Inspection Report
Enforcement
Census: 51
Capacity: 67
Deficiencies: 3
Jul 9, 2025
Visit Reason
The inspection was conducted due to an incident involving abuse and theft allegations, as well as dietary needs compliance issues, resulting in violations found during unannounced inspections on July 9 and July 17, 2025.
Findings
Violations included abuse and neglect of residents, fraudulent charges on a resident's credit card, and failure to comply with dietary needs requirements. The facility's certificate of compliance was revoked and a third provisional license was issued based on an acceptable plan of correction.
Complaint Details
The complaint involved abuse and neglect of Resident 1, including choking and improper emergency response, and fraudulent credit card charges involving Resident 2. The abuse was substantiated with ongoing criminal investigation and court hearing scheduled.
Deficiencies (3)
| Description |
|---|
| Resident 1 was neglected and physically abused, including choking incident and improper emergency response. |
| Resident 2 had fraudulent charges on their credit card, involving theft and exploitation. |
| Resident 1 was ordered a pureed diet but EMTs were contacted due to choking incident; dietary needs documentation was inadequate. |
Report Facts
License Capacity: 67
Residents Served: 51
Secure Dementia Care Unit Capacity: 14
Residents Served in Secure Dementia Care Unit: 13
Fraudulent Charges: 434.63
Inspection Report
Enforcement
Census: 46
Capacity: 67
Deficiencies: 10
Apr 10, 2025
Visit Reason
The inspection was conducted as a complaint investigation with interim follow-up to review compliance with medication administration and other care standards.
Findings
Multiple medication administration deficiencies were identified, including missed doses, improper documentation, medication labeling errors, and failure to report medication errors. Plans of correction were directed with deadlines for staff training and audits.
Complaint Details
The inspection was complaint-related, triggered by allegations concerning medication administration errors and compliance with care standards. The complaint was substantiated with multiple violations found.
Deficiencies (10)
| Description |
|---|
| Medication error not reported to the Department after missed doses of Eliquis for Resident #1. |
| Resident #2 self-administering medication without physician assessment. |
| Medication administration documentation was not completed properly; staff initialed all medications at once instead of individually. |
| Medication labels did not match prescribed dosages for Resident #3. |
| PRN acetaminophen medication was not available for Resident #1 at time of inspection. |
| Medication records missing required information such as diagnosis or purpose for several residents. |
| Medications not initialed as administered at the time of administration for multiple residents. |
| Prescriber was not notified of medication refusals for Resident #1. |
| Prescriber's orders were not followed for Resident #1, including missed doses and incorrect dosing. |
| Medication errors were not immediately reported to the resident, designated person, and prescriber. |
Report Facts
License Capacity: 67
Residents Served: 46
Secured Dementia Care Unit Capacity: 14
Residents Served in Secured Dementia Care Unit: 11
Total Daily Staff: 58
Waking Staff: 44
Medication Deficiencies Cited: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Juliet Marsala | Deputy Secretary | Signed the letter issuing the second provisional license. |
| Unnamed Executive Director | Executive Director | Named in multiple findings related to medication administration errors and staff training. |
| Unnamed Director of Health and Wellness | Director of Health and Wellness | Responsible for maintaining compliance and staff education related to medication administration. |
Inspection Report
Enforcement
Census: 46
Capacity: 67
Deficiencies: 10
Apr 10, 2025
Visit Reason
The inspection was conducted as a complaint and interim review with follow-up on plan of correction submissions and enforcement actions related to violations found during prior inspections.
Findings
Multiple medication administration deficiencies were identified, including missed medications, improper documentation, medication errors not reported timely, and unsafe medication storage. Additional deficiencies included unsafe resident equipment, incomplete medical evaluations, and failure to comply with hospice care evacuation protocols during fire drills.
Complaint Details
The inspection was complaint-related, triggered by allegations resulting in identification of multiple medication administration and documentation violations, as well as other regulatory noncompliance.
Deficiencies (10)
| Description |
|---|
| Medication not administered as ordered and medication error not reported to the Department. |
| Resident self-administering medication without physician assessment. |
| Medication administration documentation not completed properly; staff initialed all medications at once rather than individually. |
| Medication labels did not match medication administration records. |
| PRN medication not available at time of inspection. |
| Medication record missing required information such as medication name, strength, dosage, route, frequency, and administration times. |
| Medications not initialed as administered at the time of administration. |
| Refusal of medication not documented or reported to prescriber. |
| Prescriber's orders not followed; medications missed or dosages incorrect. |
| Medication errors not reported to resident, designated person, or prescriber immediately. |
Report Facts
License Capacity: 67
Residents Served: 46
Secured Dementia Care Unit Capacity: 14
Residents Served in Secured Dementia Care Unit: 11
Total Daily Staff: 58
Waking Staff: 44
Deficiencies Cited: 10
Inspection Report
Enforcement
Census: 46
Capacity: 67
Deficiencies: 10
Apr 10, 2025
Visit Reason
The inspection was conducted as a complaint and interim review to address violations found during previous licensing inspections on December 3, 2024, February 7, 2025, and April 10, 2025, resulting in a second provisional license being issued.
Findings
Multiple medication administration deficiencies were identified, including missed doses, improper documentation, medication labeling errors, and failure to report medication errors. Additional deficiencies included unsafe resident equipment, incomplete resident assessments, and fire safety violations related to hospice care residents.
Complaint Details
The inspection was complaint-related, triggered by violations found during prior inspections on December 3, 2024, February 7, 2025, and April 10, 2025. The complaint involved medication administration errors, resident safety issues, and regulatory noncompliance.
Deficiencies (10)
| Description |
|---|
| Medication was not administered as ordered and the medication error was not reported to the Department. |
| Resident self-administering medication without physician assessment. |
| Medication administration documentation was not completed properly; staff initialed all medications at once instead of individually. |
| Medication labels did not match the Medication Administration Record (MAR). |
| PRN medication was not available at the time of inspection. |
| Medication record missing required information such as medication name, strength, dosage, route, frequency, and administration times. |
| Medications were not initialed as administered at the time of administration. |
| Refusal of medication was not documented or reported to the prescriber. |
| Prescriber's orders were not followed; medications were missed or administered incorrectly. |
| Medication errors were not immediately reported to the resident, designated person, and prescriber. |
Report Facts
License Capacity: 67
Residents Served: 46
Secured Dementia Care Unit Capacity: 14
Residents Served in Secured Dementia Care Unit: 11
Total Daily Staff: 58
Waking Staff: 44
Deficiency Counts: 10
Inspection Report
Follow-Up
Census: 44
Capacity: 67
Deficiencies: 1
Oct 17, 2024
Visit Reason
The visit was a partial, unannounced inspection conducted as a follow-up to verify the submitted plan of correction for previous deficiencies.
Findings
The inspection found that the submitted plan of correction was fully implemented, specifically addressing medication administration record (MAR) documentation issues where medications were administered but not initialed. Staff education and weekly audits were implemented to maintain compliance.
Deficiencies (1)
| Description |
|---|
| Medications administered at 5pm were not initialed as administered on the Medication Administration Record (MAR). |
Report Facts
License Capacity: 67
Residents Served: 44
Secured Dementia Care Unit Capacity: 14
Secured Dementia Care Unit Residents Served: 12
Current Hospice Residents: 2
Residents Age 60 or Older: 44
Residents with Mobility Need: 13
Residents with Physical Disability: 2
Total Daily Staff: 57
Waking Staff: 43
Inspection Report
Follow-Up
Census: 47
Capacity: 67
Deficiencies: 4
Aug 26, 2024
Visit Reason
The visit was a partial, unannounced follow-up inspection conducted due to an incident and fine, to review the submitted plan of correction for the facility.
Findings
The inspection found medication labeling errors, incomplete medication administration records, and missed medication administrations. The facility submitted plans of correction which were accepted and implemented, with ongoing monitoring and staff inservice to ensure compliance.
Deficiencies (4)
| Description |
|---|
| Pharmacy labels for medications were incorrect or missing parameters such as dosage times and blood pressure/heart rate hold parameters. |
| Medications scheduled for administration were not initialed as given on the medication administration record (MAR). |
| Medications were administered beyond the documented end date on the MAR without proper documentation. |
| Resident morning medications were not administered on 8/2/24 due to unavailability. |
Report Facts
License Capacity: 67
Residents Served: 47
Secured Dementia Care Unit Capacity: 14
Secured Dementia Care Unit Residents Served: 11
Hospice Current Residents: 1
Residents with Mobility Need: 11
Residents Age 60 or Older: 47
Total Daily Staff: 58
Waking Staff: 44
Inspection Report
Enforcement
Census: 49
Capacity: 67
Deficiencies: 26
May 31, 2024
Visit Reason
The visit was conducted as a complaint investigation and enforcement action following licensing inspections on March 26, 2024, March 28, 2024, and May 31, 2024, which found violations leading to revocation of the previous license and issuance of a first provisional license.
Findings
Multiple violations were found related to facility maintenance, fire safety, medication management, resident support plans, and staff training. The facility was issued a first provisional license with a requirement to correct all deficiencies by specified dates. Several deficiencies were not implemented by the directed completion dates.
Complaint Details
The inspection was complaint-related and interim enforcement action was taken due to violations found during licensing inspections on March 26, 2024, March 28, 2024, and May 31, 2024. The certificate of compliance was revoked and a first provisional license was issued with conditions to correct violations.
Deficiencies (26)
| Description |
|---|
| The grounds surrounding the concrete patio areas of the memory care courtyard were overgrown with grass and weeds approximately one foot tall. |
| Resident #1 was not evacuated during the fire drill conducted on 5/20/24 at 9pm. |
| Medication Divalproex Sodium 125mg was found in the cart for resident #4 without a current order. |
| Novolin and Novolog insulin pens for residents #2 and #3 were not dated and initialed when opened. |
| Pharmacy labels for insulin medications did not match the prescribed dosages for residents #2 and #5. |
| Resident #3’s medication administration record did not list diagnoses or purposes for Magnesium Oxide and Ferrous Sulfate. |
| Refusal of medication Metoprol Tartrate by resident #4 on 5/24/24 and 5/25/24 was not documented on the MAR. |
| Prescriber’s orders were not followed for multiple residents, including incorrect administration of insulin and missed medications. |
| Residents #6, #7, and #8 had enabler bars attached to their beds but support plans did not document the device details or risks. |
| The gate in the memory care courtyard had a magnetic lock but the code to operate the keypad was not posted. |
| Contract for resident #1 did not include the monthly fee charged for the home’s fall monitoring service. |
| Staff persons A and B did not have signed training sheets verifying receipt of required fire safety and abuse reporting trainings. |
| Staff persons C and D did not receive required annual training on fire safety, Older Adult Protective Services Act, and falls prevention during the 2023 training year. |
| Poisonous materials were accessible in the memory care kitchenette area due to unlocked gate and storage under sink. |
| Keypad next to the gate used to exit the memory care courtyard was not functioning during initial walk through. |
| Combustible blankets were found stacked in the home’s designated smoking area. |
| During a fire drill on 8/19/23, only 40 of 46 residents were evacuated; six hospice residents did not participate. |
| Resident #2’s medical evaluation form was completed more than 60 days prior to admission. |
| Staff persons A and E did not have documentation of completed medication administration training or annual practicum. |
| Resident #3 had an expired inhaler that should have been disposed of one month after opening. |
| Resident #4’s Novolog insulin pen was stored without a pharmacy label; Levemir insulin pen label dosage did not match MAR. |
| Resident #4’s blood glucose readings were documented incorrectly on multiple dates. |
| Resident #4’s MAR did not indicate diagnosis or purpose for Furosemide and Magnesium Oxide medications. |
| Resident #4 and others had multiple instances of medications not administered as ordered or documented incorrectly. |
| Resident #1’s support plan did not specify details or risks of enabler bar use, was not updated for hospice admission, and did not document fall monitoring system use. Similar omissions for residents #2 and #6. |
| Resident #2’s support plan was not signed by the resident. |
Report Facts
License Capacity: 67
Residents Served: 49
Secure Dementia Care Unit Capacity: 14
Secure Dementia Care Unit Residents Served: 14
Fine Amount: 245
Fine Mandated Correction Days: 5
Staffing Hours: 66
Waking Staff: 50
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Juliet Marsala | Deputy Secretary | Signed enforcement letter and licensing correspondence. |
Inspection Report
Enforcement
Census: 49
Capacity: 67
Deficiencies: 10
May 31, 2024
Visit Reason
The inspection was conducted as a complaint investigation and interim exit conference to address violations found during prior licensing inspections on March 26, 2024, March 28, 2024, and May 31, 2024, leading to the issuance of a first provisional license and enforcement actions.
Findings
Multiple violations were found including exterior hazards, fire drill evacuation failures, medication management issues such as outdated prescriptions, improper labeling, failure to follow prescriber's orders, and deficiencies in resident support plans. Enforcement actions include fines and a provisional license with required corrections.
Complaint Details
The inspection was complaint-related, triggered by allegations leading to a complaint and interim exit conference on 05/31/2024. The report includes substantiation of multiple violations.
Deficiencies (10)
| Description |
|---|
| The grounds surrounding the concrete patio areas of the memory care courtyard were overgrown with grass and weeds approximately one foot tall. |
| Resident #1 was not evacuated during the fire drill conducted on 5/20/24 at 9pm. |
| Medication Divalproex Sodium 125mg found in medication cart for resident #4 without a current order. |
| Novolin and Novolog insulin pens for residents #2 and #3 were not dated and initialed when opened. |
| Pharmacy labels for insulin medications did not match prescribed dosages for residents #2 and #5. |
| Resident #3's medication administration record did not list diagnoses or purposes for Magnesium Oxide and Ferrous Sulfate. |
| Refusal of medication by resident #4 on 5/24/24 and 5/25/24 was not documented on the MAR. |
| Failure to follow prescriber's orders for insulin administration and medication holds for residents #2, #3, #4, #5, #6, and #7 on multiple dates. |
| Support plans for residents #6, #7, and #8 did not document use of enabler bars attached to beds or indicate if covers are required. |
| Magnetic lock keypad code was not posted at the gate in the memory care courtyard. |
Report Facts
License Capacity: 67
Residents Served: 49
Residents Served in Secure Dementia Care Unit: 14
Total Daily Staff: 66
Waking Staff: 50
Fine Amount: 245
Census at Inspection: 49
Inspection Report
Renewal
Census: 50
Capacity: 67
Deficiencies: 11
May 24, 2023
Visit Reason
The inspection was conducted as a renewal and incident review of the facility to ensure compliance with licensing requirements.
Findings
The inspection identified multiple deficiencies related to annual medical evaluations, self-administration assessments, medication labeling, medication records, support plan documentation, cognitive preadmission screening, and secured dementia unit assessments. Plans of correction were directed and later implemented to address these issues.
Deficiencies (11)
| Description |
|---|
| Resident 1's most recent annual medical evaluation was outdated, last dated 3/31/2022. |
| Resident 1 self-administers medications but had not been assessed in the last year for this ability. |
| Expired medication found on the medication cart with expiration date 7/2022. |
| Resident 2's prescribed medication had a pharmacy label that was faded and illegible for dosage, administration instructions, and prescriber information. |
| Medication Administration Record (MAR) for Resident 3 was incomplete; staff failed to identify the amount of insulin given. |
| Resident 4's Resident Assessment Support Plan (RASP) was not updated to reflect current diet of soft and ground foods. |
| Resident 5's RASP was not signed by the assessor. |
| Resident 6 admitted to the secured dementia unit (SDU) without a completed cognitive preadmission screening. |
| Resident 7 in the secured dementia unit had not been assessed annually for continuing need since an unspecified date. |
| Resident 6 admitted to SDU without an assessment completed within 72 hours of admission. |
| Resident 7's most recent RASP was not current as required. |
Report Facts
License Capacity: 67
Residents Served: 50
Secured Dementia Unit Capacity: 14
Secured Dementia Unit Residents Served: 12
Current Hospice Residents: 1
Residents Age 60 or Older: 50
Residents with Mobility Need: 15
Total Daily Staff: 65
Waking Staff: 49
Inspection Report
Follow-Up
Census: 55
Capacity: 67
Deficiencies: 2
May 9, 2023
Visit Reason
The visit was a follow-up review conducted on 05/09/2023 and 05/10/2023 to verify the implementation of the submitted plan of correction related to a prior incident.
Findings
The submitted plan of correction was determined to be fully implemented as of the follow-up visit. The report notes that continued compliance must be maintained.
Deficiencies (2)
| Description |
|---|
| Failure to immediately report suspected resident abuse; incident involving Resident #2 striking Resident #1 was not reported timely to the Area Agency on Aging or the Department. |
| Failure to report the incident or condition to the Department’s personal care home regional office or complaint hotline within 24 hours as required by law. |
Report Facts
License Capacity: 67
Residents Served: 55
Secured Dementia Care Unit Capacity: 14
Secured Dementia Care Unit Residents Served: 14
Current Hospice Residents: 2
Residents Age 60 or Older: 55
Residents with Mobility Need: 18
Inspection Report
Complaint Investigation
Census: 45
Capacity: 67
Deficiencies: 0
Mar 7, 2023
Visit Reason
The inspection was conducted as a complaint and incident investigation at the facility.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Complaint Details
The inspection was triggered by a complaint and incident, but no deficiencies or citations were found, indicating no substantiated issues.
Report Facts
Residents Served: 45
License Capacity: 67
Current Hospice Residents: 1
Residents Age 60 or Older: 45
Residents with Mobility Need: 11
Inspection Report
Routine
Deficiencies: 0
Apr 21, 2022
Visit Reason
The inspection was conducted as a routine licensing inspection by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Inspection Report
Renewal
Census: 55
Capacity: 67
Deficiencies: 5
Mar 22, 2022
Visit Reason
The inspection was conducted as a renewal visit to review compliance with licensing requirements at Mifflin Court.
Findings
The inspection identified several deficiencies including incomplete medical evaluations, unlabeled resident medications, missed medication administrations, and missing preadmission screening forms. Plans of correction were submitted and implemented with ongoing monitoring established.
Deficiencies (5)
| Description |
|---|
| Resident #1 and #2 had incomplete annual medical evaluations missing dates and medication lists. |
| Resident #3 had over-the-counter medications not labeled with the resident's name. |
| Resident #2 did not receive certain 9:00 AM medications on 3/9/22 and 3/17/22. |
| Resident #4 did not have a preadmission screening form completed. |
| Resident #4 did not have a cognitive screening completed prior to entering the secured dementia care unit. |
Report Facts
License Capacity: 67
Residents Served: 55
Secured Unit Capacity: 14
Residents Served in Secured Unit: 14
Total Daily Staff: 69
Waking Staff: 52
Missed Medication Administrations: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kelly Grainger | Resident Care Director | Named in relation to re-education and monitoring of medication administration and admission paperwork compliance. |
| Casey Hoffman | LPN | Responsible for auditing medication carts weekly to ensure compliance with medication labeling. |
Inspection Report
Follow-Up
Census: 55
Capacity: 67
Deficiencies: 2
Jan 27, 2022
Visit Reason
The inspection visit on 01/27/2022 was a follow-up to verify the implementation of a previously submitted plan of correction related to complaint and incident reports.
Findings
The facility was found to have fully implemented the plan of correction regarding delayed reporting of a resident abuse allegation. Continued compliance is required. The plan of correction was accepted and verified through subsequent document submissions.
Complaint Details
The visit was complaint-related due to allegations of delayed reporting of resident abuse. The complaint was substantiated as the facility did not report the abuse allegation from 8/20/21 until 11/12/21.
Deficiencies (2)
| Description |
|---|
| Failure to immediately report suspected abuse of a resident; the incident was reported late to the Department of Aging. |
| Failure to report the incident or condition to the Department’s personal care home regional office or complaint hotline within 24 hours as required. |
Report Facts
License Capacity: 67
Residents Served: 55
Secured Dementia Care Unit Capacity: 14
Secured Dementia Care Unit Residents Served: 13
Hospice Residents: 1
Total Daily Staff: 68
Waking Staff: 51
Residents with Mobility Need: 13
Residents 60 Years or Older: 55
Inspection Report
Routine
Deficiencies: 0
Jun 30, 2021
Visit Reason
The inspection was conducted as a routine licensing inspection by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Notice
Capacity: 67
Deficiencies: 0
Apr 16, 2021
Visit Reason
The document serves as a renewal license approval for the Personal Care Home 'Mifflin Court' and notifies that an annual onsite inspection will be conducted within the next twelve months as required by regulation.
Findings
No inspection findings are reported in this document; it confirms issuance of a regular license following the renewal application and outlines the requirement for a future annual inspection.
Report Facts
Maximum licensed capacity: 67
Secure Dementia Care Unit capacity: 14
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary, Office of Long-term Living | Signed the renewal license approval letter. |
Inspection Report
Renewal
Census: 48
Capacity: 67
Deficiencies: 6
Mar 10, 2021
Visit Reason
The inspection was conducted as a renewal review of the facility's compliance with licensing requirements on 03/10/2021 and 03/11/2021.
Findings
The facility was found to have multiple deficiencies related to record confidentiality, medication management, medication error reporting, and annual resident assessments. The submitted plan of correction was determined to be fully implemented.
Deficiencies (6)
| Description |
|---|
| Resident records confidentiality was breached by posting a Licensing Inspection Summary with attached resident privacy coding sheet at the front desk. |
| Medication for a discharged resident was found in the medication cart. |
| Medication Administration Records (MAR) were not properly maintained due to incorrect transcription of blood glucose test results for residents. |
| Medication administration record did not indicate a prescribed medication was given on the correct date for a resident. |
| Medication error was not reported to the department, resident, designated person, and prescriber as required. |
| Residents did not receive annual assessments within the required timeframe. |
Report Facts
License Capacity: 67
Residents Served: 48
Medication Cart Error: 1
Medication Transcription Errors: 2
Medication Administration Error: 1
Residents Missing Annual Assessment: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Michele Moskalczyk | Human Services Licensing Supervisor | Signed the letter confirming plan of correction implementation |
Inspection Report
Renewal
Deficiencies: 0
Jan 21, 2021
Visit Reason
The inspection was conducted as part of the Pennsylvania Department of Human Services, Bureau of Human Service Licensing licensing inspections on 01/21/2021, 01/22/2021, and 01/25/2021 for the facility Mifflin Court.
Findings
No regulatory citations were identified as a result of this inspection.
Inspection Report
Follow-Up
Census: 43
Capacity: 67
Deficiencies: 4
Jan 12, 2021
Visit Reason
The inspection was a partial, unannounced follow-up visit to review the submitted plan of correction related to medication administration errors.
Findings
The facility was found to have previously committed medication administration errors involving failure to administer medications to 10 residents and falsification of medication administration records. The submitted plan of correction was determined to be fully implemented, including staff termination, re-education, and monitoring to prevent recurrence.
Deficiencies (4)
| Description |
|---|
| Failure to keep prescription medications in original labeled containers and removal of medications more than 2 hours in advance, resulting in medications being left undistributed overnight. |
| Failure to record the date/time of medication administration accurately, with staff initialing records without administering medications. |
| Failure to administer prescribed medications to 10 residents at the scheduled time. |
| Failure to immediately report medication errors to residents, designated persons, and prescribers. |
Report Facts
Residents affected: 10
Staff total daily: 59
Waking staff: 44
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maria Salgado | Med Tech | Staff Member A who failed to administer medications and falsified medication administration records |
Loading inspection reports...
