer cleaning |
Inspection Report
Renewal
Census: 81
Capacity: 100
Deficiencies: 1
Aug 2, 2022
Visit Reason
The inspection was conducted as a full, unannounced renewal inspection due to the sale of the legal entity operating the facility.
Findings
The facility was found to be in substantial compliance with applicable regulations, but citations were issued including a deficiency for not conducting a fire drill during sleeping hours within the required timeframe. A plan of correction was accepted and follow-up inspections were scheduled.
Deficiencies (1)
| Description |
|---|
| No fire drill was completed during sleeping hours from December 2021 through May 2022. |
Report Facts
License Capacity: 100
Residents Served: 81
Secured Dementia Care Unit Capacity: 40
Residents Served in Dementia Unit: 29
Staffing Hours - Total Daily Staff: 111
Staffing Hours - Waking Staff: 83
Residents with Mobility Need: 30
Loading inspection reports...
