Deficiencies per Year
12
9
6
3
0
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Renewal
Census: 52
Capacity: 64
Deficiencies: 3
Jan 7, 2025
Visit Reason
The inspection was conducted as a renewal inspection with an incident review at the facility on 01/07/2025 and 01/08/2025.
Findings
The inspection found violations related to resident abuse, medication procedures, and medication administration documentation. Immediate corrective actions were taken, and plans of correction were implemented and overseen by the Executive Director to ensure ongoing compliance.
Deficiencies (3)
| Description |
|---|
| Resident #1 hit Resident #2 causing injury; failure to prevent abuse and ensure resident safety. |
| Discrepancy in narcotic medication count for Resident #6; failure to properly document medication administration on narcotic count sheet. |
| Medication administration documentation was completed before medications were actually administered to Resident #3. |
Report Facts
License Capacity: 64
Residents Served: 52
Secured Dementia Care Unit Capacity: 48
Residents Served in Dementia Unit: 36
Current Hospice Residents: 7
Residents 60 Years or Older: 51
Residents with Mobility Need: 38
Staff Total Daily: 90
Staff Waking: 68
Medication doses available: 43
Medication doses recorded: 44
Inspection Report
Complaint Investigation
Census: 57
Capacity: 64
Deficiencies: 0
Sep 27, 2024
Visit Reason
The inspection was conducted as a complaint and incident investigation during an unannounced partial licensing inspection.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Complaint Details
The inspection was complaint-related and included an incident review; no deficiencies were found and no follow-up was required.
Report Facts
Total Daily Staff: 105
Waking Staff: 79
Resident Support Staff: 0
License Capacity: 64
Residents Served: 57
Secured Dementia Care Unit Capacity: 48
Secured Dementia Care Unit Residents Served: 46
Hospice Current Residents: 9
Residents Age 60 or Older: 56
Residents with Mobility Need: 48
Inspection Report
Renewal
Census: 52
Capacity: 64
Deficiencies: 9
Jan 31, 2024
Visit Reason
The inspection was conducted as a renewal review of the facility's license by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing on 01/31/2024 and 02/01/2024.
Findings
The inspection identified multiple deficiencies including lack of a carbon monoxide alarm near a gas stove, unsecured poisonous materials accessible to residents in the secured dementia care unit, unsanitary conditions with urine odor detected, unlabeled leftover food items, failure to evacuate to designated meeting places during fire drills, expired medications in the medication cart, medication administration errors, and missing resident signatures on support plans. Plans of correction were accepted and implemented by 02/16/2024.
Deficiencies (9)
| Description |
|---|
| No carbon monoxide alarm installed within 15 feet of gas stove in main kitchen. |
| Poisonous materials (mouthwash, toothpaste, deodorant) unlocked and accessible to residents in secured dementia care unit. |
| Pungent odor of urine detected in family room near bedrooms 1-8 of Mt. Hope cottage. |
| Unlabeled, undated container of individually wrapped chocolate chip and sugar cookies found in bottom kitchenette cabinet in Tabor cottage. |
| Residents did not evacuate to designated meeting places during multiple fire drills in various cottages. |
| Expired medications found in home's medication cart for Resident 6. |
| Discrepancy in controlled substance log for Resident 4's lorazepam medication; packet contained fewer tablets than recorded. |
| Medication administration errors: Resident 3 missed prescribed medication doses; Resident 5 received medication daily instead of monthly. |
| Residents 1, 2, and 3 participated in support plan development but did not sign or indicate inability to sign the support plan. |
Report Facts
License Capacity: 64
Residents Served: 52
Residents in Secured Dementia Care Unit: 34
Staffing Hours: 87
Waking Staff: 65
Current Hospice Residents: 1
Residents with Mobility Need: 35
Residents Age 60 or Older: 52
Inspection Report
Census: 38
Capacity: 64
Deficiencies: 0
Mar 6, 2023
Visit Reason
The inspection was conducted as a partial, unannounced visit due to an incident at the facility.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Total Daily Staff: 70
Waking Staff: 53
Residents Served: 38
License Capacity: 64
Secured Dementia Care Unit Capacity: 48
Residents Served in Dementia Care Unit: 31
Current Residents in Hospice: 2
Residents Age 60 or Older: 37
Residents with Mobility Need: 32
Inspection Report
Renewal
Census: 34
Capacity: 64
Deficiencies: 5
Jan 31, 2023
Visit Reason
The inspection was conducted as a renewal review of the facility's compliance with licensing regulations.
Findings
The report found multiple deficiencies including ventilation issues in bathrooms, overdue fire safety inspection and drill, missing annual medical evaluations for residents, discrepancies in medication storage and documentation, and incomplete preadmission screening forms. Plans of correction were accepted and implemented.
Deficiencies (5)
| Description |
|---|
| Bathrooms in four buildings lacked operable windows and exhaust fans had no switches; vents in two buildings had no air circulation. |
| The last fire safety inspection and drill by a fire safety expert was overdue, last conducted on 01/21/2022 with a prior gap since 08/19/2019. |
| Two residents did not have annual medical evaluations completed for 2022. |
| Blood glucose readings for a resident did not match the numbers transcribed on the Medication Administration Record (MAR). |
| The preadmission screening form for a resident lacked the date of completion and signature. |
Report Facts
License Capacity: 64
Residents Served: 34
Memory Care Unit Capacity: 48
Memory Care Residents Served: 26
Hospice Current Residents: 3
Residents Age 60 or Older: 33
Residents with Mobility Need: 1
Inspection Report
Follow-Up
Census: 40
Capacity: 64
Deficiencies: 2
Aug 2, 2022
Visit Reason
The inspection was a partial, unannounced follow-up visit triggered by an incident to verify the implementation of a previously submitted plan of correction.
Findings
The facility was found to have fully implemented the plan of correction related to timely reporting and notification of suspected resident abuse. The Executive Director submitted required abuse reports and conducted in-service training for staff to ensure compliance with reporting regulations.
Complaint Details
The visit was related to an incident involving alleged resident abuse reported by an outside agency on 07/14/2022. The complaint was substantiated by the facility's failure to timely report and notify as required, but corrective actions were accepted and implemented.
Deficiencies (2)
| Description |
|---|
| Failure to immediately report suspected abuse of a resident within 48 hours as required by the Older Adult Protective Services Act. |
| Failure to immediately notify the resident's designated person of a report of suspected abuse involving the resident. |
Report Facts
License Capacity: 64
Residents Served: 40
Secured Dementia Care Unit Capacity: 32
Residents Served in Dementia Unit: 29
Current Hospice Residents: 2
Residents 60 Years or Older: 40
Residents with Mobility Need: 29
Total Daily Staff: 69
Waking Staff: 52
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee A | Named in findings related to failure to timely report and notify suspected abuse; received in-service training by the Executive Director. | |
| Executive Director | Submitted the Act 13 Mandatory Abuse form and conducted in-service training for staff regarding abuse reporting and notification requirements. |
Inspection Report
Follow-Up
Census: 37
Capacity: 64
Deficiencies: 7
Jun 9, 2021
Visit Reason
The inspection was conducted as a follow-up to verify the implementation of a previously submitted plan of correction, triggered by renewal and complaint reasons.
Findings
The submitted plan of correction was determined to be fully implemented. Multiple deficiencies related to contract signatures, multiple buildings staffing, medication administration, following prescriber's orders, support plan signatures, admission support plans, and support plan needs elements were identified and addressed with corrective actions and completion dates.
Deficiencies (7)
| Description |
|---|
| The contract for Resident 2 was not signed by the resident; Resident 3 refused to sign the contract. |
| For a home with multiple buildings, direct care staffing requirements were not met as staff left the building for breaks leaving residents unattended. |
| Staff members poured medications into medication cups for multiple residents and administered them later, sometimes leaving cups with residents without staff supervision. |
| Resident 1 and Resident 2 had physician orders for daily blood glucose testing that were not completed on specified dates. |
| The support plan of Resident 3 was not signed by the resident and lacked notation of refusal to sign. |
| Resident 1 was admitted to the Secure Dementia Care Unit (SDCU) without completion of the initial support plan within 72 hours. |
| Resident 1 was admitted to the SDCU with a medical evaluation identifying need for secure dementia unit due to disorientation and confusion, but these needs were not addressed in Resident 1's support plan. |
Report Facts
License Capacity: 64
Residents Served: 37
Secured Dementia Care Unit Capacity: 32
Residents Served in Secured Dementia Care Unit: 27
Staffing Hours - Total Daily Staff: 65
Staffing Hours - Waking Staff: 49
Residents with Mobility Need: 28
Residents Age 60 or Older: 37
Inspection Report
Complaint Investigation
Census: 48
Capacity: 64
Deficiencies: 3
Mar 8, 2021
Visit Reason
The inspection was conducted as a complaint investigation to review compliance with regulations following concerns about resident care and medical evaluations.
Findings
The facility was found deficient in providing required assistance with activities of daily living (ADLs) for Resident 1, incomplete medical evaluations missing critical information about a deep brain stimulator, and failure to document and secure medical care related to the resident's health status decline, including multiple falls.
Complaint Details
The visit was complaint-related, focusing on Resident 1's care deficiencies including failure to provide assistance with ADLs, incomplete medical evaluations, and lack of documentation for securing medical care after health status decline. The complaint was substantiated as deficiencies were found.
Deficiencies (3)
| Description |
|---|
| Resident 1 did not receive required stand-by assistance for transfers as indicated in the assessment, resulting in multiple falls. |
| Resident 1's medical evaluation did not include information about the placement of the deep brain stimulator. |
| The home did not document the need for follow-up care related to Resident 1's deep brain stimulator or update the assessment and support plan accordingly. |
Report Facts
Residents Served: 48
License Capacity: 64
Falls: 15
Staffing: 74
Staffing: 56
Capacity: 35
Residents Served: 25
Loading inspection reports...
