Inspection Reports for The Manor at Market Square
803 Penn St, Reading, PA 19601, United States, PA, 19601
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Inspection Report
Census: 73
Capacity: 80
Deficiencies: 0
Sep 3, 2025
Visit Reason
The inspection was conducted as a licensing inspection due to an incident, with an unannounced partial inspection on 09/03/2025.
Findings
No regulatory citations or deficiencies were identified during this licensing inspection.
Report Facts
License Capacity: 80
Residents Served: 73
Secured Dementia Care Unit Capacity: 18
Secured Dementia Care Unit Residents Served: 15
Current Hospice Residents: 1
Residents with Mobility Need: 15
Residents Age 60 or Older: 73
Inspection Report
Plan of Correction
Census: 64
Capacity: 80
Deficiencies: 1
Dec 17, 2024
Visit Reason
The inspection was a partial, unannounced visit conducted due to an incident involving resident behavior.
Findings
The report documents a physical altercation between residents resulting in injury requiring surgery. The facility implemented immediate corrective actions including 1:1 supervision and a 30-day discharge notice for the aggressive resident. Ongoing quality assurance measures were established to ensure resident safety and compliance.
Deficiencies (1)
| Description |
|---|
| A resident caused another resident to fall resulting in injury requiring surgery; the incident involved physical aggression and inadequate supervision. |
Report Facts
License Capacity: 80
Residents Served: 64
Secured Dementia Care Unit Capacity: 18
Secured Dementia Care Unit Residents Served: 14
Current Hospice Residents: 11
Residents Age 60 or Older: 78
Residents with Mobility Need: 20
Total Daily Staff: 84
Waking Staff: 63
Inspection Report
Renewal
Census: 72
Capacity: 80
Deficiencies: 9
Oct 16, 2024
Visit Reason
The inspection was conducted as a renewal visit for the facility license, with a full, unannounced inspection on 10/16/2024 and exit conference on 10/17/2024.
Findings
The inspection found multiple deficiencies including failure to complete annual fire safety training, missing emergency telephone numbers, improperly labeled food, incomplete evacuation during fire drills, unlocked medication carts, improper medication storage, inaccurate narcotic counts, incomplete medication records, and failure to follow prescriber's orders. All deficiencies had accepted plans of correction with proposed completion dates by 12/31/2024 and were implemented by 11/21/2024.
Deficiencies (9)
| Description |
|---|
| Staff persons A, B, and C did not complete annual fire safety education by a fire safety expert for the training year 2023. |
| The phone located in the main lobby area did not have the required emergency numbers posted on or near the phone. |
| The main kitchen freezer contained a 10-pound box of sausage links with an open bag of sausage that was not dated when opened. |
| Fire drills conducted on 10/19/23, 11/30/23, 12/26/23, and 1/9/23 indicated more residents were in the home than were evacuated; the record does not indicate why all residents were not evacuated. |
| On 10/17/24, the medication cart located in the nursing office was unlocked and unattended; the nursing office door was also unlocked. |
| Insulin pens for Residents #1, #2, and #3 were located in the medication cart but were not refrigerated as instructed. |
| Narcotic counts were not accurate for Resident #5; staff signed medications out on the Medication Administration Record but did not sign the controlled drug record. Medication Administration Records for Residents #6, #7, and #8 had incorrect or missing blood glucose readings. |
| Resident #6's medication administration record did not indicate administration of prescribed medication at the correct times, despite staff interviews confirming administration. |
| Staff C was unable to administer medications to Residents #7 and #8 due to medications not being available in the medication cart. |
Report Facts
License Capacity: 80
Residents Served: 72
Secured Dementia Care Unit Capacity: 18
Secured Dementia Care Unit Residents Served: 14
Hospice Current Residents: 9
Total Daily Staff: 93
Waking Staff: 70
Inspection Report
Complaint Investigation
Census: 72
Capacity: 80
Deficiencies: 4
Oct 1, 2024
Visit Reason
The inspection was conducted as a complaint and incident investigation at the secured dementia care unit of the facility.
Findings
The inspection found multiple deficiencies including resident abuse due to neglect of fall prevention, incomplete medical evaluations lacking required signatures, unsigned cognitive preadmission screenings, and failure to update support plans to reflect residents' increased supervision needs and fall interventions.
Complaint Details
The visit was complaint-related and included investigation of incidents involving resident falls and behavioral issues. The complaint was substantiated by findings of neglect and documentation deficiencies.
Deficiencies (4)
| Description |
|---|
| Resident experienced multiple falls resulting in injury with inadequate documented interventions or supervision. |
| Resident medical evaluation did not include a medical professional's name, signature, or license number. |
| Cognitive preadmission screening was not signed prior to admission to the secured dementia unit. |
| Support plan was not updated to reflect numerous falls and increased supervision needs for residents. |
Report Facts
License Capacity: 80
Residents Served: 72
Secured Dementia Care Unit Capacity: 18
Residents Served in Secured Dementia Care Unit: 13
Resident Falls: 6
Staffing: 91
Waking Staff: 68
Inspection Report
Census: 72
Capacity: 80
Deficiencies: 0
May 14, 2024
Visit Reason
The inspection was a partial, unannounced visit conducted due to an incident at the facility on 05/14/2024.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
License Capacity: 80
Residents Served: 72
Secured Dementia Care Unit Capacity: 18
Secured Dementia Care Unit Residents Served: 14
Hospice Current Residents: 9
Total Daily Staff: 82
Waking Staff: 62
Resident Support Staff: 0
Residents 60 Years or Older: 71
Residents with Mobility Need: 10
Inspection Report
Follow-Up
Census: 67
Capacity: 80
Deficiencies: 1
Mar 12, 2024
Visit Reason
The inspection was a partial, unannounced follow-up visit conducted on 03/12/2024 to review the submitted plan of correction related to an incident.
Findings
The submitted plan of correction was determined to be fully implemented as of the inspection date. The report notes a deficiency related to incomplete resident medical evaluations, specifically missing medical information pertinent to diagnosis and treatment, which was corrected by the Resident Care Director through audits and obtaining necessary physician orders.
Deficiencies (1)
| Description |
|---|
| Resident Documentation of Medical Evaluation is not complete; the section of Medical Information Pertinent to Diagnosis and Treatment is blank and was not reviewed during the process. |
Report Facts
License Capacity: 80
Residents Served: 67
Secured Dementia Care Unit Capacity: 18
Residents Served in Secured Dementia Care Unit: 13
Hospice Residents: 7
Residents with Mobility Need: 13
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Resident Care Director | Named in corrective actions related to medical evaluation deficiencies | |
| Executive Director | Involved in ongoing quality assurance actions for medical evaluations |
Inspection Report
Complaint Investigation
Census: 60
Capacity: 80
Deficiencies: 2
Jul 20, 2023
Visit Reason
The inspection was conducted as a complaint and incident investigation, as indicated by the unannounced partial inspection on 07/20/2023.
Findings
The inspection found rodent feces in a chemical closet inside the kitchen and an ongoing rodent infestation problem reported in multiple areas of the facility including the kitchen, dining rooms, resident room, break room, atrium, and offices. The facility has implemented corrective actions including cleaning and increased pest control visits.
Complaint Details
The visit was complaint-related and incident-driven. The report references a complaint and incident as the reason for inspection. No substantiation status is explicitly stated.
Deficiencies (2)
| Description |
|---|
| Rodent feces were found on the floor of a chemical closet inside the kitchen with no evidence of cleanup. |
| Ongoing rodent infestation reported in multiple areas of the facility with no evidence that pest control visits occurred as scheduled. |
Report Facts
Licensed Capacity: 80
Residents Served: 60
Secured Dementia Care Unit Capacity: 22
Secured Dementia Care Unit Residents Served: 13
Current Residents Receiving Hospice: 5
Residents with Mobility Need: 22
Residents Age 60 or Older: 60
Residents with Physical Disability: 1
Inspection Report
Complaint Investigation
Census: 56
Capacity: 80
Deficiencies: 0
Dec 20, 2022
Visit Reason
The inspection was conducted as a complaint and interim investigation at the facility.
Findings
No regulatory citations or deficiencies were identified during this inspection.
Complaint Details
The inspection was complaint-related and partial in nature, with no deficiencies found and no follow-up required.
Report Facts
Resident Census: 56
Total Licensed Capacity: 80
Current Residents in Hospice: 2
Residents Age 60 or Older: 56
Residents with Mobility Need: 14
Total Daily Staff: 70
Waking Staff: 53
Inspection Report
Follow-Up
Census: 60
Capacity: 80
Deficiencies: 3
Nov 3, 2022
Visit Reason
The inspection was conducted as a partial, unannounced incident review following multiple review dates in November and December 2022, to verify the implementation of a previously submitted plan of correction.
Findings
The facility was found to have implemented the plan of correction related to privacy violations involving unauthorized video and audio recording, bedrail safety concerns posing entrapment risks, and failure to timely assess a resident after a fall. The facility outlined corrective actions including policy reinforcement, staff education, and equipment updates.
Deficiencies (3)
| Description |
|---|
| Unauthorized video and audio recording by a designated person in a resident's room violating privacy rights. |
| Bedrail without cover and openings wider than 4 3/4 inches posing an entrapment risk. |
| Failure to timely assess a resident after a fall, resulting in delayed medical care by approximately 2 hours. |
Report Facts
License Capacity: 80
Residents Served: 60
Secured Dementia Care Unit Capacity: 16
Secured Dementia Care Unit Residents Served: 14
Current Hospice Residents: 1
Residents Age 60 or Older: 60
Residents with Mobility Need: 19
Residents with Physical Disability: 2
Inspection Report
Renewal
Census: 63
Capacity: 80
Deficiencies: 15
Oct 12, 2022
Visit Reason
The inspection was conducted as a renewal review of the facility license on 10/12/2022 and 10/13/2022 to determine compliance with applicable regulations.
Findings
The inspection identified multiple deficiencies related to safety, staffing, training, sanitary conditions, medication administration, and resident care plans. All deficiencies had accepted plans of correction which were fully implemented by 12/29/2022.
Deficiencies (15)
| Description |
|---|
| CO2 monitor in the kitchen lacked date and battery checks as required by Pennsylvania law. |
| Insufficient staffing during night shift to meet evacuation needs of immobile residents. |
| Not enough CPR trained staff on duty as required. |
| New staff did not complete first day orientation and 40 hours of required training timely. |
| Resident bed enablers and bed rails were not properly secured or covered. |
| Resident bed sheets found with fecal smears. |
| Hot water temperatures in resident rooms exceeded the maximum allowed 120°F. |
| Resident in room 3 did not have an operable bedside lamp. |
| Shared bathroom soap bars were not labeled or separated. |
| Food in memory care freezer was not covered, exposing it to contamination. |
| Outdated or undated food items found in memory care refrigerator and freezer. |
| Discontinued medication was found in a resident's medication cart. |
| Medication Administration Records (MAR) were inaccurately transcribed and glucometers were not calibrated correctly. |
| Resident missed prescribed medication doses as per prescriber's orders. |
| Resident's support plan did not document special dietary needs as indicated by DME. |
Report Facts
Residents served: 63
License capacity: 80
Staff persons scheduled: 3
Residents needing evacuation assistance: 26
Hot water temperature: 142.6
Hot water temperature: 123.5
Hot water temperature: 129.1
Staff persons: 8
CPR trained nursing staff: 8
Breakfast sausage links: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Resident Care Director | Named in multiple findings related to resident mobility assessment, medication audits, and training oversight | |
| Executive Director | Named in multiple findings related to compliance reviews, training, and plan of correction implementation | |
| Maintenance Assistant | Responsible for checking CO2 units quarterly and ensuring bed enablers are properly fastened | |
| Maintenance Director | Responsible for water heater adjustments and periodic compliance checks | |
| Business Office Manager | Responsible for overseeing staff orientation, CPR training, and competency test compliance | |
| Food Service Director | Responsible for food storage training and weekly compliance checks | |
| Marketing Director | In-serviced staff on bed enabler requirements and informs families at admission |
Inspection Report
Follow-Up
Census: 55
Capacity: 80
Deficiencies: 2
Jun 9, 2022
Visit Reason
The inspection was a partial, unannounced review conducted due to an incident, with multiple on-site and off-site dates, to follow up on a previously submitted plan of correction.
Findings
The facility was found to have implemented the submitted plan of correction related to medication storage and resident support plan documentation. The deficiencies involved failure to send all prescribed PRN medications with a resident leaving the facility and outdated resident support plan documentation regarding challenging behaviors.
Deficiencies (2)
| Description |
|---|
| Resident #1 left the facility on 6/2/22 on a family visit. The home did not send all the residents prescribed PRN medications with the family. |
| Resident #1's RASP was not updated regarding the resident's current care needs, including challenging behaviors and care acceptance. |
Report Facts
License Capacity: 80
Residents Served: 55
Secured Dementia Care Unit Capacity: 16
Secured Dementia Care Unit Residents Served: 14
Hospice Residents: 2
Resident Support Staff: 16
Total Daily Staff: 87
Waking Staff: 65
Residents with Mobility Need: 16
Residents with Physical Disability: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Anne Graziano | Signed letter approving plan of correction implementation | |
| Resident Care Director | Conducted training on medication administration and protocols | |
| Executive Director | Led training on RASP and challenging behaviors; responsible for periodic chart reviews |
Inspection Report
Renewal
Census: 60
Capacity: 80
Deficiencies: 2
Nov 2, 2021
Visit Reason
The inspection was conducted as a renewal visit with an incident review at THE MANOR AT MARKET SQUARE on 11/02/2021 and 11/03/2021.
Findings
The facility was found to have deficiencies related to menu posting in the main dining room and secured dementia care unit, and incomplete resident record content regarding identifiable body marks. The submitted plan of correction was accepted and fully implemented.
Deficiencies (2)
| Description |
|---|
| The home's main dining room did not have the upcoming week's menu posted; the menu posted was only for the week of 10/31/21 thru 11/06/21. The secured unit did not have a menu posted for the present and upcoming week in a public and conspicuous space. |
| Resident #1's resident record did not state if the resident had any identifiable body marks in their resident information. |
Report Facts
License Capacity: 80
Residents Served: 60
Secured Dementia Care Unit Capacity: 15
Secured Dementia Care Unit Residents Served: 13
Hospice Residents: 2
Resident Diagnosed with Mental Illness: 6
Residents with Mobility Need: 16
Residents with Physical Disability: 2
Total Daily Staff: 76
Waking Staff: 57
Notice
Capacity: 80
Deficiencies: 0
Aug 31, 2021
Visit Reason
The document serves as a renewal notification and license issuance for The Manor at Market Square Personal Care Home, with a reminder that an annual onsite inspection will be conducted within the next twelve months.
Findings
No inspection findings are reported; the document confirms receipt of the renewal application and issuance of a regular license.
Report Facts
Maximum capacity: 80
Secure Dementia Care Unit capacity: 18
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary | Signed the renewal notification letter |
Inspection Report
Renewal
Deficiencies: 0
Jun 3, 2021
Visit Reason
The inspection visits on 05/13/2021 and 06/03/2021 were conducted as licensing inspections by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing.
Findings
No regulatory citations were identified as a result of these inspections.
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