Inspection Reports for Maple Shade Meadows Senior Living
50 E Locust St, Nesquehoning, PA 18240, United States, PA, 18240
Back to Facility ProfileDeficiencies per Year
28
21
14
7
0
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Census: 65
Capacity: 85
Deficiencies: 0
Jan 28, 2025
Visit Reason
The inspection was an unannounced partial licensing inspection conducted as an interim review of the facility.
Findings
No regulatory citations or deficiencies were identified during the inspection.
Report Facts
Total Daily Staff: 108
Waking Staff: 81
License Capacity: 85
Residents Served: 65
Secured Dementia Care Unit Capacity: 25
Secured Dementia Care Unit Residents Served: 14
Hospice Current Residents: 7
Residents Age 60 or Older: 65
Residents with Mobility Need: 43
Inspection Report
Renewal
Census: 65
Capacity: 85
Deficiencies: 17
Nov 7, 2024
Visit Reason
The inspection was conducted as a renewal inspection of Maple Shade Meadows Senior Living to assess compliance with licensing requirements and regulations.
Findings
The inspection identified multiple deficiencies related to staff training, medication administration, sanitary conditions, emergency preparedness, food storage, fire safety, resident assessments, and documentation. Plans of correction were accepted and implemented with proposed completion dates mostly by December 2024 and follow-up monitoring ongoing.
Deficiencies (17)
| Description |
|---|
| Staff persons A and B did not receive required annual training topics for 2023 including medication self-administration and care for residents with dementia. |
| Staff persons A, B, and C did not receive required annual training topics for 2023 including fire safety and emergency preparedness. |
| Unlocked poisonous materials (hand sanitizer and moisturizer) found accessible to residents in memory care unit. |
| Glucometer belonging to resident #1 was not sanitized after use and had dried red substance on it. |
| Emergency telephone numbers were not posted by the telephone in A hall. |
| Unlabeled and undated frozen food items found in memory care unit freezer. |
| Food stored in refrigerator not properly sealed or covered in memory care unit. |
| Insufficient drinking water supply on site for emergency (189 gallons vs required 195 gallons). |
| Door to enclosed patio in memory care unit lacked signage indicating it is not an exit. |
| Fire extinguisher in outdoor courtyard had expired inspection sticker. |
| Fire drill logs indicated resident #2 was not evacuated to a fire safe area during fire drill. |
| Resident #3 medication was not held as per prescriber’s orders based on blood pressure readings. |
| Resident #4 initial assessment was not completed within 15 days of admission. |
| Resident #5 and #6 support plans did not reflect dietary requirements and device use information. |
| Resident #7 cognitive preadmission screening was not completed prior to or on admission to secured dementia care unit. |
| Resident #8 lacked documentation of no objection to admission to secured dementia care unit. |
| Staff persons A and B did not receive required six hours of dementia training for 2023. |
Report Facts
License Capacity: 85
Residents Served: 65
Secured Dementia Care Unit Capacity: 25
Secured Dementia Care Unit Residents Served: 12
Hospice Residents: 10
Total Daily Staff: 109
Waking Staff: 82
Mobility Need Residents: 44
Required Drinking Water: 195
Actual Drinking Water: 189
Fire Drill Residents Present: 66
Fire Drill Residents Evacuated: 66
Inspection Report
Follow-Up
Census: 70
Capacity: 85
Deficiencies: 1
Aug 20, 2024
Visit Reason
The inspection visit on 08/20/2024 was a partial, unannounced follow-up to verify the implementation of a previously submitted plan of correction related to an incident.
Findings
The submitted plan of correction was determined to be fully implemented, with continued compliance required. The deficiency involved a resident's initial assessment not being completed within the required 15 days of admission, which was corrected through staff re-education and monitoring.
Deficiencies (1)
| Description |
|---|
| Resident's initial assessment was not finalized within the required 15 days of admission. |
Report Facts
License Capacity: 85
Residents Served: 70
Secured Dementia Care Unit Capacity: 25
Secured Dementia Care Unit Residents Served: 17
Total Daily Staff: 118
Waking Staff: 89
Residents with Mobility Need: 48
License Expiration Date: Nov 20, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Responsible for fixing the initial assessment deficiency and monitoring compliance |
| Administrator | Administrator | Responsible for monitoring compliance and conducting random chart audits |
Inspection Report
Census: 93
Capacity: 104
Deficiencies: 0
Nov 14, 2023
Visit Reason
The inspection was a partial, unannounced visit conducted due to an incident at the facility.
Findings
No regulatory citations or deficiencies were identified during this inspection.
Report Facts
Total Daily Staff: 146
Waking Staff: 110
Resident Support Staff: 0
Residents Served: 93
License Capacity: 104
Secured Dementia Care Unit Capacity: 25
Secured Dementia Care Unit Residents Served: 22
Hospice Current Residents: 6
Residents Age 60 or Older: 93
Residents with Mobility Need: 53
Inspection Report
Renewal
Census: 73
Capacity: 104
Deficiencies: 14
Oct 11, 2023
Visit Reason
The inspection was conducted as a renewal and complaint investigation of Maple Shade Meadows Senior Living on 10/11/2023 and 10/12/2023.
Findings
The facility was found to have multiple deficiencies including unsigned resident contracts, lack of documentation for staff qualifications, incomplete staff training, unsafe resident equipment, inadequate trash receptacle lids, missing bedside lighting, incomplete fire drill compliance, missing posted menus, unlabeled medications, unavailable PRN medication, incomplete preadmission screening forms, incomplete support plans, and missing documentation for resident admission objections. All deficiencies had plans of correction accepted and were implemented by 11/03/2023.
Deficiencies (14)
| Description |
|---|
| Resident-home contract for Resident #1 was not signed by the resident. |
| Direct care staff person A lacked documentation of GED or high school diploma. |
| Direct care staff person B did not receive training in medication self-administration and DME/RASP during training year 2022. |
| Resident #2’s bed enabler was not securely fastened and had an uncovered opening posing entrapment risk. |
| Three trash cans in the kitchen had broken or missing lids that could not completely cover trash. |
| Residents #3 and #4 did not have operable lamps or other bedside lighting. |
| The home did not conduct a fire drill during sleeping hours every six months as required. |
| The memory care unit did not have posted menus for the current and upcoming week in a public and conspicuous area. |
| OTC medication bottles belonging to Resident #6 were not labeled with the resident’s name. |
| Resident #7’s PRN medication was not available at the time of inspection. |
| Resident #8’s preadmission screening form was incomplete; Part III determination was left blank. |
| Resident #2’s support plan did not document the enabler bar device, its intended use, risks, or resident’s ability to use it safely. |
| Resident #1 did not have a completed written cognitive preadmission screening prior to admission to the secured dementia unit. |
| Resident #1 and designee did not have documentation of no objection to admission or transfer to the secured dementia care unit. |
Report Facts
License Capacity: 104
Residents Served: 73
Secured Dementia Care Unit Capacity: 25
Residents Served in Dementia Unit: 20
Current Hospice Residents: 5
Residents with Mobility Need: 44
Residents with Physical Disability: 1
Staff Total Daily: 117
Staff Waking: 88
Trash Cans with Broken Lids: 3
Inspection Report
Census: 73
Capacity: 104
Deficiencies: 0
Aug 22, 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 during the inspection.
Report Facts
Total Daily Staff: 117
Waking Staff: 88
License Capacity: 104
Residents Served: 73
Secured Dementia Care Unit Capacity: 25
Secured Dementia Care Unit Residents Served: 22
Hospice Current Residents: 7
Residents Age 60 or Older: 73
Residents with Mobility Need: 44
Inspection Report
Census: 78
Capacity: 104
Deficiencies: 0
Apr 18, 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
Residents Served: 78
License Capacity: 104
Secured Dementia Care Unit Capacity: 25
Secured Dementia Care Unit Residents Served: 21
Hospice Current Residents: 3
Residents Age 60 or Older: 78
Residents with Mobility Need: 41
Inspection Report
Complaint Investigation
Census: 73
Capacity: 104
Deficiencies: 2
Jan 19, 2023
Visit Reason
The inspection was conducted as a complaint investigation with an unannounced partial inspection on 01/19/2023.
Findings
The facility was found to have deficiencies related to medical evaluations and support plan documentation for Resident #1, including failure to complete a medical evaluation within 30 days of admission and failure to update the support plan to reflect changes in the resident's condition. The submitted plan of correction was accepted and fully implemented by 01/31/2023.
Complaint Details
The inspection was complaint-driven and unannounced. The plan of correction was accepted and fully implemented as of 01/31/2023.
Deficiencies (2)
| Description |
|---|
| Resident #1 did not have a medical evaluation completed and documented within 30 days of admission; the evaluation was completed by a physician who did not evaluate the resident in person. |
| Resident #1's support plan was not updated to reflect changes in the resident's condition as required. |
Report Facts
License Capacity: 104
Residents Served: 73
Secured Dementia Care Unit Capacity: 25
Secured Dementia Care Unit Residents Served: 17
Resident Mobility Need: 17
Total Daily Staff: 90
Waking Staff: 68
Inspection Report
Renewal
Census: 70
Capacity: 104
Deficiencies: 26
Nov 29, 2022
Visit Reason
The inspection was conducted as a renewal visit to review compliance with licensing requirements and verify the implementation of a previously submitted plan of correction.
Findings
The inspection identified multiple deficiencies including failure to post current license inspection summaries, breaches of resident record confidentiality, outdated carbon monoxide monitor batteries, unsigned resident contracts, incomplete criminal background checks, inadequate staffing during certain shifts, lack of required First Aid/CPR trained staff, improper storage of poisonous materials and food, locked exit doors preventing immediate egress, incomplete medical evaluations and support plans, medication storage and documentation issues, and deficiencies in fire safety drills and inspections. All deficiencies had plans of correction accepted and were reported as implemented by January 24, 2023.
Deficiencies (26)
| Description |
|---|
| License Inspection Summary reports dated 06/09/2022 and 11/14/21 were not posted in the home as required. |
| Resident hospital visit paperwork and medication blister packs were left unattended in a private dining room, exposing confidential resident information. |
| Carbon monoxide monitor batteries throughout the home had not been changed within the past 12 months. |
| Resident contracts for three residents were not signed. |
| Criminal background check was not conducted on a staff person hired in 2022. |
| Inadequate staffing during certain shifts on unspecified dates, with only 3 staff persons present when more were needed for emergencies. |
| The home did not have at least two staff persons with First Aid and CPR training on specified dates and times. |
| Two bottles of Dawn dish liquid were found in an unlocked cabinet in the memory care unit’s dining area. |
| Frozen chicken cutlets and pancakes were stored in the freezer without proper sealing. |
| Exit doors outside the secure dementia unit were locked with mag locks preventing immediate egress. |
| Residents #4 and #5 with hearing impairments did not have signaling devices to alert them during fire emergencies. |
| The home did not conduct a supervised fire drill or fire safety inspection by a fire safety expert by 12/31/2021. |
| Fire drills were conducted during sleeping hours with additional staff present, not during minimal staffing times. |
| Medical evaluations for residents #1 and #3 were completed more than 60 days prior to admission. |
| Medical evaluation forms for residents #5, #2, and #6 did not include a list of medications or resident weight. |
| Medication pen for resident #7 was not dated when opened, contrary to disposal instructions. |
| PRN medications for residents #8 and #9 were not available in the medication cart; documentation errors for resident #10's medication administration. |
| Medication record for resident #9 lacked diagnosis or purpose for a medication; pharmacy label discrepancy noted. |
| Resident #10's blood glucose reading was not documented in the resident’s record; resident #6 did not receive medication due to unavailability. |
| Resident #1's support plan was not updated after significant change in condition requiring additional support and evacuation assistance. |
| Resident #5's support plan did not document hearing impairment and fire alarm response needs. |
| Medical evaluations for residents #3 and #6 did not properly document need for secured dementia care unit. |
| Cognitive preadmission screenings for residents #2 and #6 were completed more than 72 hours prior to admission to secured dementia care unit. |
| Resident records for residents #2 and #6 lacked signed no objection statements for admission to secured dementia care unit. |
| Support plans for residents #2 and #6 were completed late, past the required 72-hour timeframe after admission. |
| Correction fluid tape was used on resident #6’s cognitive screening form, violating documentation policy. |
Report Facts
Residents served: 70
License capacity: 104
Memory care capacity: 38
Memory care residents served: 17
Current hospice residents: 5
Residents with mobility needs: 25
Residents age 60 or older: 70
Residents with physical disability: 1
Total daily staff: 95
Waking staff: 71
Staff present during low staffing times: 3
Fire drills conducted during sleeping hours: 3
Inspection Report
Follow-Up
Census: 64
Capacity: 104
Deficiencies: 5
Jun 9, 2022
Visit Reason
The inspection was a partial, unannounced follow-up visit conducted due to an incident, with the purpose of reviewing the submitted plan of correction and verifying compliance.
Findings
The facility was found to have multiple deficiencies related to resident abuse, preadmission screening, no objection statements, and admission support plans, all of which had plans of correction submitted and were determined to be fully implemented by the date of this follow-up inspection.
Deficiencies (5)
| Description |
|---|
| Failure to immediately report suspected abuse of a resident as required by the Older Adult Protective Services Act. |
| Resident abuse involving inappropriate sexual touching between residents. |
| Failure to complete a written cognitive preadmission screening within 72 hours prior to admission to a secured dementia care unit. |
| Lack of documentation that the resident and/or designated person did not object to admission or transfer to the secured dementia care unit. |
| Failure to develop, implement, and document a support plan within 72 hours of admission or transfer to the secured dementia care unit. |
Report Facts
License Capacity: 104
Residents Served: 64
Secured Dementia Care Unit Capacity: 25
Secured Dementia Care Unit Residents Served: 17
Hospice Residents: 5
Residents with Mobility Need: 23
Total Daily Staff: 87
Waking Staff: 65
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Michele Moskalczyk | Human Services Licensing Supervisor | Signed the letter confirming the plan of correction was fully implemented. |
| Director of Memory Care | Named as responsible for fixing abuse and compliance issues, including monitoring ongoing compliance. | |
| Administrator | Responsible for ensuring compliance with abuse reporting, preadmission screening, no objection statements, and support plans. | |
| DON | Director of Nursing | Responsible for monitoring ongoing compliance related to abuse and admission requirements. |
Inspection Report
Routine
Deficiencies: 0
Apr 7, 2022
Visit Reason
The inspection was conducted as a licensing inspection by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing.
Findings
No regulatory citations were identified as a result of this inspection.
Inspection Report
Renewal
Census: 52
Capacity: 104
Deficiencies: 20
Nov 2, 2021
Visit Reason
The inspection was conducted as a renewal visit to assess compliance with licensing requirements at Maple Shade Meadows Senior Living.
Findings
The inspection identified multiple deficiencies including failure to report suspected abuse, confidentiality breaches, incomplete medical evaluations, medication administration errors, incomplete staff qualifications and training, missing resident documentation, and failure to post emergency phone numbers. Plans of correction were accepted and implemented with follow-up submissions.
Deficiencies (20)
| Description |
|---|
| Failure to complete and submit Act 13 report for suspected resident abuse. |
| Failure to notify the Department of an alleged abuse incident within 24 hours. |
| Medication Administration records and narcotic count book left unsecured and accessible. |
| Failure to change and date batteries in CO2 monitors annually and lack of gas boiler inspection documentation. |
| Quality management plan review did not include names of staff involved. |
| Background checks for staff were outdated or not completed within 12 months of hire. |
| Direct care staff lacked required high school diploma, GED, or active nurse aide registry status. |
| Medical evaluations for residents were incomplete or unsigned by a physician. |
| Over-the-counter medications and CAM were not labeled with resident names. |
| Medication Administration Records were not signed or initialed by staff administering medications. |
| Failure to follow prescriber's orders due to medication unavailability and missed doses. |
| Resident's preadmission screening form was not completed within required timeframe. |
| Resident initial assessment was completed more than 15 days after admission. |
| Resident support plans lacked documentation of diet and missing resident signatures. |
| Resident records missing race, hair color, eye color, and dated photographs. |
| Direct care staff did not receive required orientation on fire safety and emergency preparedness on first day. |
| Direct care staff did not complete required training within first 40 hours of work. |
| Direct care staff provided unsupervised ADL services without completing required training and competency test. |
| Emergency telephone numbers were not posted by phones in resident room NW12 as required. |
| Medication storage procedures were not properly followed; medication not administered due to unavailability and MAR transcription errors. |
Report Facts
License Capacity: 104
Residents Served: 52
Secured Dementia Care Unit Capacity: 38
Residents in Secured Dementia Care Unit: 13
Hospice Residents: 5
Total Daily Staff: 65
Waking Staff: 49
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Mentioned in relation to background check violation and orientation/training deficiencies. | |
| Staff B | Mentioned for lacking required qualifications, incomplete training, and direct care training violations. | |
| Staff C | Mentioned for lacking required qualifications. | |
| Staff D | Mentioned for not completing direct care training and competency test. |
Inspection Report
Renewal
Capacity: 104
Deficiencies: 0
Sep 7, 2021
Visit Reason
The document is a renewal application and license issuance for Maple Shade Meadows Senior Living, a Personal Care Home, confirming the facility's authorization to operate and advising that an annual inspection will be conducted within the next twelve months.
Findings
The Department has issued a regular license in response to the renewal application and advises that an onsite inspection will be conducted within the next twelve months to ensure compliance with applicable regulations.
Report Facts
Maximum licensed capacity: 104
Secure Dementia Care Unit capacity: 25
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary, Office of Long-term Living | Signed renewal license letter |
Notice
Deficiencies: 0
Sep 3, 2021
Visit Reason
The document serves to notify Maple Shade Meadows Senior Living that their request to waive the administrator training requirement under 55 Pa.Code § 64(a)(1) has been granted temporarily to allow time to complete training.
Findings
The waiver is granted with conditions including attendance at a Department-approved orientation course and documentation of training to be maintained. The waiver is effective from September 2, 2021 to October 6, 2021, after which full compliance is expected.
Report Facts
Waiver effective dates: From September 2, 2021 to October 6, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jeanne Parisi | Bureau Director, Human Services Licensing | Signed the waiver approval letter |
Inspection Report
Complaint Investigation
Census: 80
Capacity: 104
Deficiencies: 3
May 6, 2021
Visit Reason
The inspection was conducted as a complaint investigation to review compliance with regulatory requirements and to verify the submitted plan of correction.
Findings
The facility had repeat violations including failure to report a resident incident, inadequate staffing to safely evacuate residents, and incomplete medication administration documentation. The submitted plan of correction was accepted and determined to be fully implemented.
Complaint Details
The visit was complaint-related as indicated by the inspection reason. The complaint involved failure to report an incident and staffing concerns. The submitted plan of correction was accepted and fully implemented.
Deficiencies (3)
| Description |
|---|
| Failure to report a resident incident involving a closed head injury within 24 hours as required. |
| Inadequate staffing during night shifts to safely evacuate all residents in the event of an emergency. |
| Medication administration was not documented on the medication administration record for multiple residents on various dates. |
Report Facts
License Capacity: 104
Residents Served: 80
Secured Dementia Care Unit Capacity: 25
Secured Dementia Care Unit Residents Served: 10
Residents Age 60 or Older: 80
Residents with Mobility Need: 21
Staffing: 2
Medication Documentation Violations: 5
Inspection Report
Renewal
Deficiencies: 0
Feb 26, 2021
Visit Reason
The inspection was conducted as part of licensing inspections by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing on 02/26/2021, 03/08/2021, and 03/11/2021.
Findings
No regulatory citations were identified as a result of this inspection.
Report Facts
Inspection dates: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Michele Moskalczyk | Human Services Licensing Supervisor | Signed the inspection report |
Inspection Report
Renewal
Deficiencies: 0
Feb 4, 2021
Visit Reason
The inspection visits on 01/06/2021 and 02/04/2021 were conducted as licensing inspections by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing.
Findings
No regulatory citations or deficiencies were identified as a result of these inspections.
Notice
Capacity: 104
Deficiencies: 0
Jan 12, 2021
Visit Reason
The document serves as a renewal notification and issuance of a regular license for Maple Shade Meadows Senior Living, a Personal Care Home, pursuant to Title 55, PA Code, Chapter 2600.
Findings
The Department has approved the renewal application and issued a regular license. It advises that an onsite annual inspection will be conducted within the next twelve months to ensure compliance with applicable regulations.
Report Facts
Maximum capacity: 104
Secure Dementia Care Unit capacity: 25
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary, Office of Long-Term Living | Signed the renewal notification letter |
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