Inspection Reports for Magnolia Place of Saxonburg
100 BELLA COURT,, SAXONBURG, PA, 16056
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
49% worse than Pennsylvania average
Pennsylvania average: 4.7 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
58% occupied
Based on a August 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Follow-Up
Census: 58
Capacity: 100
Deficiencies: 1
Date: Aug 14, 2025
Visit Reason
The inspection visit on 08/14/2025 was a partial, unannounced follow-up related to a complaint and incident at the facility.
Complaint Details
The visit was complaint-related with substantiation implied by the abuse incident described. The incident involved physical abuse between residents in the secure dementia care unit.
Findings
The submitted plan of correction was determined to be fully implemented. The report details an abuse incident involving two residents in the secure dementia care unit, with appropriate immediate actions taken including transfer to emergency care and notifications to authorities. Staff education and behavioral status reviews were planned and implemented.
Deficiencies (1)
A resident was physically abused by another resident in the secure dementia care unit, resulting in injuries and requiring emergency transfer and legal intervention.
Report Facts
License Capacity: 100
Residents Served: 58
Capacity of Secured Dementia Care Unit: 32
Residents Served in Secured Dementia Care Unit: 22
Current Hospice Residents: 12
Total Daily Staff: 85
Waking Staff: 64
Residents Age 60 or Older: 57
Residents with Mobility Need: 27
Residents with Physical Disability: 1
Inspection Report
Complaint Investigation
Census: 59
Capacity: 100
Deficiencies: 0
Date: Apr 24, 2025
Visit Reason
The inspection was a partial, unannounced visit conducted due to a complaint and incident.
Complaint Details
The inspection was triggered by a complaint and incident; no deficiencies were found and no citations issued.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
License Capacity: 100
Residents Served: 59
Secured Dementia Care Unit Capacity: 32
Secured Dementia Care Unit Residents Served: 18
Current Hospice Residents: 8
Resident Age 60 or Older: 58
Residents Diagnosed with Intellectual Disability: 2
Residents with Mobility Need: 22
Inspection Report
Follow-Up
Census: 57
Capacity: 100
Deficiencies: 2
Date: Jan 15, 2025
Visit Reason
The inspection visit on 01/15/2025 was conducted as a full, unannounced inspection for renewal, complaint, and incident reasons, including a follow-up on a previously submitted plan of correction.
Findings
The submitted plan of correction was determined to be fully implemented with continued compliance required. Deficiencies were related to fire drill recordkeeping, specifically failure to record evacuation times in minutes and seconds and failure to alternate exit routes during fire drills throughout 2024. Corrective actions included staff education, observation of fire drills, and ongoing audits.
Deficiencies (2)
The home did not record the evacuation time in minutes and seconds for fire drills conducted on 11/26/24, 6/27/24, 4/30/24, and 1/29/24.
The home failed to alternate exit routes used during fire drills from January 2024 through December 2024, using 'Safe Area' as the exit route on all drills.
Report Facts
License Capacity: 100
Residents Served: 57
Residents in Secured Dementia Care Unit: 17
Capacity of Secured Dementia Care Unit: 32
Current Hospice Residents: 10
Total Daily Staff: 79
Waking Staff: 59
Inspection Report
Renewal
Census: 32
Capacity: 100
Deficiencies: 9
Date: Dec 6, 2023
Visit Reason
The inspection was conducted as a renewal and incident review of Magnolia Place of Saxonburg on 12/06/2023, 12/07/2023, and 01/02/2024 to verify compliance and implementation of the submitted plan of correction.
Findings
Multiple deficiencies were identified including uncovered trash receptacles, missing fitted sheets on a resident's bed, lack of individual toiletry items, missing toilet paper in a bathroom, incorrect fire safety evacuation diagrams, missing annual fire extinguisher inspection documentation, incorrect exit signage, and medication labeling and administration errors. All deficiencies had plans of correction accepted and were implemented by 03/22/2024.
Deficiencies (9)
Uncovered/open garbage bag half filled with refuse in the kitchen located on the garden's unit.
Resident #1 had no fitted sheets on bed.
Common bathroom next to nurse station in memory care unit had no toilet paper.
Fire safety diagram on memory care unit incorrectly indicated two sets of double fire safety doors; only one set present.
Fire extinguisher next to laundry room on memory care unit had no attached documentation of annual inspection by a fire safety expert.
Doorway in rear of memory care unit's dining room had signage indicating egress as an exit, but this point of egress was not an exit.
Resident #2 medication label indicated incorrect insulin dosage instructions.
Resident #2 medication administration record showed blood glucose level discrepancies.
Resident #2 was administered incorrect insulin dosage; Resident #3 was not administered prescribed medication due to unavailability.
Report Facts
License Capacity: 100
Residents Served: 32
Residents Served in Secured Dementia Care Unit: 17
Current Residents in Hospice: 8
Residents with Mobility Need: 18
Residents Age 60 or Older: 49
Residents Diagnosed with Mental Illness: 2
Blood Glucose Level: 202
Inspection Report
Complaint Investigation
Census: 58
Capacity: 100
Deficiencies: 1
Date: Aug 10, 2023
Visit Reason
The inspection was conducted as a complaint investigation with an indicator, unannounced, to review compliance at Magnolia Place of Saxonburg.
Complaint Details
The inspection was complaint-related with a substantiated deficiency regarding the resident support plan for medical/dental care services.
Findings
The submitted plan of correction was found to be fully implemented. A deficiency was noted regarding the support plan for resident #1, which did not include care services provided by home health services or how the home would meet the resident's wound/skin care needs. The plan of correction was accepted and implemented.
Deficiencies (1)
The support plan for resident #1 did not include the care services provided by home health services or how the home will meet the resident's need for wound/skin care.
Report Facts
License Capacity: 100
Residents Served: 58
Secured Dementia Care Unit Capacity: 32
Secured Dementia Care Unit Residents Served: 22
Hospice Current Residents: 10
Residents Age 60 or Older: 57
Residents Diagnosed with Mental Illness: 1
Residents Diagnosed with Intellectual Disability: 2
Residents with Mobility Need: 25
Residents with Physical Disability: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN Support Nurse | Re-educated on regulation 2600.227(d) and facility policy and procedures; involved in auditing support plans | |
| Resident Services Director | Re-educated on regulation 2600.227(d) and facility policy and procedures; involved in auditing support plans | |
| PCHA | Corrected support plan for resident #1; involved in auditing support plans and reviewing compliance |
Inspection Report
Complaint Investigation
Census: 59
Capacity: 100
Deficiencies: 2
Date: Jun 8, 2023
Visit Reason
The inspection was conducted as a complaint investigation, unannounced, to review allegations related to resident abuse and treatment at Magnolia Place of Saxonburg.
Complaint Details
The complaint investigation was substantiated by BHSL representatives onsite. Protective services specialist found the abuse unsubstantiated, but the overall findings led to staff termination and corrective actions.
Findings
The investigation substantiated abuse and improper treatment of residents by staff person A, including physical abuse and mistreatment. Staff person A was terminated, and corrective actions including staff re-education and ongoing resident monitoring were implemented.
Deficiencies (2)
Resident #1 was physically abused by staff person A, including being held by the forearm and yelled at, resulting in a skin tear and distress.
Resident #2 was treated without dignity and respect when staff person A smacked the resident's hand and made inappropriate comments during care.
Report Facts
License Capacity: 100
Residents Served: 59
Capacity of Secured Dementia Care Unit: 32
Residents Served in Dementia Care Unit: 21
Current Hospice Residents: 11
Inspection Report
Original Licensing
Census: 52
Capacity: 84
Deficiencies: 0
Date: Mar 28, 2023
Visit Reason
The inspection was conducted as a new licensing inspection of the facility on 03/28/2023.
Findings
No regulatory citations or deficiencies were identified during this licensing inspection.
Report Facts
License Capacity: 84
Residents Served: 52
Secured Dementia Care Unit Capacity: 32
Secured Dementia Care Unit Residents Served: 22
Hospice Current Residents: 8
Residents Age 60 or Older: 52
Residents Diagnosed with Mental Illness: 1
Residents Diagnosed with Intellectual Disability: 2
Residents with Mobility Need: 25
Residents with Physical Disability: 3
Inspection Report
Original Licensing
Census: 52
Capacity: 84
Deficiencies: 0
Date: Mar 28, 2023
Visit Reason
The inspection was conducted as a new licensing inspection of Magnolia Place of Saxonburg on 03/28/2023 by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing.
Findings
No regulatory citations or deficiencies were identified during this licensing inspection.
Report Facts
License Capacity: 84
Residents Served: 52
Secured Dementia Care Unit Capacity: 32
Secured Dementia Care Unit Residents Served: 22
Hospice Current Residents: 8
Residents Age 60 or Older: 52
Residents Diagnosed with Mental Illness: 1
Residents Diagnosed with Intellectual Disability: 2
Residents with Mobility Need: 25
Residents with Physical Disability: 3
Inspection Report
Complaint Investigation
Census: 56
Capacity: 84
Deficiencies: 0
Date: Dec 28, 2022
Visit Reason
The inspection was conducted as a result of an incident, with multiple licensing inspections occurring on 12/28/2022, 12/30/2022, 01/11/2023, and 01/12/2023.
Complaint Details
The inspection was incident-related and no deficiencies were found, indicating no substantiated complaints.
Findings
No regulatory citations or deficiencies were identified as a result of these inspections.
Report Facts
License Capacity: 84
Residents Served: 56
Current Residents in Hospice: 9
Resident Support Staff Hours: 0
Total Daily Staff Hours: 85
Waking Staff Hours: 64
Residents Age 60 or Older: 56
Residents Diagnosed with Mental Illness: 1
Residents Diagnosed with Intellectual Disability: 2
Residents with Mobility Need: 29
Residents with Physical Disability: 2
Residents Receiving Supplemental Security Income: 0
Inspection Report
Renewal
Census: 58
Capacity: 84
Deficiencies: 9
Date: Nov 15, 2022
Visit Reason
The inspection was conducted as a renewal of the facility license for Magnolia Place of Saxonburg, with unannounced full inspections on 11/15/2022 and 11/16/2022.
Findings
The inspection found multiple deficiencies related to resident safety, medication administration, storage procedures, and equipment maintenance. The facility submitted a plan of correction which was fully implemented and accepted by the Department of Human Services.
Deficiencies (9)
Resident #1 had an enabler attached to bed with two open areas creating a potential entrapment hazard.
Poisonous materials (alkaline bathroom cleaner and Clorox wipes) were unsecured and accessible in the secure unit kitchenette.
The right side door of the double fire doors next to bedroom #315 swung shut very fast and with force, creating a potential hazard.
Resident #1's medication label dosage instructions were inconsistent with the prescribed dosage.
Resident #1's prescribed medication was not available in the home at the time of inspection.
Blood glucose records for residents #1, #3, and #4 showed discrepancies between recorded readings and the home's blood glucose log.
Resident #3's medication administration record had data entry errors requiring correction.
Resident #5 was prescribed medication to be applied bilaterally to legs daily, but the home failed to apply it as ordered.
Resident #6's annual assessment and support plan indicated independence, but the comprehensive nursing assessment showed the resident requires assistance with bathing.
Report Facts
License Capacity: 84
Residents Served: 58
Secured Dementia Care Unit Capacity: 32
Secured Dementia Care Unit Residents Served: 24
Hospice Current Residents: 7
Residents Age 60 or Older: 58
Residents Diagnosed with Mental Illness: 2
Residents Diagnosed with Intellectual Disability: 3
Residents with Mobility Need: 27
Residents with Physical Disability: 2
Total Daily Staff: 85
Waking Staff: 64
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Environmental Services Director | Named in findings related to enabler hazard correction, fire door repair, and audit responsibilities | |
| Business Office Manager | Ordered permanent cover for enabler | |
| Administrator | Involved in re-education, submission of medication error report, and compliance review | |
| Resident Services Director | Involved in re-education, audits, medication error investigation, and compliance monitoring |
Inspection Report
Complaint Investigation
Census: 58
Capacity: 84
Deficiencies: 0
Date: Feb 22, 2022
Visit Reason
The inspection was conducted as a complaint investigation at Magnolia Place of Saxonburg on 02/22/2022.
Complaint Details
The inspection was complaint-related, but no deficiencies were found and follow-up was not required.
Findings
No regulatory citations or deficiencies were identified during the inspection.
Report Facts
License Capacity: 84
Residents Served: 58
Secured Dementia Care Unit Capacity: 32
Secured Dementia Care Unit Residents Served: 19
Hospice Current Residents: 2
Total Daily Staff: 80
Waking Staff: 60
Inspection Report
Renewal
Deficiencies: 0
Date: Nov 18, 2021
Visit Reason
The inspection was conducted as part of licensing inspections on 11/18/2021 and 11/22/2021 for Magnolia Place of Saxonburg.
Findings
No regulatory citations were identified as a result of this inspection.
Inspection Report
Complaint Investigation
Census: 61
Capacity: 84
Deficiencies: 4
Date: Oct 20, 2021
Visit Reason
The inspection visit occurred as a complaint investigation at Magnolia Place of Saxonburg on 10/20/2021.
Complaint Details
The inspection was complaint-driven as stated under Inspection Information with reason: Complaint.
Findings
The inspection found multiple deficiencies related to resident treatment, medication storage and administration, and support plan documentation. Specific issues included staff yelling at a deaf resident, medication unavailability leading to missed doses, and incomplete medical device documentation in the resident's support plan.
Deficiencies (4)
Staff person yelled loudly into resident's ear during communication, upsetting the resident who is deaf and requires specific communication methods.
Medication Hydrocodone Acetaminophen 5-325mg was unavailable from 9:00 AM on 10/12/21 to 2:00 PM on 10/14/21.
Medication Zolpidem Tartrate 10mg was not administered on multiple dates in September 2021 due to unavailability.
Resident's support plan lacked information on previous pacemaker including frequency of checks and responsible party.
Report Facts
License Capacity: 84
Residents Served: 61
Secured Dementia Care Unit Capacity: 20
Secured Dementia Care Unit Residents Served: 16
Hospice Current Residents: 3
Medication Unavailability Duration: 53
Missed Medication Days: 8
Notice
Capacity: 84
Deficiencies: 0
Date: Jan 20, 2021
Visit Reason
This document serves as a certificate of compliance and notification of license renewal for Magnolia Place of Saxonburg, a Personal Care Home. It informs the facility that an annual onsite inspection will be conducted within the next twelve months as required by state regulations.
Findings
The Department has issued a regular license in response to the renewal application and advises that an annual inspection will be conducted to ensure compliance with applicable laws and regulations. No findings or deficiencies are reported in this document.
Report Facts
Maximum capacity: 84
Secure Dementia Care Unit capacity: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary | Signed the renewal notification letter |
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