Inspection Reports for Meadow Glen at Phoebe Richland
108 SOUTH MAIN STREET,, PA, 18955
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
12 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
155% worse than Pennsylvania average
Pennsylvania average: 4.7 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
70% occupied
Based on a November 2024 inspection.
Census over time
Inspection Report
Follow-Up
Census: 70
Capacity: 100
Deficiencies: 2
Nov 26, 2024
Visit Reason
The inspection was conducted as a partial, unannounced visit due to an incident, with a follow-up on the submitted plan of correction.
Findings
The facility was found to have implemented the submitted plan of correction fully. Deficiencies related to the use of chemical restraints without documented non-pharmacological interventions and incomplete preadmission screening forms were addressed with corrective actions and education.
Deficiencies (2)
| Description |
|---|
| Use of chemical restraint medication without documentation of attempted non-pharmacological interventions prior to administration. |
| Preadmission screening form was not completed within 30 days prior to resident admission. |
Report Facts
Residents Served: 70
License Capacity: 100
Secured Dementia Care Unit Capacity: 40
Residents Served in Secured Dementia Care Unit: 32
Current Residents in Hospice: 5
Residents Age 60 or Older: 70
Residents Diagnosed with Mental Illness: 25
Residents with Mobility Need: 38
Residents with Physical Disability: 3
Inspection Report
Renewal
Census: 70
Capacity: 100
Deficiencies: 9
Oct 16, 2024
Visit Reason
The inspection was conducted as a renewal visit to review compliance and verify the implementation of the submitted plan of correction.
Findings
Multiple deficiencies were identified related to staff training, resident personal equipment, locking of poisonous materials, lighting, unobstructed egress, medication storage procedures, and support plan documentation. All deficiencies had accepted plans of correction with completion dates and were implemented by 12/24/2024.
Deficiencies (9)
| Description |
|---|
| Direct care staff person A received only 1.75 hours of annual training in training year 2023, less than the required 12 hours. |
| Direct care staff person A did not receive required training in medication self-administration, resident needs, dementia care, infection control, personal care, safe management techniques during training year 2023. |
| Staff person A did not receive training in emergency preparedness, resident rights, Older Adult Protective Services Act, falls and accident prevention during training year 2023. |
| Resident has a bedside mobility device that is not secured to the bed frame. |
| Poisonous materials (Sani Cloth disinfectant wipes and DG Home Disinfectant Spray) were unlocked, unattended, and accessible to residents in Memory Care Wing B nurse station. |
| Resident does not have access to a source of light that can be turned on/off at bedside. |
| Two doors in Memory Care wing A and B were labeled as 'not an exit' but had exit signs above them. |
| Medication prescribed as needed was not available in the home; glucometer reading was not documented on the medication administration record. |
| Resident's assessment and support plan did not document the need for an enabler, including specific need, intended use, risks, and resident's ability to use it safely. |
Report Facts
License Capacity: 100
Residents Served: 70
Secured Dementia Care Unit Capacity: 40
Secured Dementia Care Unit Residents Served: 32
Current Hospice Residents: 3
Total Daily Staff: 106
Waking Staff: 80
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Amanda Laporte | Administrator | Named in facility information section |
Inspection Report
Follow-Up
Census: 78
Capacity: 100
Deficiencies: 16
Jun 21, 2023
Visit Reason
The inspection was conducted as a full, unannounced review for renewal, complaint, and incident reasons at the facility.
Findings
The inspection found multiple deficiencies including violations of resident dignity and privacy, incomplete criminal background checks, lack of fire safety training, missing emergency telephone numbers, improper refrigerator/freezer temperatures, incomplete emergency management submissions, fire drill record deficiencies, medication storage and labeling issues, and missing documentation for resident admissions and key-locking device instructions. All deficiencies had plans of correction accepted and were implemented by August 15, 2023.
Deficiencies (16)
| Description |
|---|
| Violation of resident dignity and respect by staff recording and removing a resident's wig without consent and sharing the video on social media. |
| Violation of resident privacy by recording a resident without consent and sharing the video externally. |
| Staff person employed without a completed criminal background check prior to first day of work. |
| Direct care staff did not receive required annual fire safety training by a qualified trainer during 2022. |
| No emergency telephone numbers posted by telephone in Memory Support A kitchen. |
| Refrigerator and freezer temperatures exceeded regulatory limits on inspection day. |
| No documentation of submitting emergency procedures to local emergency management agency. |
| Fire drill record missing exit route used during drill on 10/31/22. |
| Fire drill evacuation time exceeded maximum safe time; drill took 45 minutes instead of 15. |
| Fire alarm was not activated during multiple fire drills in 2022 and early 2023. |
| Resident medical evaluation did not reflect capability to self-administer medication. |
| Loose pills found in medication cart drawer in Personal Care A. |
| Pharmacy labels on resident medications did not match prescribed orders. |
| Resident glucometer not calibrated to correct date; inaccurate blood glucose documentation. |
| No objection statements documented for residents admitted to Secure Dementia Care Unit. |
| Directions for operating key-locking device not conspicuously posted near exit door to Secure Dementia Care Unit stairwell #3. |
Report Facts
License Capacity: 100
Residents Served: 78
Memory Support Unit Capacity: 40
Memory Support Unit Residents Served: 34
Current Hospice Residents: 3
Residents Diagnosed with Mental Illness: 18
Residents with Mobility Need: 45
Residents Age 60 or Older: 77
Refrigerator Temperature: 46
Freezer Temperature: 10
Fire Drill Evacuation Time: 45
Inspection Report
Follow-Up
Census: 76
Capacity: 100
Deficiencies: 1
Jan 5, 2023
Visit Reason
The inspection visit was conducted as a follow-up to verify the implementation of a previously submitted plan of correction related to an incident at the facility.
Findings
The submitted plan of correction was determined to be fully implemented. The facility addressed a violation involving failure to use positive interventions when managing a resident's behavior, including staff termination and education measures.
Deficiencies (1)
| Description |
|---|
| Failure to use positive interventions to modify or eliminate a behavior that endangers the resident or others, specifically staff forcibly making a resident go back inside during a storm without positive intervention techniques. |
Report Facts
Residents Served: 76
License Capacity: 100
Secured Dementia Care Unit Capacity: 40
Secured Dementia Care Unit Residents Served: 38
Current Hospice Residents: 2
Residents Age 60 or Older: 75
Residents with Mobility Need: 46
Inspection Report
Renewal
Census: 76
Capacity: 100
Deficiencies: 0
Apr 4, 2022
Visit Reason
The inspection was conducted as a renewal licensing inspection of the facility.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Total Daily Staff: 130
Waking Staff: 98
Residents Served: 76
License Capacity: 100
Secured Dementia Care Unit Capacity: 38
Residents Served in Dementia Care Unit: 37
Current Hospice Residents: 2
Residents Age 60 or Older: 73
Residents with Mobility Need: 54
Residents with Physical Disability: 3
Inspection Report
Follow-Up
Census: 76
Capacity: 100
Deficiencies: 6
Nov 2, 2021
Visit Reason
The inspection was a follow-up visit to verify the implementation of a previously submitted plan of correction related to an incident at the facility.
Findings
The submitted plan of correction was determined to be fully implemented. Deficiencies primarily involved missing signatures on resident-home contracts, lack of signed statements acknowledging receipt of resident rights, incomplete resident education on medication refusal rights, and incomplete or missing preadmission screening documentation for residents. The facility implemented electronic signature software (Docusign) and auditing processes to address these issues.
Deficiencies (6)
| Description |
|---|
| Resident-home contracts were not signed by the resident or payor as required. |
| Resident #1's record lacked a signed statement acknowledging receipt of resident rights and complaint procedures. |
| Resident #1 was not educated on the right to refuse medication if a medication error was suspected. |
| Resident #1’s preadmission screening form did not include a determination that the resident's needs could be met by the home or the resident's level of supervision. |
| Resident #1's written cognitive preadmission screening was not completed within 72 hours prior to admission to the secured dementia care unit. |
| Resident #2's record did not include the preadmission screening for the resident's initial admission to the home. |
Report Facts
License Capacity: 100
Residents Served: 76
Secured Dementia Care Unit Capacity: 38
Residents Served in Secured Dementia Care Unit: 35
Total Daily Staff: 115
Waking Staff: 86
Residents 60 Years or Older: 75
Residents with Mobility Need: 39
Residents with Physical Disability: 2
Notice
Capacity: 100
Deficiencies: 0
Oct 20, 2021
Visit Reason
The document serves as a renewal notification and license issuance for the Personal Care Home Meadow Glen at Phoebe Richland, with a reminder that an annual inspection will be conducted within the next twelve months.
Findings
No inspection findings are reported; the document confirms issuance of a regular license following the renewal application and advises that an annual inspection will occur within the next year.
Report Facts
Maximum capacity: 100
Secure Dementia Care Unit capacity: 38
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary, Office of Long-term Living | Signed the renewal notification letter. |
Inspection Report
Renewal
Census: 68
Capacity: 100
Deficiencies: 14
Mar 31, 2021
Visit Reason
The inspection was conducted as a renewal licensing inspection of Meadow Glen at Phoebe Richland, an assisted living facility, on 03/31/2021 and 04/01/2021.
Findings
Multiple deficiencies were identified including unlocked poisonous materials accessible to residents, missing emergency telephone numbers in resident rooms, incomplete first aid kits, lack of a system to safeguard resident laundry, incomplete medical evaluations, outdated posted menus, improper medication storage and labeling, missing medications, incomplete medication administration records, use of chemical restraints for behavior control, and lack of resident involvement in support plan development. Plans of correction were accepted for most deficiencies with specified completion dates.
Deficiencies (14)
| Description |
|---|
| Unlocked, unattended, and accessible poisonous materials (Dawn Mist fluoride toothpaste) in resident rooms where not all residents are assessed capable of safe use. |
| No emergency telephone numbers posted on or by the telephone in resident room #112. |
| First aid kit in 2nd floor med room missing a thermometer. |
| No system to safeguard resident laundry from loss; residents reported lost bed sheets and blankets. |
| Resident #2's medical evaluation did not include ability to self-administer medications and health status. |
| Menus posted in the dining area of the secured dementia care unit were for past two weeks, not current or upcoming week. |
| Medications (Latanoprost Ophthalmic sol 0.005%) lacked open date on label as required. |
| Pharmacy label for resident #3's Lorazepam 0.5 mg did not reflect changed order to 'as needed' and lacked direction change sticker. |
| Resident #5's prescribed Nitroglycerin Sub 0.4 mg as needed was not available in the home on 04/01/2021. |
| Resident #6's glucometer reading was not logged on 03/15/2021 at 05:55 AM. |
| Resident #5's March MAR missing initials of staff who administered Lorazepam 0.25 mg as needed on 03/13/2021 at 07:30 AM. |
| Resident #3's prescribed Pantoprazole 40 mg twice daily was not administered on 04/01/2021 at 06:30 AM due to medication unavailability. |
| Resident #7 was administered Lorazepam gel 0.5 mg as needed for agitation to control behaviors on multiple dates, constituting chemical restraint use. |
| Resident #8's support plan was finalized without involvement of the resident or designated person. |
Report Facts
License Capacity: 100
Residents Served: 68
Secured Dementia Care Unit Capacity: 38
Secured Dementia Care Unit Residents Served: 32
Hospice Residents: 4
Staffing Hours - Total Daily Staff: 106
Staffing Hours - Waking Staff: 80
Inspection Report
Renewal
Capacity: 100
Deficiencies: 0
Feb 8, 2021
Visit Reason
The document is a renewal license issued in response to the facility's renewal application to operate a Personal Care Home, with a reminder that an annual inspection will be conducted within the next twelve months.
Findings
A regular license is being issued for Meadow Glen at Phoebe Richland to operate as a Personal Care Home with a maximum capacity of 100 residents, including a Secure Dementia Care Unit with a capacity of 38. The Department will conduct an inspection within the next twelve months and take enforcement action if noncompliance is found.
Report Facts
Maximum capacity: 100
Secure Dementia Care Unit capacity: 38
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary | Signed the renewal license letter |
Loading inspection reports...
