Inspection Reports for McCallum Assisted Life
7141 MCCALLUM STREET,, PA, 19119
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
52 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
1006% worse than Pennsylvania average
Pennsylvania average: 4.7 deficiencies/yearDeficiencies per year
40
30
20
10
0
Census
Latest occupancy rate
54% occupied
Based on a June 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Renewal
Census: 26
Capacity: 48
Deficiencies: 9
Jun 9, 2025
Visit Reason
The inspection was a renewal licensing inspection conducted on June 9, 2025, to assess compliance with 55 Pa. Code Chapter 2600 relating to Personal Care Homes.
Findings
The facility was found to be in compliance overall, with several deficiencies identified related to staffing hours during waking hours, bathroom ventilation, emergency telephone numbers, bedside lighting, emergency procedures, unobstructed egress, medical evaluation completeness, emergency medical information, and self-administration assessments. All deficiencies had plans of correction accepted and were implemented by July 28, 2025.
Deficiencies (9)
| Description |
|---|
| On 6/7 and 6/8/2025, only 73% of required direct care hours were provided during waking hours. |
| On 6/9/2025, the bathroom in room 303 did not have an operable window or ventilation fan; the exhaust fan was not circulating air. |
| No emergency telephone numbers, including nearest hospital and fire department, were posted on or by the telephone in room 303. |
| On 6/9/2025, residents in rooms 112 and 205 did not have access to a source of light that can be turned on/off at bedside. |
| The home's written emergency procedures did not include contact information for each resident’s designated person. |
| On 6/9/2025, the egress door from the second-floor boiler room was triple-locked and difficult to open due to swollen wood. |
| Resident #3's medical evaluation did not include body positioning and movement; assessment noted use of rollator for ambulation. |
| The home's emergency medical plan had not been updated since 2013 and was missing required contents for 13 residents including resident #4. |
| Resident #1 self-administers blood sugar tests with supervision, but assessment and medical evaluation indicate inability to self-administer medications. |
Report Facts
License Capacity: 48
Residents Served: 26
Staffing Hours: 26
Waking Staff Hours: 20
Deficiency Count: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Juliet Marsala | Deputy Secretary | Signed licensing letter and certificate of compliance. |
Inspection Report
Follow-Up
Census: 27
Capacity: 48
Deficiencies: 5
Jan 30, 2025
Visit Reason
The visit was a follow-up review conducted on February 21, 2025 and May 6, 2025 to assess the implementation of the plan of correction submitted for the January 30, 2025 inspection.
Findings
The facility was found to have multiple deficiencies including evidence of insect infestation, damaged mattresses, missing bed linens, menus not posted one week in advance, and staff administering medications without completing required training. The submitted plan of correction was not implemented as of the follow-up dates.
Deficiencies (5)
| Description |
|---|
| A roach was observed crawling on the toilet paper in the bathroom of room #117. |
| The mattress belonging to Resident #1 had a hole along the edge and was in poor condition. |
| The bed for Resident #1 did not have any bed linens. |
| Menus were not posted one week in advance in a conspicuous location; only the current week's menu was posted. |
| Staff persons A, B, C, and D administered medications without successfully completing the Department-approved medication administration course. |
Report Facts
License Capacity: 48
Residents Served: 27
Total Daily Staff: 27
Waking Staff: 20
Residents Receiving Supplemental Security Income: 4
Residents 60 Years or Older: 23
Residents Diagnosed with Mental Illness: 16
Residents with Physical Disability: 1
Inspection Report
Plan of Correction
Census: 25
Capacity: 48
Deficiencies: 3
Jul 29, 2024
Visit Reason
The inspection was a partial, unannounced visit conducted due to an incident at the facility on 07/29/2024.
Findings
The inspection identified deficiencies related to medication administration, including a resident being allowed to self-administer medications without proper assessment and documentation errors regarding medication administration times. The facility submitted a plan of correction which was accepted and fully implemented by 09/20/2024.
Deficiencies (3)
| Description |
|---|
| Resident 1 was given medications to self-administer despite being assessed as unable to self-administer and needing reminders. |
| Medication administration records were inaccurately completed, with staff initialing medication as administered when it was given to the resident to take later. |
| The facility failed to follow prescriber's orders by giving resident 1 medications to take with them without proper authorization. |
Report Facts
License Capacity: 48
Residents Served: 25
Residents with Mental Illness: 15
Residents 60 Years or Older: 21
Residents with Supplemental Security Income: 4
Residents with Mobility Need: 1
Residents with Physical Disability: 1
Total Daily Staff: 26
Waking Staff: 20
Inspection Report
Monitoring
Census: 25
Capacity: 48
Deficiencies: 20
Jun 25, 2024
Visit Reason
The visit was a monitoring inspection to review compliance with licensing regulations and verify correction of previous deficiencies at McCallum Assisted Life.
Findings
The inspection found multiple deficiencies including issues with staff hiring practices, waking hours staffing, first aid/CPR training, ancillary staff orientation, training topics, sanitary conditions, hot water temperature, emergency telephone numbers, food labeling, lint removal, medical evaluations, menu postings, medication labeling and administration, support plans, and record content. Plans of correction were accepted but many were not yet implemented at the time of inspection.
Deficiencies (20)
| Description |
|---|
| Failure to apply Nixon Decision steps for staff hiring with a prohibitive offense. |
| Less than 75% of personal care service hours provided during waking hours. |
| No staff person trained in first aid and CPR was on duty during night hours. |
| Ancillary staff did not receive general orientation to job functions prior to working. |
| Direct care staff did not receive required medication self-administration training documentation. |
| Sanitary conditions not maintained; no paper towels in shared bathroom and cigarettes found in medication cart. |
| Hot water temperature exceeded 120°F in resident accessible areas. |
| Emergency telephone numbers not posted by nurse station telephone. |
| Unlabeled and undated leftover food found in kitchen refrigerator. |
| Lint accumulation in clothes dryer lint traps. |
| Resident medical evaluations missing required information such as body positioning and movement. |
| Weekly menus not posted in a conspicuous and public place in the home. |
| Medication container label not updated to reflect changes in directions. |
| Glucometers not calibrated correctly and blood sugar logs inaccurately recorded. |
| Medication administration record missing initials of staff who administered medication. |
| Prescriber's orders not followed regarding insulin dosage and blood sugar testing times. |
| Staff administered medications without completing Department-approved medication administration course. |
| Medication administration training records incomplete for staff. |
| Resident support plans missing required medical, dental, vision, and dietary information. |
| Resident records missing recent photographs. |
Report Facts
License Capacity: 48
Census: 25
Staffing Hours: 26
Waking Staff: 20
Fine Per Resident Per Day: 3
Calculated Fine: 75
Mandated Correction Date: 15
Inspection Report
Monitoring
Census: 25
Capacity: 48
Deficiencies: 21
Jun 25, 2024
Visit Reason
The visit was a monitoring inspection to review compliance with licensing regulations and follow up on previous deficiencies.
Findings
The facility had multiple deficiencies related to staff hiring practices, waking hours, staff training, sanitary conditions, medication administration, medical evaluations, support plans, and documentation. Several repeat violations were noted, and plans of correction were submitted with proposed completion dates.
Deficiencies (21)
| Description |
|---|
| Staff person was hired despite a prohibitive offense without following required steps of the Nixon Decision. |
| Less than 75% of personal care service hours were available during waking hours on specified dates. |
| No staff person trained in first aid was on duty during specified night hours. |
| Ancillary staff person did not have a general orientation to specific job functions prior to working. |
| Direct care staff did not receive training in medication self-administration during the training year 2023. |
| No paper towel or hand drying available in a shared bathroom; cigarettes found in medication cart. |
| Hot water temperature in resident accessible area exceeded 120°F. |
| Emergency telephone numbers were not posted by the nurse station telephone. |
| Unlabeled and undated leftover food found in kitchen refrigerator. |
| Lint accumulation found in lint trap of clothes dryers. |
| Resident medical evaluation did not include body positioning and movement stimulation. |
| Weekly menus were not posted in a conspicuous and public place in the home. |
| Medication container label did not reflect changes in directions for use. |
| Glucometers were not calibrated to the correct date and time; blood sugar logs inaccurate. |
| Medication administration record did not include initials of staff administering medication. |
| Prescriber's directions were not followed for insulin administration and blood sugar checks. |
| Staff administered medications without completing Department-approved medication administration course. |
| Medication administration training record lacked documentation of successful course completion. |
| Resident support plans did not document medical, dental, vision, or dietary needs as required. |
| Resident records lacked a photograph no more than 2 years old. |
| Resident initial support plan was not completed within 30 days of admission. |
Report Facts
Fine Per Resident Per Day: 3
Calculated Fine Per Day: 75
Mandated Correction Days: 15
Census at Inspection: 25
License Capacity: 48
Residents Served: 24
Total Daily Staff: 25
Waking Staff: 19
Residents Served: 25
Total Daily Staff: 26
Waking Staff: 20
Inspection Report
Complaint Investigation
Census: 26
Capacity: 48
Deficiencies: 5
Mar 20, 2024
Visit Reason
The inspection was conducted as a partial, unannounced visit due to complaint, provisional, and monitoring reasons.
Findings
The inspection found multiple deficiencies including inadequate administrator training hours, lighting issues, damaged surfaces, broken window blinds, and unlabeled leftover food containers. Plans of correction were submitted and accepted, with full implementation confirmed by May 2, 2024.
Complaint Details
The inspection was complaint-related, provisional, and monitoring in nature. The submitted plan of correction was reviewed and found fully implemented.
Deficiencies (5)
| Description |
|---|
| Administrator completed only 14.5 hours of Department-approved training in 2023, less than the required 24 hours. |
| Room was dimly lit with at least one burnt out lightbulb. |
| Missing strip of hardwood floor in kitchen and missing ceiling tile above medicine room. |
| Blinds in a resident room were cracked and bent, particularly the bottom third of the slats on the left side. |
| Unlabeled and undated containers of sliced peaches and other foods found in refrigerator. |
Report Facts
License Capacity: 48
Residents Served: 26
Administrator Training Hours Completed: 14.5
Staffing Hours: 27
Waking Staff: 20
Inspection Report
Follow-Up
Census: 24
Capacity: 48
Deficiencies: 2
Feb 22, 2024
Visit Reason
The inspection was a follow-up review conducted on 02/22/2024 to verify the implementation of a previously submitted plan of correction related to deficiencies found at MCCALLUM ASSISTED LIFE.
Findings
The submitted plan of correction was determined to be fully implemented as of the inspection date. Deficiencies related to incomplete medical evaluations and inaccurate support plans were addressed with ongoing audits and staff training to ensure compliance.
Deficiencies (2)
| Description |
|---|
| Resident medical evaluation did not include special health or dietary needs, allergies were incorrectly documented, and medication self-administration ability was inconsistently recorded. |
| Support plan inaccurately documented resident's need for laundry service and diet type, conflicting with medical evaluation. |
Report Facts
Total Daily Staff: 26
Waking Staff: 20
Residents Served: 24
License Capacity: 48
Residents 60 Years or Older: 20
Residents Diagnosed with Mental Illness: 18
Residents with Mobility Need: 2
Residents with Physical Disability: 1
Inspection Report
Monitoring
Census: 26
Capacity: 48
Deficiencies: 7
Nov 30, 2023
Visit Reason
The inspection was a monitoring visit conducted on November 30, 2023, with follow-up reviews on January 16, 2024 and February 15, 2024, to verify the implementation of the plan of correction from the November 30, 2023 inspection.
Findings
The facility was cited for multiple violations including labeling of electrical rooms, interior surfaces needing repair, improper storage of combustibles, furniture and equipment disrepair, combustible storage near heat sources, and inoperative fire alarm and smoke detectors. The submitted plan of correction was not fully implemented as of the February 15, 2024 review.
Deficiencies (7)
| Description |
|---|
| Labeling of electrical rooms not properly completed. |
| Interior surfaces requiring repair. |
| Improper storage of combustibles in equipment rooms. |
| Sprinkler room cluttered with pipes, materials, combustible paint, and trash. |
| Light fixture hanging in disrepair from a live wire. |
| Combustible materials stored in the boiler room. |
| Fire alarm and smoke detectors found inoperative and disrepair. |
Report Facts
License Capacity: 48
Residents Served: 26
Total Daily Staff: 28
Waking Staff: 21
Residents 60 Years or Older: 22
Residents Diagnosed with Mental Illness: 20
Residents with Mobility Need: 2
Residents with Physical Disability: 1
Inspection Report
Complaint Investigation
Census: 29
Capacity: 48
Deficiencies: 38
Sep 25, 2023
Visit Reason
The inspection was a complaint investigation conducted due to allegations or concerns raised about the facility's compliance with regulations.
Findings
The inspection found multiple deficiencies including sanitary condition violations, staff qualification issues, medication administration errors, safety hazards, and maintenance problems throughout the facility. Several deficiencies were repeat violations and many plans of correction were not implemented by the follow-up date.
Complaint Details
The inspection was complaint-related with multiple deficiencies found including repeat violations and ongoing noncompliance with regulations.
Deficiencies (38)
| Description |
|---|
| Criminal background check was not obtained timely for a staff member. |
| Housekeeping tasks were not fulfilled, resulting in unsanitary resident rooms and bathrooms. |
| Unsanitary conditions observed including feces stains in shower, overflowing trash, soiled sheets, dirty floors, and malodorous smells. |
| Leak in ceiling in medication room exposing pipe and water leaking into sink. |
| Sink in medication room clogged and not in good repair with stagnant red water. |
| Exterior handrail bent and detached, presenting a tripping hazard. |
| Medication administration records missing staff initials for multiple medications. |
| Medication administration records missing route, frequency, times, diagnosis, and date/time of administration. |
| Current license not posted in a conspicuous and public place. |
| Administrator did not provide immediate access to all staff timecards upon request. |
| Carbon monoxide alarm installed less than 15 feet from gas-fired hot water heater. |
| Direct care staff person lacked required qualifications and training. |
| No direct care staff present in the building during certain overnight hours when residents were present. |
| Direct care staff availability and training documentation could not be verified for required hours. |
| Staffing insufficient to meet resident needs during certain times. |
| First aid and CPR trained staff presence could not be verified during certain periods. |
| Direct care staff hired after 2006 lacked required training and competency testing. |
| Sanitary conditions not maintained; mold and black substance observed in multiple areas including bathrooms, ceilings, walls, and kitchen. |
| Evidence of infestation including mice droppings, moths, stink bugs, and gnats found in various areas. |
| Floors, walls, ceilings, windows, doors and other surfaces were not clean, in good repair, or free of hazards; multiple structural and water damage issues noted. |
| Windows missing screens, dirty, or covered with broken plastic allowing insect entry. |
| Furniture and equipment in disrepair including worn couch, missing drawer parts, broken heat detector, and stained seating. |
| Exterior building grounds in disrepair with buckling patio roof and holes. |
| Mattress soiled with large yellow stain. |
| Bedside lamps and lighting in resident rooms not working. |
| Window blinds broken and in disrepair. |
| Towels, washcloths, and soap not individually labeled for residents. |
| Soap dispensers missing or unlabeled bar soap present in bathrooms. |
| Condiments not available at dining tables during meals. |
| Emergency exit routes obstructed by furniture, boxes, and trash. |
| Combustible and flammable materials stored near heat sources and hot water heaters. |
| Resident medical evaluation missing pertinent emergency diagnosis and treatment information. |
| Resident support plan did not document dietary restrictions indicated in medical evaluation. |
| Blood sugar logs contained transcription errors and missed entries. |
| Medication storage procedures not properly followed; loose pills and medication packets found unsecured. |
| Staff administered medications without current Department-approved medication administration training. |
| Medication administration training records incomplete or missing for staff. |
| Resident initial assessments not dated, preventing determination of timely completion. |
Report Facts
License Capacity: 48
Residents Served: 29
Staffing Hours: 35
Waking Staff: 26
Fines Proposed: 280
Inspection Report
Complaint Investigation
Census: 29
Capacity: 48
Deficiencies: 33
Sep 25, 2023
Visit Reason
The inspection was conducted as a complaint investigation to assess compliance with regulations following allegations or concerns.
Findings
The inspection identified multiple deficiencies including unsanitary conditions, infestation, structural and maintenance issues, incomplete or missing documentation, staffing and training deficiencies, and medication administration errors. Several corrective actions and plans of correction were proposed but many were not implemented as of the report date.
Complaint Details
The inspection was complaint-driven with multiple cited violations including sanitation, staffing, training, medication administration, and facility maintenance issues. Several repeat violations were noted.
Deficiencies (33)
| Description |
|---|
| Criminal background check not obtained timely for staff. |
| Housekeeping tasks not fulfilled; unsanitary resident rooms and bathrooms. |
| Sanitary conditions not maintained; feces stains, overflowing trash, soiled sheets, malodorous smells. |
| Leak and water damage in medication room ceiling and other areas. |
| Furniture and equipment in disrepair including worn couch, missing drawer parts, stained sofa and chairs. |
| Exterior handrail bent and detached, presenting tripping hazard. |
| Medication administration records missing staff initials and documentation errors. |
| Missing or incomplete medication administration details including route, frequency, diagnosis, and administration times. |
| Current license not posted in a conspicuous place. |
| Administrator failed to provide immediate access to all requested records. |
| Carbon monoxide alarm installed too close to gas-fired hot water heater. |
| Direct care staff lacked required qualifications and training. |
| No direct care staff present during certain shifts when residents were present. |
| Sanitary conditions not maintained; mold, water damage, damaged ceilings, and walls throughout the building. |
| Evidence of infestation including mice droppings, moths, stink bugs, and gnats found in multiple areas. |
| Windows and screens missing or in disrepair; some windows open without screens. |
| Furniture and equipment in poor condition including worn carpet, broken heat detector, and damaged drawers. |
| Exterior building grounds in disrepair; patio roof with holes and buckling. |
| Resident bedroom mattress soiled with large stain. |
| Bedroom lamps and lighting not working. |
| Window blinds broken and in disrepair. |
| Towels, washcloths, and soap not individually labeled for residents. |
| Soap dispensers missing or unlabeled bar soap present in bathrooms. |
| Condiments not available at dining tables during meals. |
| Emergency exit routes obstructed by furniture, boxes, and trash. |
| Combustible materials stored near heat sources and hot water heaters. |
| Resident medical evaluations missing required emergency medical information. |
| Resident support plans not updated to reflect medical dietary restrictions. |
| Menus posted were outdated and not current. |
| Medication storage procedures not properly followed; loose pills found on resident dresser. |
| Staff administered medications without current Department-approved medication administration training. |
| Medication administration training records incomplete or missing for staff. |
| Resident initial assessments not dated or completed within required timeframe. |
Report Facts
License Capacity: 48
Residents Served: 29
Staffing Hours: 35
Waking Staff: 26
Fine Per Resident Per Day: 5
Calculated Fine: 140
Census at Inspection: 28
Inspection Report
Complaint Investigation
Census: 29
Capacity: 48
Deficiencies: 35
Sep 25, 2023
Visit Reason
The inspection was a complaint investigation conducted due to complaints received about the facility's compliance with regulations.
Findings
The inspection found multiple deficiencies including sanitary condition issues such as mold and pest infestation, unsafe and damaged furniture and equipment, lack of proper staff qualifications and training, incomplete resident medical and support documentation, and safety hazards including obstructed egress and combustible storage.
Complaint Details
The inspection was complaint-driven with multiple cited violations related to sanitation, staff qualifications, medication administration, safety hazards, and documentation deficiencies. Follow-up inspections and enforcement actions were conducted.
Deficiencies (35)
| Description |
|---|
| Criminal background check not obtained timely for staff. |
| Housekeeping tasks not fulfilled, unsanitary resident rooms and bathrooms. |
| Sanitary conditions not maintained; feces stains in shower, overflowing trash, soiled sheets, malodorous smell. |
| Leak in ceiling in medication room exposing pipe; water leaked into sink. |
| Sink in medication room clogged and not in good repair. |
| Exterior handrail bent and detached, presenting tripping hazard. |
| Medication administration records missing staff initials for multiple medications. |
| Medication administration records missing route, frequency, times, diagnosis, and date/time of administration. |
| Current license not posted in a conspicuous place. |
| Administrator did not provide all requested staff timecards for review. |
| Carbon monoxide alarm installed less than 15 feet from gas heater. |
| Direct care staff person lacked required qualifications and training. |
| No direct care staff present during certain shifts; residents present without qualified staff. |
| Sanitary conditions not maintained; mold observed in multiple areas, unlabeled towels and washcloths. |
| Evidence of infestation of insects and rodents found in multiple areas. |
| Floors, walls, ceilings, windows, doors and other surfaces not clean, in good repair or free of hazards; water damage, leaks, exposed wiring, damaged walls and ceilings. |
| Windows missing screens, dirty, or broken allowing insect entry. |
| Furniture and equipment in disrepair including worn couch, missing drawer parts, broken heat detector, stained sofa and chairs. |
| Exterior building grounds in disrepair; patio roof with holes and buckling. |
| Mattress soiled with large stain. |
| Bedside lamp and room lights not working. |
| Window blinds broken and in disrepair. |
| Towels, washcloths and soap not labeled or individualized. |
| Soap dispensers missing or unlabeled bar soap present. |
| Condiments not available at dining tables. |
| Egress routes blocked by furniture, trash and debris. |
| Combustible materials stored near heat sources. |
| Resident medical evaluation missing pertinent emergency information. |
| Menus not posted current or one week in advance. |
| Medication storage procedures not followed; loose pills and packets found unsecured. |
| Staff administered medications without current Department-approved medication administration training. |
| Medication administration training records incomplete or missing. |
| Resident initial assessment not dated. |
| Resident support plan not updated to reflect medical dietary restrictions. |
| Ceiling in medication room sustaining water damage; shower head leaking. |
Report Facts
License Capacity: 48
Residents Served: 29
Staffing Hours: 35
Waking Staff: 26
Fine Per Resident Per Day: 5
Calculated Fine Per Day: 140
Correction Deadline Days: 5
Inspection Report
Renewal
Census: 28
Capacity: 48
Deficiencies: 11
Mar 21, 2023
Visit Reason
The inspection was conducted as a renewal of the facility license, including a full unannounced inspection and follow-up reviews.
Findings
The inspection identified multiple deficiencies including unlocked medications accessible to residents, missing pillow cases, incomplete emergency procedures, lack of documentation to the fire department, incomplete medical evaluations, staff training deficiencies, medication administration errors, incomplete medication records, failure to follow prescriber's orders, medication error reporting issues, and incomplete resident support plans. Plans of correction were accepted and implemented with specified completion dates.
Deficiencies (11)
| Description |
|---|
| Several medications were unlocked, unattended, and accessible on the medication cart for multiple residents. |
| The pillow for resident #6 was missing the pillow case. |
| The home’s written emergency procedures did not include contact information for each resident's designated person, the home's plan to provide emergency medical information ensuring confidentiality, and means of transportation. |
| The home lacked documentation of written notification to the local fire department regarding the address, bedroom locations, and assistance needed for evacuation. |
| Medical evaluations for residents #3 and #7 were missing required information such as height, weight, blood pressure, special health needs, immunization, and ability to self-administer medications. |
| Resident #8's most recent medical evaluation was not completed within the required annual timeframe. |
| Staff person A transported residents without completing the required initial new hire direct care staff training. |
| Resident #5's medication was unattended and sitting in a cup on the medication cart; medication administration protocol was not followed. |
| Resident #9 was prescribed a medication that was not administered and not included on the medication administration record. |
| Resident #9 was not given prescribed medication at home; medication error was not reported to the resident, designated person, or prescriber. |
| Resident support plans for residents #9 and #10 did not document how identified medical/dental needs would be met. |
Report Facts
License Capacity: 48
Residents Served: 28
Total Daily Staff: 29
Waking Staff: 22
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Resident Care Coordinator | Named as responsible staff for multiple deficiencies including medication administration, record confidentiality, medical evaluations, medication error reporting, and support plan documentation. | |
| Administrator | Named as responsible staff for updating emergency procedures, notifying fire department, staff training, and oversight of compliance. | |
| Med Techs | Named as responsible staff for medication administration and confidentiality deficiencies. | |
| Laundry/Care Staff | Named as responsible staff for linen and pillow case deficiencies. |
Inspection Report
Complaint Investigation
Census: 29
Capacity: 48
Deficiencies: 1
Jul 11, 2022
Visit Reason
The inspection was conducted as a complaint investigation to review compliance at MCCALLUM ASSISTED LIFE.
Findings
The submitted plan of correction related to the lack of an active dumpster license was fully implemented. The facility was not aware a license was required and took multiple steps to obtain it, including submitting applications and coordinating with the city. Continued compliance must be maintained.
Complaint Details
The visit was complaint-related and the submitted plan of correction was determined to be fully implemented.
Deficiencies (1)
| Description |
|---|
| The home did not have an active dumpster license as required by the City of Philadelphia License and Inspections Department. |
Report Facts
License Capacity: 48
Residents Served: 29
Total Daily Staff: 30
Waking Staff: 23
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Named as responsible for following up with City of Philadelphia for dumpster license application |
Inspection Report
Complaint Investigation
Census: 29
Capacity: 48
Deficiencies: 0
Jun 1, 2022
Visit Reason
The inspection was conducted as a complaint investigation at MCCALLUM ASSISTED LIFE.
Findings
No regulatory citations or deficiencies were identified during the inspection.
Complaint Details
The inspection was complaint-related, but no deficiencies were found and the complaint was not substantiated.
Report Facts
License Capacity: 48
Residents Served: 29
Total Daily Staff: 30
Waking Staff: 23
Residents 60 Years or Older: 25
Residents Diagnosed with Mental Illness: 25
Residents with Mobility Need: 1
Residents with Physical Disability: 1
Inspection Report
Renewal
Census: 29
Capacity: 48
Deficiencies: 14
Apr 20, 2022
Visit Reason
The inspection was conducted as a renewal inspection of the MCCALLUM ASSISTED LIFE facility on 04/20/2022.
Findings
The inspection identified multiple deficiencies including broken and missing floor tiles, hot water temperature exceeding limits, missing emergency telephone numbers, leaking bathroom sink, missing bedside table, outdated food, fire safety inspection concerns, incomplete annual medical evaluations, expired and improperly documented medications, and incomplete resident records. Plans of correction were accepted or directed with completion dates mostly by 04/30/2022 or 05/10/2022.
Deficiencies (14)
| Description |
|---|
| The 1st floor bathroom by the nurses station has broken and missing floor tiles by the toilet; 7 ceiling tiles with water damage in the hall by the dining area. |
| Hot water temperature in room 112 measured 145.6°F and in room 115 measured 144.1°F, exceeding the 120°F limit. |
| No emergency telephone numbers including nearest hospital and fire department on or by the telephone in room 112. |
| Water leaking from the sink pipes in the 1st floor bathroom by the nurses station. |
| No bedside table or shelf beside resident #2’s bed in bedroom (redacted). |
| Expired food in kitchen (flour expired 10/10/21, sugar expired 12/23/21) and unlabeled frozen food in basement freezer. |
| Last fire safety inspection observed by a fire safety expert was conducted on 3/7/22; prior inspection was 8/17/18, with disagreement on violation. |
| Resident #1’s annual medical evaluation was overdue but completed on 1/18/22 after previous on 12/11/19. |
| Expired medication (Resident #1's Insulin Lispro Kwikpen U-100 expired 12/11/21) was still on medication cart. |
| Glucometer readings for Resident #1 were inaccurately documented or missing in Medication Administration Record. |
| Use of alternative Novolog sliding scale chart for Resident #1 without written prescriber order. |
| Resident #1 had insulin doses administered inconsistent with prescribed sliding scale on multiple dates in April 2022. |
| Resident #2's record missing hair color, eye color, and identifying marks. |
| Resident #3's record missing eye color. |
Report Facts
License Capacity: 48
Residents Served: 29
Staffing: 30
Waking Staff: 23
Hot Water Temperature: 145.6
Hot Water Temperature: 144.1
Expired Food Items: 2
Glucometer Readings Missing: 4
Incorrect Insulin Administration Dates: 8
Inspection Report
Follow-Up
Census: 29
Capacity: 48
Deficiencies: 10
Jan 28, 2022
Visit Reason
The inspection was an unannounced partial licensing inspection conducted as an interim visit on 01/28/2022, with a follow-up plan of correction submission due on 02/21/2022.
Findings
The inspection found multiple deficiencies related to staff training, medical evaluations, medication administration, medication labeling, storage procedures, and resident assessments. Plans of correction were accepted or directed with specified completion dates.
Deficiencies (10)
| Description |
|---|
| Direct care staff person A provided unsupervised ADL services without completing the Department-approved direct care training and competency test. |
| Resident #1 does not have a completed medical evaluation within the required timeframe. |
| Discontinued nicotine patches and lozenges were found in the medication room. |
| Resident #2's January medication administration record does not list prescribed Urea 20% cream. |
| Resident #3 is administered double the prescribed dose of Risperidone according to staff statement. |
| Resident #2 was not administered Vitamin D Tab 2000 Unit on 1/28/22 at 8:00 am due to medication unavailability. |
| Resident #1’s assessments dated in 2020 and 2021 do not include supervision and mobility assessments. |
| Pharmacy label for Resident #3's Risperidone medication conflicts with the medication administration record and physician’s order. |
| Resident #2's prescribed Trazadone 50 MG as needed was not available in the home on 1/28/22. |
| Resident #3’s medication administration record does not include initials of staff who administered medications on 1/28/22 at 8:00 am. |
Report Facts
License Capacity: 48
Residents Served: 29
Total Daily Staff: 30
Waking Staff: 23
Residents 60 Years or Older: 23
Residents Diagnosed with Mental Illness: 26
Residents with Mobility Need: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff person A | Named in deficiency for providing unsupervised ADL services without required training. | |
| Staff person B | Named in deficiencies related to medication administration errors and record keeping. |
Inspection Report
Complaint Investigation
Census: 29
Capacity: 48
Deficiencies: 10
Jan 20, 2022
Visit Reason
The inspection was conducted as a complaint investigation with a partial unannounced review on 01/20/2022 and an exit conference on 01/26/2022.
Findings
Multiple deficiencies were found including expired elevator certificate, missing medical evaluations for residents, lack of documentation of residents' dietary needs, medication labeling errors, improper medication records, and incomplete additional resident assessments. Plans of correction were accepted and implemented with follow-up dates scheduled.
Complaint Details
The inspection was complaint-related as indicated by the reason 'Complaint' and the partial unannounced inspection conducted on 01/20/2022 with an exit conference on 01/26/2022.
Deficiencies (10)
| Description |
|---|
| The elevator certificate expired on 12/31/21 and the home did not have a current certificate of operation. |
| Resident #1 did not have a medical evaluation documented on a form specified by the Department. |
| Resident #1 did not have an annual medical evaluation completed. |
| The home does not have documentation of the residents' dietary needs listed in the record or available to dietary staff. |
| The pharmacy label for resident #2's Risperidone 3 mg does not include correct instructions as per the medication administration record. |
| The glucometer for resident #3 was not calibrated to the correct time. |
| Resident #5's medication administration record does not indicate the diagnosis or purpose of Risperidone 4 mg. |
| Resident #4 was administered Alogliptin 25 mg and Vitamin A 1000 unit capsules on 1/20/22 but these medications were not included on the medication administration record. |
| Resident #1’s medication administration record does not include initials of staff administering Atorvastatin on 1/4/22 at 8:00 pm; Resident #4’s medication administration record lacks initials for Daily-VITE tablet and Lidocaine Pad removals on specified dates. |
| Resident #1’s assessment does not include information about behavioral changes witnessed by the neighboring community. |
Report Facts
License Capacity: 48
Residents Served: 29
Total Daily Staff: 29
Waking Staff: 22
Completion Date: Feb 16, 2022
Completion Date: Feb 28, 2022
Completion Date: Feb 15, 2022
Completion Date: Jan 26, 2022
Inspection Report
Complaint Investigation
Census: 29
Capacity: 48
Deficiencies: 18
Nov 17, 2021
Visit Reason
The inspection was conducted as a complaint investigation with a partial, unannounced visit on November 17-19, 2021, and a follow-up partial inspection on January 28, 2022, to review compliance and plan of correction implementation.
Findings
The facility was found deficient in multiple areas including neglect and abuse of residents, inadequate safeguarding of resident property, insufficient administrator presence, inadequate staffing for resident needs, lack of required staff training and certifications, incomplete medical evaluations, failure to follow prescriber's medication orders, and incomplete resident assessments and support plans. The submitted plan of correction was determined to be fully implemented by April 2022.
Complaint Details
The inspection was complaint-driven as indicated by the reason 'Complaint' and the visit was a partial, unannounced inspection with follow-up reviews of plan of correction submissions.
Deficiencies (18)
| Description |
|---|
| The home failed to assist resident #1 as mental status declined and caused unsafe behaviors including wandering streets at night and aggressive behavior towards staff. |
| The home rules failed to safeguard residents' money and property, stating staff are not responsible for missing or stolen items. |
| Administrator was not present or available as scheduled during inspection days and resident interviews indicated infrequent presence. |
| Insufficient staffing to safely care for residents, especially overnight with only one staff for 29 residents. |
| Staff person was not certified in First Aid/CPR while working overnight shifts. |
| Direct care staff provided unsupervised ADL services without completing required training and competency test. |
| Staff training plan lacked positive intervention techniques and did not include dates, times, and locations of scheduled training. |
| Residents did not have annual medical evaluations completed timely. |
| Positive interventions to modify or eliminate resident behaviors were not implemented, including failure to enforce curfew. |
| Activities program was not implemented since the pandemic. |
| The home was unable to produce a written description of services and activities including admission and discharge criteria. |
| Resident support plans did not document aggressive behaviors or health needs adequately. |
| Medications were found discontinued but still present in the medication room. |
| Medication administration records did not list prescribed medications or were missing staff initials for administration. |
| Prescriber's medication orders were not followed, including incorrect dosages and missed medications due to unavailability. |
| Resident assessments lacked required supervision and mobility evaluations. |
| Pharmacy labels did not match medication administration records or prescriber orders. |
| Procedures for safe storage, access, and use of medications were not fully implemented. |
Report Facts
License Capacity: 48
Residents Served: 29
Total Daily Staff: 33
Waking Staff: 25
Residents with Mental Illness: 26
Residents 60 Years or Older: 21
Residents with Intellectual Disability: 4
Residents with Mobility Need: 4
Residents with Physical Disability: 1
Administrator Hours: 20
Residents Present During Medication Deficiencies: 29
Inspection Report
Renewal
Census: 32
Capacity: 48
Deficiencies: 18
Apr 20, 2021
Visit Reason
The inspection was an unannounced full renewal inspection conducted to assess compliance with licensing requirements.
Findings
The facility had multiple deficiencies including missing signatures on resident contracts, lack of proper signage for video surveillance, incomplete staff qualifications documentation, insufficient CPR and first aid certified staff, unsanitary bathroom conditions, inoperable lighting and ventilation, medication storage and labeling issues, incomplete resident assessments, and missing emergency evacuation diagrams. Plans of correction were accepted and implemented for all deficiencies.
Deficiencies (18)
| Description |
|---|
| Resident-home contract was not signed by the Administrator or Designee. |
| No signage on 2nd and 3rd floors indicating video recording; audio recording prohibited but signage indicated audio surveillance. |
| Direct care staff person lacked documentation of high school diploma, GED, or active nurse aide registry status. |
| Insufficient staff certified in CPR and first aid; no certified staff working 1st, 2nd, or 3rd shifts during inspection. |
| Unsanitary bathroom conditions including dirty and stained toilet seats, clogged toilet, food stored in bathroom, and mold in bathtub. |
| Trash can in bathroom was uncovered and lacked a lid. |
| Bathroom ventilation fan was inoperable and no window present. |
| 2nd floor emergency egress stairwell light was blown out. |
| Resident #3's bed foundation was broken and not in good repair. |
| Bedside lamp inoperable; light switch would not turn on. |
| 2nd floor emergency evacuation diagram was not posted. |
| Resident #3's Lantus pen was open with no date to determine discard time. |
| Medication label and administration record mismatched for resident #3's Omeprazole and Albuterol. |
| Medications prescribed for resident #3 (Acetaminophen 325mg, Benzonate, Saline Nasal Spray) were not available or incorrect strength present. |
| Medication administration record for resident #3 was not signed documenting administration of Pravastatin on 4/16/21. |
| No preadmission screening form in resident #1's record. |
| Resident #4 did not have an annual assessment completed in 2020. |
| Resident #4's photo was outdated (last taken 9/2017). |
Report Facts
Residents Served: 32
License Capacity: 48
Total Daily Staff: 32
Waking Staff: 24
Deficiencies cited: 17
Notice
Capacity: 48
Deficiencies: 0
Apr 16, 2021
Visit Reason
This document serves as a renewal notification and license issuance for McCallum Assisted Life, a Personal Care Home, following receipt of the renewal application dated March 23, 2021.
Findings
The Department issued a regular license in response to the renewal application and advised that an onsite inspection will be conducted within the next twelve months to ensure compliance with applicable regulations.
Report Facts
Maximum capacity: 48
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary | Signed the renewal notification letter |
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