Inspection Reports for Luther Ridge at Seiders Hill
160 RED HORSE ROAD, POTTSVILLE, PA, 17901
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
54.4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
1057% worse than Pennsylvania average
Pennsylvania average: 4.7 deficiencies/yearDeficiencies per year
80
60
40
20
0
Census
Latest occupancy rate
46% occupied
Based on a September 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Follow-Up
Census: 62
Capacity: 135
Deficiencies: 4
Date: Sep 23, 2025
Visit Reason
The inspection was conducted due to a change in legal entity and included a follow-up review of the submitted plan of correction.
Findings
The facility was found to have several deficiencies including lack of operable bathroom ventilation, inoperable bedside lighting for a resident, outdated emergency procedures, and delayed annual fire drill. All cited deficiencies had plans of correction accepted and were implemented by late October 2025.
Deficiencies (4)
Bathroom did not have an operable window or ventilation fan.
Resident did not have access to a source of light that can be turned on/off at bedside.
Written emergency procedures were not updated and submitted to the local emergency management agency.
Annual fire safety inspection and fire drill were not conducted in a timely manner.
Report Facts
License Capacity: 135
Residents Served: 62
Current Hospice Residents: 5
Total Daily Staff: 69
Waking Staff: 52
Residents Age 60 or Older: 61
Residents with Mobility Need: 7
Inspection Report
Follow-Up
Census: 65
Capacity: 135
Deficiencies: 5
Date: Jul 1, 2025
Visit Reason
The inspection was a complaint and interim review conducted on 07/01/2025 to verify the implementation of a previously submitted plan of correction.
Complaint Details
The inspection was complaint-related and interim in nature, conducted to verify correction of previous deficiencies. The plan of correction was accepted and fully implemented as of the inspection date.
Findings
The facility was found to have fully implemented the submitted plan of correction. Deficiencies cited included issues with resident contracts, insufficient staffing during overnight hours, trash receptacle management, inoperable elevator, and unlabeled over-the-counter medications.
Deficiencies (5)
Resident admitted did not have a dated resident contract, making it unclear if it was signed timely by the resident or the home.
Insufficient staffing during the third shift hours of 11 p.m. to 7 a.m., impacting the ability to safely evacuate all residents in an emergency.
Dumpster lid was open with garbage inside, not preventing penetration of insects and rodents.
Small lobby elevator was inoperable and had ongoing operational issues since prior to the last renewal inspection.
Over-the-counter medications in the medcart were not labeled with the resident's names.
Report Facts
License Capacity: 135
Residents Present: 65
Current Hospice Residents: 3
Residents Needing Assist of 2 to Evacuate: 2
Residents Needing Assist of 1 to Evacuate: 41
Staff on Third Shift: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Provided education on resident contracts, staffing procedures, and maintenance issues; supervised correction of medication labeling. | |
| Director of Nursing (DON) | Oversight of staffing levels and supervised clinical staff correcting medication labeling. | |
| Scheduler | Updated staffing levels to align with residents' needs. | |
| Director of Maintenance | Responsible for ensuring equipment, including elevators, is kept in good repair. |
Inspection Report
Renewal
Census: 62
Capacity: 135
Deficiencies: 15
Date: May 7, 2025
Visit Reason
The inspection was conducted as a renewal licensing inspection for Luther Ridge at Seiders Hill to assess compliance with 55 Pa. Code Ch. 2600 relating to Personal Care Homes.
Findings
The facility was found to be in compliance overall, with several deficiencies noted including contract signature issues, staffing inadequacies during third shift, incomplete administrator training, missing staff training on medication administration and fire safety, equipment maintenance issues such as an inoperable elevator, fire drill documentation and execution problems, smoking area cleanliness, medication labeling and storage errors, and incomplete resident assessments. Plans of correction were submitted and implemented for all deficiencies.
Deficiencies (15)
Resident contract was not signed by a second witness or legal representative as required.
Insufficient staffing during third shift hours to safely evacuate all residents in an emergency.
Administrator did not complete required orientation program prior to employment.
Staff did not receive required training in medication self-administration and instruction on meeting residents' needs.
Staff did not receive fire safety training by a fire safety expert and resident rights training during 2024.
Left side main elevator was inoperable for several weeks.
Fire drill logs inaccurately documented number of residents evacuated; one resident was not evacuated during drill.
Fire drills were routinely held on or near the last day of the month, not varying days or times.
Resident receiving hospice care was not evacuated during fire drill.
Cigarette butts observed in designated smoking area for staff.
Medication label for Acetaminophen incorrectly indicated dosage as two tablets three times daily instead of every 8 hours as needed.
Medications (Imodium and Senna Plus) were not available in medication cart at time of inspection.
Medication administration record incorrectly stated dose for Fluticasone as two sprays instead of one spray daily.
Resident assessments did not include specific needs, risks, or device use for assistive devices such as enabler bars and roam alert devices.
Resident records containing personal information were found in an unlocked storage closet.
Report Facts
License Capacity: 135
Residents Served: 62
Staffing Hours: 73
Waking Staff: 55
Hospice Residents: 5
Residents with Mobility Needs: 11
Fire Drills Conducted: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Juliet Marsala | Deputy Secretary | Signed licensing letter and certificate. |
| Director of Nursing | Director of Nursing | Supervised correction of medication errors and staff education. |
| Administrator | Administrator | Responsible for staffing updates, training, and compliance with regulations. |
| Director of Maintenance | Director of Maintenance | Conducted fire drills, fire safety training, and maintenance oversight. |
| Admissions Director | Admissions Director | Trained on contract signing procedures. |
| Executive Director | Executive Director | Provided training on fire drills and evacuation procedures. |
| Regional Director of Nursing | Regional Director of Nursing | Incorporated training topics into company-wide annual training. |
Inspection Report
Complaint Investigation
Census: 64
Capacity: 135
Deficiencies: 0
Date: Mar 20, 2025
Visit Reason
The inspection was conducted as a complaint and incident investigation during an unannounced partial inspection.
Complaint Details
The inspection was triggered by a complaint and incident, but no deficiencies or citations were found.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Total Daily Staff: 74
Waking Staff: 56
Residents Served: 64
License Capacity: 135
Current Hospice Residents: 6
Residents Age 60 or Older: 62
Residents with Mobility Need: 10
Inspection Report
Follow-Up
Census: 61
Capacity: 135
Deficiencies: 1
Date: Jan 22, 2025
Visit Reason
The inspection was an unannounced partial review conducted due to a complaint and incident at the facility.
Complaint Details
The visit was complaint-related and substantiated as the facility failed to provide required supervision and safeguards for a resident with multiple falls.
Findings
The facility was found to have neglected a resident with a significant fall history by not providing 24-hour direct supervision as indicated in the assessment and support plan. Staff have since been educated on charting and fall prevention, and the plan of correction was fully implemented by March 3, 2025.
Deficiencies (1)
Resident with significant fall history sustained multiple falls including closed head injuries and a hip fracture; no additional safeguards or 24-hour supervision were provided as required.
Report Facts
Falls sustained by resident: 8
License Capacity: 135
Residents Served: 61
Current Hospice Residents: 4
Staffing Hours - Total Daily Staff: 73
Staffing Hours - Waking Staff: 55
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Educated staff on charting and fall prevention as part of plan of correction. |
| Executive Director | Executive Director | Educated staff on charting and fall prevention as part of plan of correction. |
Inspection Report
Renewal
Capacity: 135
Deficiencies: 0
Date: Jan 3, 2025
Visit Reason
The Pennsylvania Department of Human Services conducted licensing inspections on multiple dates in 2024 and refused to renew the certificate of compliance, issuing a third provisional license based on an acceptable plan of correction.
Findings
Violations were found related to compliance with 55 Pa. Code Chapter 2800 for Assisted Living Residences, requiring correction by specified dates to maintain compliance and avoid license revocation.
Report Facts
Inspection dates count: 10
License capacity: 135
Inspection Report
Plan of Correction
Census: 73
Capacity: 135
Deficiencies: 3
Date: Jul 30, 2024
Visit Reason
The inspection was conducted as a follow-up review of a previously submitted plan of correction related to medication administration errors at the facility.
Findings
The facility was found to have fully implemented the submitted plan of correction addressing medication administration violations, including failure to record medication administration properly and administering medication in error. Continued compliance must be maintained.
Deficiencies (3)
Failure to initial the resident's Medication Administration Record (MAR) at the time medication was administered.
Administering a second dose of medication to a resident in error without proper documentation.
Failure to follow prescriber's orders resulting in medication administration error.
Report Facts
License Capacity: 135
Residents Served: 73
Current Hospice Residents: 5
Total Daily Staff: 93
Waking Staff: 70
Residents with Mobility Need: 20
Residents 60 Years or Older: 73
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff person A | Named in medication administration errors and corrective actions. |
Inspection Report
Complaint Investigation
Census: 73
Capacity: 135
Deficiencies: 44
Date: May 7, 2024
Visit Reason
The inspection was a complaint investigation conducted at Luther Ridge at Seiders Hill to address allegations of resident abuse, ADL assistance issues, privacy violations, and other regulatory concerns.
Complaint Details
Complaint investigation with substantiated findings of resident abuse, privacy violations, and multiple care deficiencies.
Findings
Multiple deficiencies were found including resident abuse via unauthorized filming, inadequate assistance with ADLs, privacy violations, furniture and equipment issues, fire drill record inaccuracies, and failure to follow prescriber orders. Plans of correction were submitted with various implementation dates.
Deficiencies (44)
Staff Person A filmed residents in a common area on a cellphone and posted the footage to social media without reporting as required.
Resident #4 required physical assistance with incontinence care but staff did not perform additional checks as required.
Staff Person A filmed residents in a common area on a cellphone and posted the footage to social media, violating residents' privacy.
The smaller of the 2 elevators was inoperable for several weeks and could not be used until inspection and permit were obtained.
Fire drill logs were incomplete and evacuation times were not clearly documented, with repeated violations noted.
Resident #1, #2, and #3 medical evaluations were missing information on medication regimen, contraindications, or side effects.
Resident #4 and #6 used bedside mobility devices but their assessment support plans did not include specific device needs or safety information.
Resident #5 required 1-person assist with transfers and ambulated with a wheelchair but documentation was incomplete.
Resident #6's glucometer was not calibrated correctly and medication administration records were incomplete.
Resident #7's assessment and support plan was not signed by the resident.
Resident #8's support plan did not indicate receipt of home health care and wound care services.
Resident #127 did not have a bedside lamp or other source of illumination.
Fire drill logs did not include complete time documentation and evacuation times were inaccurate.
Residents were not evacuated within the required timeframe during fire drills.
Resident #1 had missing medication administration documentation and resident #10 was not connected to portable oxygen as ordered.
Residents #1 and #6 used bedside mobility devices but their support plans lacked necessary safety and usage information.
Resident #2, #3, and #4 had undocumented falls and incomplete documentation of mobility device use.
Resident #4 and #5 had incomplete support plans regarding mobility devices and care needs.
Resident #4's medical evaluation was missing medication information.
Resident #5 had incomplete documentation for transfers and showering assistance.
Resident #6's glucometer and medication administration records were incomplete and inaccurate.
Resident #7's support plan was not signed by the resident.
Resident #8's support plan lacked documentation of home health and wound care services.
Resident #14's record did not include a photograph no more than 2 years old.
Resident #4 required physical assistance with incontinence care but staff did not perform additional checks as required.
Resident #4's medication sliding scale was incorrectly labeled on the pharmacy label.
Resident #4's glucometer was not calibrated correctly and medication administration records were incomplete.
Resident #5 had incomplete documentation for transfers and showering assistance.
Resident #127 did not have a bedside lamp or other source of illumination.
Dryer lint was not cleaned and was caked on the vent and bushes outside the laundry room.
Residents #1, #2, #6, and #8 did not evacuate to designated meeting place during fire drill.
Resident #1, #2, #3, and #4 had incomplete medication documentation and missing medication side effect information.
Resident #4 and #6 used bedside mobility devices but their assessment support plans did not include specific device needs or safety information.
Resident #4 and #5 had incomplete support plans regarding mobility devices and care needs.
Resident #4 and #5 had incomplete support plans regarding mobility devices and care needs.
Resident #4 and #5 had incomplete support plans regarding mobility devices and care needs.
Resident #4 and #5 had incomplete support plans regarding mobility devices and care needs.
Resident #4 and #5 had incomplete support plans regarding mobility devices and care needs.
Resident #4 and #5 had incomplete support plans regarding mobility devices and care needs.
Resident #4 and #5 had incomplete support plans regarding mobility devices and care needs.
Resident #4 and #5 had incomplete support plans regarding mobility devices and care needs.
Resident #4 and #5 had incomplete support plans regarding mobility devices and care needs.
Resident #4 and #5 had incomplete support plans regarding mobility devices and care needs.
Resident #4 and #5 had incomplete support plans regarding mobility devices and care needs.
Report Facts
License Capacity: 135
Residents Served: 73
Current Residents: 6
Resident Support Staff: 0
Total Daily Staff: 92
Waking Staff: 69
Deficiencies cited: 29
Residents Served: 73
Current Residents: 7
Total Daily Staff: 85
Waking Staff: 64
Inspection Report
Complaint Investigation
Census: 73
Capacity: 135
Deficiencies: 60
Date: May 7, 2024
Visit Reason
The inspection was a complaint investigation conducted at Luther Ridge at Seiders Hill to address allegations and concerns raised about the facility.
Complaint Details
The inspection was complaint-related with substantiated findings as detailed in the Licensing Inspection Summary.
Findings
The inspection identified multiple deficiencies including resident abuse, ADL assistance issues, privacy violations, furniture and equipment problems, fire drill record inaccuracies, follow prescriber’s orders, support plan deficiencies, and documentation errors. Plans of correction were submitted with various implementation dates.
Deficiencies (60)
Staff Person A filmed residents in a common area on a cellphone and posted the footage to social media, not reported as required.
Resident #4 required physical assistance with incontinence care but staff did not perform additional checks as required.
Staff Person A filmed residents in a common area on a cellphone and posted the footage to social media, violating residents’ privacy.
One of the two elevators was inoperable for several weeks and could not be used until inspection and permit obtained.
Fire drill logs were not clearly documented with correct times and evacuation times were not properly recorded.
Resident #1, #2, and #3 medical evaluations were missing information on medication regimen, contraindications, or side effects.
Resident #4 and #6 used bedside mobility devices but their assessment support plans did not include specific device needs or safety information.
Resident #5 required 1-person assist with transfers and ambulation but documentation was incomplete regarding care needs and assistive device use.
Resident #6’s glucometer was not calibrated correctly and blood glucose readings were inaccurate.
Resident #7, #8, and #9 medication administration records were missing or had errors in documentation.
Resident #10 oxygen tank was not connected properly prior to dining room use.
Resident #11’s assessment support plan was not signed by the resident.
Resident #14’s record did not include a photograph no more than 2 years old.
Resident #1 did not have a bedside lamp or other source of illumination.
Several holes measuring 1-3 inches were observed in the wall of resident room 115 behind the recliner.
The dryer vent had not been cleaned and had lint buildup on the vent and outside bushes.
Residents #1 and #6 used bedside mobility devices but their support plans did not reflect specific device needs or safety.
Residents #2, #3, and #4 had falls in May 2024 with no documentation of safeguards or safety measures.
Resident #4’s glucometer was not calibrated correctly and blood glucose readings were inaccurate.
Resident #4’s medical evaluation was missing medication regimen and side effect information.
Resident #5’s medication administration record was missing documentation for blood glucose monitoring.
Resident #7’s assessment support plan was not signed by the resident.
Resident #8’s support plan did not indicate home health care and wound care services.
Resident #9’s medication administration record was missing documentation for blood glucose monitoring.
Resident #10’s medication administration record was missing documentation for blood pressure and heart rate prior to medication.
Resident #11’s support plan did not indicate specific device needs or safety for mobility devices.
Resident #12’s support plan did not indicate home health care and wound care services.
Resident #13’s support plan did not indicate home health care and wound care services.
Resident #14’s record did not include a photograph no more than 2 years old.
Resident room #127 did not have a bedside lamp or other source of illumination.
The drink cooler in the kitchen was holding a temperature of 52 degrees and the walk-in freezer was holding 11 degrees.
The home’s fire drill logs were not clearly documented with correct times and evacuation times were not properly recorded.
Residents #1 and #6 used bedside mobility devices but their support plans did not reflect specific device needs or safety.
Residents #2, #3, and #4 had falls in May 2024 with no documentation of safeguards or safety measures.
Resident #4 and #5 were no longer residents of the facility but care plans were not updated accordingly.
Correction fluid was used on the staff statement dated 4/12/24 related to Resident #6 incident.
Resident #4 required physical assistance with incontinence care but staff did not perform additional checks as required.
Resident #5 required 1-person assist with transfers and ambulation but documentation was incomplete regarding care needs and assistive device use.
Resident #6’s glucometer was not calibrated correctly and blood glucose readings were inaccurate.
Resident #7, #8, and #9 medication administration records were missing or had errors in documentation.
Resident #10 oxygen tank was not connected properly prior to dining room use.
Resident #11’s assessment support plan was not signed by the resident.
Resident #14’s record did not include a photograph no more than 2 years old.
Resident #1 did not have a bedside lamp or other source of illumination.
Several holes measuring 1-3 inches were observed in the wall of resident room 115 behind the recliner.
The dryer vent had not been cleaned and had lint buildup on the vent and outside bushes.
There was a garbage bag left on the sidewalk outside the back door by the laundry room.
The screen from the 2nd floor laundry room was lying on the ground behind the building and laundry room window was open.
Residents #1, #2, #6, and #8 did not evacuate to a designated meeting place during fire drill.
Resident room #127 did not have a bedside lamp or other source of illumination.
Resident #1 did not have a bedside lamp or other source of illumination.
Resident #4 and #5 were no longer residents of the facility but care plans were not updated accordingly.
Correction fluid was used on the staff statement dated 4/12/24 related to Resident #6 incident.
Resident #4 required physical assistance with incontinence care but staff did not perform additional checks as required.
Resident #5 required 1-person assist with transfers and ambulation but documentation was incomplete regarding care needs and assistive device use.
Resident #6’s glucometer was not calibrated correctly and blood glucose readings were inaccurate.
Resident #7, #8, and #9 medication administration records were missing or had errors in documentation.
Resident #10 oxygen tank was not connected properly prior to dining room use.
Resident #11’s assessment support plan was not signed by the resident.
Resident #14’s record did not include a photograph no more than 2 years old.
Report Facts
License Capacity: 135
Residents Served: 73
Current Residents: 6
Resident Support Staff: 0
Total Daily Staff: 92
Waking Staff: 69
Deficiencies cited: 35
Inspection Report
Complaint Investigation
Census: 76
Capacity: 135
Deficiencies: 31
Date: Feb 21, 2024
Visit Reason
The inspection was conducted due to complaints, provisional license status, and interim review to assess compliance with 55 Pa. Code Chapter 2800 relating to Assisted Living Residence.
Complaint Details
An incident involving Staff member B pushing Resident #1 into a room and locking the door was investigated. Resident #1 reported no forced abuse but stated a consensual sexual relationship with Staff member A. Protective Services cited the facility with Caregiver Neglect. Pennsylvania State Police conducted a criminal investigation. Staff member B was suspended and terminated. Training on abuse reporting and resident rights was immediately conducted. The case remains active.
Findings
Multiple violations were found including failure to post licensing inspection summary, lack of policies on voice-controlled devices, untimely medical evaluations, incomplete quality management plans, missing criminal background checks, inadequate staff training and orientation, fire safety deficiencies, improper medication administration documentation, and issues with resident records and support plans. A serious abuse/neglect incident involving a staff member was also investigated.
Deficiencies (31)
Licensing Inspection Summary dated 8/23/23 not posted.
No policy outlining use of voice-controlled devices by facility and residents.
Resident #2 medical evaluation completed beyond 15-day grace period after admission.
Quality Management plans lacked required elements including complaint procedure and staff training.
Staff persons A, B, and C lacked criminal background checks in employee records.
Staff person D lacked orientation in fire safety and emergency preparedness prior to first day of work.
Staff person D lacked orientation training within first 40 scheduled working hours including resident rights and emergency medical plan.
Staff person D lacked ancillary staff orientation to specific job functions prior to working in that capacity.
Staff person B did not have certificate of completion for required 18 hours of direct care training.
Direct care staff persons A, B, and C not trained in required 2023 annual training topics including medication self-administration and infection control.
One dumpster overflowing with cardboard boxes; other dumpster lid bent allowing insect and animal access.
Magnetic door alert on 3rd floor west stairwell exit door not working due to removed magnetic box.
First aid kit not located on 3rd floor; only one kit onsite.
Snow and ice not removed from west exit ramp to gazebo, obstructing safe evacuation.
Lint accumulated in lint trap of industrial dryer on ground floor.
Obstruction at top of 3rd floor western stairwell including overturned walker, blanket, pillow, and slippers.
No written notification to local fire department of residence address, living units, and evacuation assistance needs.
Fire drill records did not indicate exits used and included drill conductor in staff count.
Evacuation drill exceeded fire safety inspector's 7-minute evacuation time; recorded 10 minutes.
Resident #'s medical evaluations not completed annually as required.
Glucometer for Resident #5 not calibrated to correct date and time.
Medication Administration Records (MAR) not initialed for multiple residents indicating medications not documented as administered.
Resident #1's Assessment and Support Plan (ASP) not completed annually.
Resident #2 and #3 ASPs did not address dietary needs and roam alert respectively.
Resident #1 and #4 file photos older than 2 years.
Staff member B pushed Resident #1 into room and locked door; investigation found no forced abuse but cited for caregiver neglect.
Staff person B lacked orientation training within 40 scheduled working hours including emergency medical plan and abuse reporting.
Staff person B lacked ancillary staff orientation to specific job functions prior to working in that capacity.
Licensing Inspection Summary not posted conspicuously in the home.
Staff person A did not treat resident with dignity and respect; refused use of walker and showed frustration.
Document of medical evaluation form for resident #2 had correction fluid over original date.
Report Facts
License Capacity: 135
Residents Served: 76
Staffing Hours: 99
Waking Staff: 74
Number of Violations: 29
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff member A | Named in abuse/neglect incident and dignity/respect violation. | |
| Staff member B | Named in abuse/neglect incident, lack of training and orientation, and medication administration deficiencies; terminated. | |
| Staff member C | Named in criminal background check and training deficiencies. | |
| Staff person D | Named in multiple training and orientation deficiencies. | |
| Staff person E | Conducted fire drills with documentation deficiencies. | |
| Juliet Marsala | Deputy Secretary | Signed enforcement and licensing letters. |
Inspection Report
Complaint Investigation
Census: 76
Capacity: 135
Deficiencies: 24
Date: Feb 21, 2024
Visit Reason
The inspection was conducted due to complaints, provisional license issues, and interim reviews to assess compliance with assisted living residence regulations.
Complaint Details
An incident involving Staff member 'B' pushing Resident #1 into a room and inappropriate conduct was investigated. Staff B was suspended and terminated. Protective Services cited the facility with Caregiver Neglect. Pennsylvania State Police conducted a criminal investigation which remains active.
Findings
Multiple violations were found including failure to post licensing inspection summaries, lack of policies on voice-controlled devices, untimely medical evaluations, incomplete quality management plans, missing criminal background checks, inadequate staff training and orientation, fire safety deficiencies, improper medication administration documentation, and issues with resident records and support plans. A serious abuse/neglect incident was also investigated.
Deficiencies (24)
Licensing Inspection Summary dated 8/23/23 was not posted.
No policy outlining use of voice-controlled devices by facility and residents.
Resident #2's medical evaluation was completed beyond the 15-day grace period after admission.
Quality Management plans lacked required elements such as complaint procedure and staff training.
Staff persons A, B, and C lacked criminal background checks in employee records.
Staff person D lacked orientation in fire safety and emergency preparedness prior to first day of work.
Staff person D lacked orientation training within first 40 scheduled working hours on required topics including resident rights and emergency medical plan.
Staff person D lacked ancillary staff orientation to specific job functions prior to working in that capacity.
Staff person B did not have required 18 hours of direct care training before providing unsupervised assisted living services.
Direct care staff persons A, B, and C were not trained in required annual training topics in 2023.
One dumpster was overflowing and another had a bent lid allowing insect and animal access.
Magnetic door alert on 3rd floor west stairwell exit door was not working due to removal of magnetic box.
Staff were unable to locate the first aid kit on the 3rd floor.
Snow and ice obstructed the west exit ramp to the gazebo, preventing safe evacuation.
Lint accumulated in the lint trap of the industrial dryer on the ground floor.
Walker, blanket, pillow, and slippers blocked the top of the western stairwell on the 3rd floor.
No written notification to local fire department regarding facility address, resident living units, and evacuation assistance needs.
Fire drill records did not indicate exits used and included staff conducting drills in staff count.
Evacuation drill exceeded the fire safety inspector's specified evacuation time of 7 minutes.
Resident #5's glucometer was not calibrated to the correct date and time.
Medication Administration Records (MAR) for multiple residents were not initialed to indicate medication administration or related instructions were followed.
Resident #1's Assessment and Support Plan (ASP) was not updated annually as required.
Resident #2 and #3's ASPs did not address dietary needs and roam alert respectively.
Resident #1 and #4 had file photos older than 2 years.
Report Facts
License Capacity: 135
Residents Served: 76
Staffing Hours: 99
Waking Staff: 74
Number of Violations: 26
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff member A | Named in abuse/neglect incident and dignity/respect violation. | |
| Staff member B | Named in abuse/neglect incident, lack of training, orientation, and terminated due to incident. | |
| Staff member C | Named in criminal background check and training deficiencies. | |
| Staff person D | Named in multiple training and orientation deficiencies. | |
| Wellness Director | Responsible for oversight of training, audits, and compliance. | |
| Administrator | Responsible for oversight of compliance, audits, and corrective actions. | |
| Maintenance Director | Responsible for fire safety, maintenance, and compliance. | |
| Maintenance Assistant | Assists Maintenance Director and responsible in their absence. |
Inspection Report
Complaint Investigation
Census: 76
Capacity: 135
Deficiencies: 25
Date: Feb 21, 2024
Visit Reason
The inspection was conducted due to complaints, provisional license issues, and interim reviews to assess compliance with 55 Pa. Code Chapter 2800 relating to Assisted Living Residences.
Complaint Details
The complaint involved allegations of neglect and abuse, including an incident where Staff member B was observed pushing Resident #1 into a room and inappropriate conduct was alleged. Protective Services cited the facility with Caregiver Neglect. Pennsylvania State Police are investigating the case. Staff member B was suspended and terminated. Training on abuse reporting and resident rights was immediately conducted.
Findings
Multiple violations were found including failure to post licensing inspection summaries, lack of policies on voice-controlled devices, untimely medical evaluations, incomplete quality management plans, missing criminal background checks, inadequate staff training and orientation, fire safety deficiencies, improper medication administration documentation, and issues with resident records and support plans.
Deficiencies (25)
Licensing Inspection Summary dated 8/23/23 was not posted.
No policy outlining the use of voice-controlled devices by the facility and residents.
Resident #2's medical evaluation was completed beyond the 15-day grace period after admission.
Quality Management plans did not include complaint procedure, staff training, licensing violations, or resident/family councils.
Staff persons A, B, and C lacked criminal background checks in their employee records.
Staff person D did not have orientation in fire safety and emergency preparedness prior to first day of work.
Staff person D did not have orientation training within first 40 scheduled working hours on required topics including resident rights and emergency medical plan.
Staff person D did not have ancillary staff orientation to specific job functions prior to working.
Staff person B did not have certificate of completion for required 18 hours of direct care training.
Direct care staff persons A, B, and C were not trained in required annual training topics in 2023.
One dumpster was overflowing and another had a bent lid allowing access to insects and animals.
Magnetic door alert system on 3rd floor west stairwell exit door was not working due to removal of magnetic box.
Staff were unable to locate the first aid kit on the 3rd floor.
Snow and ice were not removed from the west exit ramp to the gazebo, obstructing safe evacuation.
Lint accumulated in the lint trap of the industrial dryer on the ground floor.
Walker, blanket, pillow, and slippers blocked the top of the western stairwell on the 3rd floor.
No written notification to local fire department of facility address, resident living units, and evacuation assistance needs.
Fire drill records did not indicate exits used and included staff conducting drill in staff count.
Evacuation drill time exceeded the 7-minute requirement, recorded at 10 minutes.
Resident #'s medical evaluations exceeded the annual requirement.
Glucometer for Resident #5 was not calibrated to correct date and time.
Medication Administration Records (MAR) for multiple residents were not initialed to indicate medication administration as prescribed.
Resident #1's Assessment and Support Plan (ASP) was not updated annually.
Resident #2 and #3 ASPs did not address dietary and roam alert needs.
Resident #1 and #4 had file photos older than 2 years.
Report Facts
License Capacity: 135
Residents Served: 76
Staffing Hours: 99
Waking Staff: 74
Number of Violations: 24
Fine Amount: 228
Fine Amount: 380
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff member A | Named in abuse and dignity/respect findings | |
| Staff member B | Named in abuse, orientation, training, and termination related to complaint investigation | |
| Staff member D | Named in multiple training and orientation deficiencies | |
| Staff person C | Named in criminal background check and training deficiencies | |
| Staff person E | Named in fire drill record deficiency | |
| Juliet Marsala | Deputy Secretary | Signed enforcement and licensing letters |
Inspection Report
Complaint Investigation
Census: 75
Capacity: 135
Deficiencies: 3
Date: Nov 28, 2023
Visit Reason
The inspection was conducted as a complaint and incident investigation following reports of resident incidents and compliance concerns.
Complaint Details
The visit was complaint-related with substantiated repeated violations including failure to report incidents timely, incomplete resident assessments after significant changes, and unsigned support plans.
Findings
The facility was found to have repeated violations related to incident reporting, assessment of significant changes in residents, and support plan signatures. The submitted plan of correction was accepted and fully implemented by January 25, 2024.
Deficiencies (3)
Incident reporting violation where a resident walked out of the residence unnoticed and the incident was not reported within 24 hours as required.
Failure to complete additional written assessments for a resident after a significant change in condition, including updating the Assessment and Support Plan.
Support plan was not signed by the assessor, resident, or resident’s designated person.
Report Facts
License Capacity: 135
Residents Served: 75
Current Hospice Residents: 7
Residents with Mobility Need: 15
Inspection Report
Complaint Investigation
Census: 77
Capacity: 135
Deficiencies: 1
Date: Sep 14, 2023
Visit Reason
The inspection was conducted as a complaint and incident investigation at Luther Ridge at Seiders Hill on September 14, 2023.
Complaint Details
The visit was complaint-related and substantiated by the finding that Resident #1 was improperly dressed in the dining room, violating dignity and respect standards.
Findings
The inspection found a violation of dignity and respect where a resident was seated in the dining room wearing only loose-fitting pajamas, socks, and a clothing protector, which exposed the resident's shoulders and made it appear they were inadequately dressed. Staff involved were suspended and re-educated, and a plan of correction was implemented.
Deficiencies (1)
Resident #1 was not treated with dignity and respect when seated in the dining room wearing only loose-fitting pajamas and socks, exposing shoulders.
Report Facts
License Capacity: 135
Residents Served: 77
Current Residents in Hospice: 5
Residents with Mobility Need: 15
Residents 60 Years or Older: 77
Residents Receiving Supplemental Security Income: 2
Inspection Report
Complaint Investigation
Census: 76
Capacity: 135
Deficiencies: 5
Date: Aug 23, 2023
Visit Reason
The inspection was conducted as a complaint and incident investigation at Luther Ridge at Seiders Hill on August 23, 2023.
Complaint Details
The inspection was complaint-related, triggered by a complaint and incident. The exit conference was held on 08/23/2023.
Findings
Multiple violations were found including failure to provide showers as per resident's assessment, missing annual medical evaluations, unsigned preliminary support plans, untimely annual assessments, and unsecured resident records allowing unauthorized access.
Deficiencies (5)
Staff are not providing a shower at least 2x weekly as indicated in Resident #1's assessment and support plan.
The most recent annual medical evaluation for Resident #2 was not completed by the required date.
The last Annual ASP for Resident #2 is not signed by the staff person who completed the assessment.
An annual ASP for Resident #2 was not completed by the required date.
Resident records were found unsecured on top of file cabinets in an unlocked and unattended office, allowing unauthorized access.
Report Facts
License Capacity: 135
Residents Served: 76
Current Residents in Hospice: 6
Residents with Mobility Need: 17
Total Daily Staff: 93
Waking Staff: 70
Inspection Report
Enforcement
Census: 74
Capacity: 135
Deficiencies: 8
Date: Jul 20, 2023
Visit Reason
The inspection was an unannounced partial licensing inspection conducted on July 20, 2023, as an interim review with follow-up on plan of correction submissions and enforcement actions.
Findings
Multiple violations were found related to staff training deficiencies, medication storage, expired insulin administration training, and incomplete resident assessments. The facility's certificate of compliance was revoked and replaced with a first provisional license based on an acceptable plan of correction.
Deficiencies (8)
Staff person A did not receive orientation on fire safety and emergency preparedness on the first workday.
Staff person A did not receive orientation on rights/abuse topics within the first 40 hours of work.
Staff person B did not receive the required 16 hours of annual training relating to job duties during the 2022 training year.
Direct Care staff person C did not receive annual training in medication self-administration, resident needs, or assisted living service needs in 2022.
Direct Care staff person B did not receive annual training in fire safety or Older Adult Protective Services Act topics in 2022.
Medication lock box for Resident #1 was found unlocked and unattended in the resident’s room.
Direct Care staff persons D and E had expired insulin administration training as of 2/7/23.
The most recent annual assessments for Resident #2 and Resident #3 were overdue, last completed on 6/12/2022 and 6/5/2022 respectively.
Report Facts
License Capacity: 135
Residents Served: 74
Current Hospice Residents: 7
Residents with Mobility Need: 19
Residents Diagnosed with Intellectual Disability: 1
Total Daily Staff: 93
Waking Staff: 70
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff person A | Named in findings for lack of orientation on fire safety and rights/abuse training. | |
| Staff person B | Named in findings for failure to complete required annual training and fire safety training. | |
| Staff person C | Named in findings for failure to complete required annual training topics. | |
| Staff person D | Named in findings for expired insulin administration training. | |
| Staff person E | Named in findings for expired insulin administration training. |
Inspection Report
Renewal
Census: 74
Capacity: 135
Deficiencies: 23
Date: Mar 9, 2023
Visit Reason
The inspection was conducted as a full, unannounced visit for renewal, complaint, and incident reasons, including multiple inspection dates in March 2023.
Findings
The inspection identified multiple violations related to medication administration, staff training deficiencies, safety and emergency preparedness, resident care plans, and documentation issues. Several plans of correction were accepted with some implemented and others pending as of the report date.
Deficiencies (23)
Resident #1 missed multiple doses of Hydrocodone-Acetaminophen due to medication not being in the facility and delayed reporting of the incident.
Carbon Monoxide detectors had batteries last changed over two years ago, violating annual battery change requirements.
Resident contracts for two residents were not signed and did not indicate refusal or inability to sign.
Use of a voice-controlled electronic device in the dining room without notification or policy regarding recording.
Insufficient number of staff trained in first aid and CPR during certain overnight shifts.
Newly hired staff person did not receive required fire safety and abuse orientation within required timeframes.
Direct care staff persons did not complete required 16 hours of annual training or specific training topics in 2022.
Emergency telephone numbers were not posted near a resident's landline telephone.
No operable lamp or light accessible bedside in a resident's room.
Fire safety inspection and fire drill were not conducted annually as required.
Fire drill evacuation time exceeded the home's approved safe evacuation time.
First aid kit in transport vehicle lacked scissors and eye coverings.
Resident #1 stored medication unlocked without assessment for self-administration.
Resident #6 self-administered medications but did not keep medications locked or bedroom door locked.
Resident #7's prescribed medication was not available in the residence at time of inspection.
Controlled substance counts were signed before completion of the count.
Resident #5's medication administration record did not document administration of prescribed B12 injection.
Resident #1 and #2 missed or did not have documented administration of prescribed medications per prescriber orders; Resident #7's vital signs were not measured before medication administration.
Staff persons administering medications had incomplete or expired medication administration training documentation.
Staff persons administering insulin had expired insulin administration training.
Resident #2's support plan did not document behavioral care needs and Resident #8's support plan did not indicate use of an enable bar on bed.
Resident #9's support plan was not signed by the assessor.
Resident #2's case record did not indicate identifying marks.
Report Facts
Inspection Dates: 6
License Capacity: 135
Residents Served: 74
Staffing Hours: 96
Waking Staff: 72
Hospice Residents: 9
Residents 60 or Older: 73
Residents with Mobility Need: 22
Medication Missed Doses: 3
Fire Drill Evacuation Time: 566
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Juliet Marsala | Deputy Secretary | Signed the letter regarding provisional license issuance. |
| Earl Ostrander | CPR Road Tour Trainer | Conducted CPR class to update nursing staff. |
Inspection Report
Complaint Investigation
Census: 74
Capacity: 135
Deficiencies: 7
Date: Jan 11, 2023
Visit Reason
The inspection was conducted as a complaint and incident investigation with an unannounced partial inspection on 01/11/2023.
Complaint Details
The inspection was complaint-driven and incident-related, with a follow-up plan of correction submission required.
Findings
The inspection found deficiencies related to delayed call bell response causing incontinence, inadequate staffing during night shifts affecting evacuation times, failure to conduct monthly and nighttime fire drills, incomplete evacuation during fire drills, and medication administration documentation errors.
Deficiencies (7)
Residents reported waiting over an hour for staff to respond to call bells, causing incontinence episodes.
Insufficient staffing on night shifts to meet residents' mobility needs and evacuation requirements.
No documentation of a fire drill completed in December 2022.
Fire drill was not completed during nighttime hours from June 2022 through December 2022.
Fire drills were routinely held on the last day or last week of the month, not on varied days and times.
Incomplete evacuation during fire drills with fewer residents evacuated than present, without documented reasons.
Medication Administration Record for a resident was not initialed to show medication was given on 12/5/2022.
Report Facts
License Capacity: 135
Residents Served: 74
Residents with Mobility Needs: 23
Staff on Night Shift: 3
Fire Drill Evacuation Time: 8.38
Fire Drill Evacuation Time: 9.26
Fire Drill Evacuation Time: 8.44
Residents Evacuated: 73
Residents Present: 74
Residents Evacuated: 68
Residents Present: 72
Inspection Report
Complaint Investigation
Census: 77
Capacity: 135
Deficiencies: 0
Date: Jul 28, 2022
Visit Reason
The inspection was conducted as a complaint investigation at the facility on 07/28/2022.
Complaint Details
The inspection was complaint-related, but no deficiencies or citations were found, and follow-up was not required.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
License Capacity: 135
Residents Served: 77
Current Hospice Residents: 10
Resident Mobility Need: 23
Residents 60 Years or Older: 77
Residents Diagnosed with Intellectual Disability: 1
Residents with Physical Disability: 1
Total Daily Staff: 100
Waking Staff: 75
Inspection Report
Renewal
Census: 78
Capacity: 135
Deficiencies: 10
Date: Jan 25, 2022
Visit Reason
The inspection was conducted as a renewal visit to review compliance with licensing requirements and verify the submitted plan of correction.
Findings
The facility was found to have multiple deficiencies including expired boiler certificates, incomplete staff training, obstructed egress due to snow and ice, inaccurate fire department notification, medication administration errors, and incomplete resident support plan reviews. All deficiencies had plans of correction submitted and were implemented by the dates noted.
Deficiencies (10)
The boiler certificate from Labor and Industry for the 3 gas fired boilers expired.
Direct care staff members did not receive training in the requirements of chapter 2800.
The exit door from the enclosed dining room would not open all the way because of snow and ice preventing the door from fully opening.
The notice to the fire department does not include the total capacity of the home and the number of residents with mobility needs is not accurate.
2 cans of extinguished cigarette butts were located outside of the receiving area of the home, which is not the designated smoking area. Cigarette butts were also found outside the resident designated smoking area.
One of the required two MAR reviews was completed for direct care staff member E's 2021 annual practicum. Two of the required four medication observations were completed for direct care staff members C and D's initial training.
Resident #3's medication does not include the initials of the staff member who opened the pen. Resident #4's medication does not have a pharmacy label attached.
Resident #5's MAR notes 30mg 1 tablet daily, but the medication bottle notes 10mg 3 tablets daily. Resident #3's medication record does not indicate the dose of the medication.
Resident #6 has an order for 3000 iu daily but is being administered 5000 iu daily. Resident #5's medication order requires monitoring of heart rate before administration, which is not being done.
Resident #7's and #8's final support plans only had one of the required quarterly reviews completed.
Report Facts
Inspection dates: 3
Resident census: 78
Total licensed capacity: 135
Staffing hours: 15
Staffing hours: 108
Staffing hours: 81
Residents with mobility needs: 15
Residents age 60 or older: 78
Residents diagnosed with intellectual disability: 1
Inspection Report
Complaint Investigation
Census: 85
Capacity: 135
Deficiencies: 2
Date: Jul 1, 2021
Visit Reason
The inspection was conducted as a complaint and incident investigation with multiple on-site and off-site review dates.
Complaint Details
The inspection was triggered by a complaint and incident report. The submitted plan of correction was fully implemented as of the latest review.
Findings
Two deficiencies were identified: delays in answering call bells reported by residents, and incomplete documentation of PRN medication effectiveness in the medication administration record. The facility submitted and implemented a plan of correction addressing these issues.
Deficiencies (2)
Residents reported waiting 30-60 minutes for call bells to be answered by staff.
Medication administration record did not document effectiveness of PRN Ibuprofen given to a resident on two occasions.
Report Facts
License Capacity: 135
Residents Served: 85
Staffing Hours - Total Daily Staff: 98
Staffing Hours - Waking Staff: 74
Inspection Report
Renewal
Census: 75
Capacity: 135
Deficiencies: 0
Date: Apr 5, 2021
Visit Reason
The inspection was conducted as a licensing renewal inspection with additional reasons including complaint and incident review.
Findings
No regulatory citations or deficiencies were identified as a result of the inspection conducted over three days from April 5 to April 7, 2021.
Report Facts
Total Daily Staff: 82
Waking Staff: 62
Current Hospice Residents: 1
Residents Served: 75
Licensed Capacity: 135
Residents 60 Years of Age or Older: 75
Residents with Mobility Need: 7
Inspection Report
Follow-Up
Census: 32
Capacity: 65
Deficiencies: 1
Date: Mar 3, 2021
Visit Reason
The inspection was conducted as a follow-up review to verify the implementation of a previously submitted plan of correction related to a complaint and incident.
Complaint Details
The inspection was complaint-related, triggered by a complaint and incident. The plan of correction was not fully implemented as of the inspection dates.
Findings
The facility's submitted plan of correction was determined to be not fully implemented. Specifically, the Resident Assessment and Support Plan (R.A.S.P.) for resident #1 did not address episodic behavioral issues, though the plan was updated during the inspection. The facility was directed to submit evidence of compliance, which had not been provided as of the latest update.
Deficiencies (1)
The Resident Assessment and Support Plan (R.A.S.P.) for resident #1 did not address episodic behaviors such as yelling, paranoia, agitation, and moodiness.
Report Facts
License Capacity: 65
Residents Served: 32
Staffing Hours: 37
Waking Staff: 28
Residents Age 60 or Older: 31
Residents with Mental Illness: 3
Residents with Mobility Need: 5
Notice
Capacity: 135
Deficiencies: 0
Date: Jan 15, 2021
Visit Reason
This document serves as a renewal notification and issuance of a regular license for Luther Ridge at Seiders Hill Assisted Living Home, pursuant to Title 55, PA Code, Chapter 2800.
Findings
The Department has received the renewal application and issued a regular license. The Department will conduct an onsite inspection within the next twelve months to ensure compliance with applicable regulations.
Report Facts
Maximum capacity: 135
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary | Signed the renewal notification letter |
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