Inspection Report
Monitoring
Census: 42
Capacity: 106
Deficiencies: 2
Aug 11, 2025
Visit Reason
The visit was an unannounced partial inspection conducted as a monitoring review to verify the implementation of a previously submitted plan of correction.
Findings
The submitted plan of correction was determined to be fully implemented. Deficiencies were noted related to incomplete staff training records and incomplete resident support plans, with corrective actions and new procedures implemented to ensure ongoing compliance.
Deficiencies (2)
| Description |
|---|
| The home's record of staff training did not include the length of time of the training, source, and content of the trainings. The training date was blank and covered by what appeared to be whiteout. |
| Resident support plans were blank for areas of physical, mental, cognitive, behavioral, social, and recreational needs despite assessments indicating these needs. |
Report Facts
Total Daily Staff: 74
Waking Staff: 56
Residents Served: 42
License Capacity: 106
Secured Dementia Care Unit Capacity: 39
Secured Dementia Care Unit Residents Served: 18
Current Hospice Residents: 3
Residents Age 60 or Older: 42
Residents with Mobility Need: 32
Inspection Report
Complaint Investigation
Census: 38
Capacity: 106
Deficiencies: 2
Apr 8, 2025
Visit Reason
The inspection was conducted as a complaint investigation following allegations of violations related to resident care and rights at Sunrise of Exton.
Findings
The investigation found that Resident #1 was neglected by not receiving necessary insulin despite high blood glucose readings, resulting in hospitalization and subsequent death. Additionally, the resident's right to choose their own healthcare provider was violated when staff forced the use of the home's physician.
Complaint Details
The complaint investigation substantiated neglect and violation of resident rights related to medical care and choice of healthcare provider for Resident #1.
Deficiencies (2)
| Description |
|---|
| Resident #1 did not receive insulin despite high blood glucose readings, leading to hospitalization and death. |
| Resident #1 was required to use the home's physician rather than their personal physician for admission. |
Report Facts
License Capacity: 106
Residents Served: 38
Secured Dementia Care Unit Capacity: 39
Residents Served in Secure Dementia Care Unit: 14
Current Hospice Residents: 6
Resident Blood Glucose Readings: 220
Resident Blood Glucose Readings: 226
Resident Blood Glucose Readings: 300
Resident Blood Glucose Readings: 200
Resident Blood Glucose Readings: 187
Resident Blood Glucose Readings: 240
Resident Blood Glucose Readings: 257
Resident Blood Glucose Readings: 226
Resident Blood Glucose Readings: 249
Resident Blood Glucose Readings: 212
Resident Weight at Admission: 114
Resident Weight per DME: 147
Inspection Report
Follow-Up
Census: 35
Capacity: 106
Deficiencies: 11
Mar 3, 2025
Visit Reason
The inspection visit was conducted as a complaint investigation with an unannounced partial inspection to review compliance and verify the submitted plan of correction.
Findings
The facility was found to have multiple deficiencies including lack of CPR-certified staff on shift, incomplete fire safety orientation for new staff, failure to keep poisonous materials locked, sanitary condition issues, improper medication management, and missing resident signatures on support plans. The submitted plan of correction was determined to be fully implemented as of the follow-up inspection date.
Complaint Details
The inspection was conducted as a complaint investigation with an unannounced partial inspection on 03/03/2025.
Deficiencies (11)
| Description |
|---|
| No staff persons were present who were certified in first aid, obstructed airway techniques and CPR during shifts with 35 residents present. |
| Staff person did not receive orientation on evacuation procedures, fire drill responsibilities, smoking safety, fire extinguisher use, smoke detectors, fire alarms, and emergency telephone use on first day. |
| Staff person did not receive required annual training in fire safety, emergency preparedness, resident rights, and related topics during 2024. |
| Poisonous materials including toothpaste, Vaseline, mouthwash, and hand sanitizer were unlocked and accessible to residents not assessed as capable of safe use. |
| Sanitary conditions were not maintained; a used disposable glove and trash were found on the floor in resident rooms. |
| Unlabeled, undated, and uncovered food items were found in the Memory Care unit. |
| Medication carts contained medications not listed on current orders and medications for residents no longer in the home. |
| Medication administration times were not accurately recorded; medication was documented as given when one tablet remained. |
| Prescriber's medication orders were not fully followed; medication remained unused despite documentation. |
| Resident participated in support plan development but did not sign the support plan. |
| No documentation that resident and designated person did not object to admission or transfer to secured dementia care unit. |
Report Facts
Residents served: 35
License capacity: 106
Capacity of secured dementia care unit: 39
Residents served in secured dementia care unit: 11
Staff total daily: 61
Waking staff: 46
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director | Named in multiple findings related to training, audits, and plan of correction implementation | |
| Director of Health and Wellness | Involved in medication audits, training, and plan of correction implementation | |
| Memory Care Director | Involved in training, audits, and plan of correction implementation | |
| Regional Director of Operations | Provided education and training on orientation and poisonous materials | |
| Employee Relations and Administration Coordinator (ERAC) | Responsible for oversight of new hires and training compliance | |
| Director of Dining Services | Received training on food labeling and dating | |
| Director of Plant Operations | Responsible for fire safety orientation training | |
| Regional Director of Health and Wellness | Conducted medication administration training and audits |
Inspection Report
Complaint Investigation
Census: 41
Capacity: 106
Deficiencies: 1
Jan 16, 2025
Visit Reason
The inspection was conducted as a complaint investigation with an unannounced partial review to assess compliance and the submitted plan of correction.
Findings
The submitted plan of correction was found to be fully implemented. Two staff members had not received required annual training in emergency preparedness, fire safety, and resident rights during the training year, but corrective actions were completed by early 2025.
Complaint Details
The visit was complaint-related with a partial, unannounced inspection conducted on 01/16/2025. The plan of correction was accepted on 02/07/2025 and fully implemented by 05/05/2025.
Deficiencies (1)
| Description |
|---|
| Two staff members did not receive training in emergency preparedness, fire safety, and resident rights during the training year. |
Report Facts
License Capacity: 106
Residents Served: 41
Secured Dementia Care Unit Capacity: 39
Secured Dementia Care Unit Residents Served: 14
Current Hospice Residents: 8
Residents Age 60 or Older: 41
Residents with Mobility Need: 26
Residents with Physical Disability: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff person A | Named in deficiency for not receiving required training | |
| Staff person B | Named in deficiency for not receiving required training |
Inspection Report
Follow-Up
Census: 47
Capacity: 106
Deficiencies: 9
Nov 6, 2024
Visit Reason
The visit was conducted as a follow-up to verify that the previously submitted plan of correction was fully implemented at the facility.
Findings
The inspection found that the facility had fully implemented the submitted plan of correction addressing multiple deficiencies including posting required information, staff training plans, furniture and equipment safety, medication storage, medication order updates, and support plan signatures. Continued compliance and monitoring were emphasized.
Deficiencies (9)
| Description |
|---|
| No Influenza Awareness Act posted in a public and conspicuous place in the residence. |
| Resident's rights poster not posted in a conspicuous and public place in the home. |
| Telephone numbers of Department’s personal care home regional office, local ombudsman, protective services, and complaint hotline not posted conspicuously. |
| Staff training plan did not include name, position, duties of direct care staff and scheduled training dates. |
| Electric outlets uncovered exposing wires; wall lamps exposing bulbs and wires; smoke detector covered in plastic due to renovation. |
| Weekly menus not prominently displayed in memory care unit or throughout the home. |
| Resident medications stored unlocked and unattended in resident's room. |
| Medication order not updated on narcotics sheet to reflect prescriber’s change. |
| Resident participated in support plan development but did not sign; no notation of refusal or inability to sign documented. |
Report Facts
Residents Served: 47
License Capacity: 106
Total Daily Staff: 85
Waking Staff: 64
Secured Dementia Care Unit Capacity: 39
Secured Dementia Care Unit Residents Served: 17
Current Hospice Residents: 11
Residents with Mobility Need: 38
Residents Age 60 or Older: 47
Inspection Report
Follow-Up
Census: 44
Capacity: 106
Deficiencies: 5
Feb 5, 2024
Visit Reason
The inspection was a partial, unannounced follow-up visit conducted on 02/05/2024 to review the submitted plan of correction related to prior incidents and compliance issues at the facility.
Findings
The facility was found to have implemented the submitted plan of correction fully. Deficiencies included failure to timely report incidents, lack of safeguarding system for residents' money, incomplete medical evaluations, missing support plan signatures, and incomplete resident records. Plans of correction were accepted and implemented as of 03/19/2024.
Deficiencies (5)
| Description |
|---|
| Incident reports did not include the date of the incident and were not reported to the Department within 24 hours as required. |
| The home does not provide a system for safeguarding residents' money and property. |
| Resident medical evaluation did not include medical information pertinent to diagnosis and treatment in case of an emergency. |
| Residents participated in the development of support plans but did not sign the support plans. |
| Resident records did not include a record of incident reports, social security numbers, or race. |
Report Facts
License Capacity: 106
Residents Served: 44
Dementia Unit Capacity: 39
Dementia Unit Residents Served: 16
Hospice Residents: 9
Total Daily Staff: 88
Waking Staff: 66
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sunrise Executive Director | Reviewed regulations, conducted training, monitored incidents, and implemented plans of correction. | |
| Health & Wellness Director | Audited support plans and resident records, provided training, and ensured compliance. | |
| Resident Care Director | Reviewed medical evaluations and received training on documentation requirements. |
Inspection Report
Monitoring
Census: 44
Capacity: 106
Deficiencies: 13
Dec 6, 2023
Visit Reason
The inspection was conducted as a provisional licensing inspection with incident and fine reasons, including follow-up on plan of correction submissions and enforcement actions.
Findings
The facility was found to have multiple violations including failure to immediately notify family of resident elopement, inadequate supervision of a resident in the secured dementia care unit, unlocked poisonous materials accessible to residents, improper storage of towels, obstructed egress routes, expired fire extinguisher inspection, expired medication in medication carts, incomplete medication labeling, medication storage and administration discrepancies, improper use of chemical restraints, and incomplete medication records. Plans of correction were accepted but many were not implemented as of the last follow-up.
Deficiencies (13)
| Description |
|---|
| Failure to immediately notify resident's designated person of elopement from secured dementia care unit. |
| Resident eloped unnoticed, inadequate supervision, failure to report incident to police or family immediately. |
| Poisonous materials (toothpaste) unlocked and accessible to residents. |
| Towels and washcloths not properly labeled or stored in shared resident rooms. |
| Obstruction of egress by a paper notice on a door. |
| Fire extinguisher not inspected since November 2022. |
| Expired medication (Acetamin 325 mg) found in medication cart. |
| Pharmacy label for insulin pen missing prescribed dosage and administration instructions. |
| Discrepancy in controlled medication record for Tramadol due to missed logging of administration. |
| Medication administration time and initials not recorded at time of administration. |
| Use of chemical restraints without proper diagnosis for PRN medications administered for agitation. |
| Medication administration record missing diagnosis or purpose for medication including PRN. |
| Failure to administer prescribed medication due to unavailability in the home. |
Report Facts
License Capacity: 106
Residents Served: 44
Residents Served in Secured Dementia Care Unit: 24
Staffing Hours: 68
Waking Staff: 51
Residents Served: 39
Total Daily Staff: 57
Waking Staff: 43
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Juliet Marsala | Deputy Secretary | Signed the licensing letter regarding issuance of second provisional license. |
Inspection Report
Monitoring
Census: 44
Capacity: 106
Deficiencies: 13
Dec 6, 2023
Visit Reason
The inspection was conducted as a provisional licensing inspection with incident and fine reasons, including follow-up on plan of correction submissions and enforcement actions.
Findings
The facility was found to have multiple violations including failure to immediately notify family of resident elopement, inadequate supervision of a resident who eloped, unsecured poisonous materials accessible to residents, improper storage of towels, obstructed egress routes, expired fire extinguisher inspection, expired medication in medication carts, improperly labeled medications, medication storage and administration record discrepancies, use of chemical restraints without proper diagnosis, and failure to follow prescriber's orders for medication administration.
Deficiencies (13)
| Description |
|---|
| Failure to immediately notify resident's designated person of suspected abuse or neglect involving resident elopement. |
| Resident eloped from secured dementia care unit unnoticed and was not properly supervised or reported. |
| Poisonous materials (toothpaste) were unlocked and accessible to residents not assessed as safe to use them. |
| Towels and washcloths were not properly labeled and stored in shared resident rooms. |
| Egress routes were obstructed by a paper notice blocking a back door. |
| Fire extinguisher had not been inspected by a fire safety expert since November 2022. |
| Expired medication (Acetamin 325 mg tabs) found in medication cart. |
| Medication label for insulin pen did not include prescribed dosage and instructions. |
| Discrepancy in controlled medication record for Tramadol due to failure to log administration. |
| Medication administration time was not recorded at time of administration for Tramadol. |
| Use of chemical restraints (Seroquel and Lorazepam) without proper diagnosis for agitation. |
| Medication record did not indicate diagnosis or purpose for Lorazepam medication. |
| Failure to follow prescriber's orders: medication not administered due to unavailability. |
Report Facts
License Capacity: 106
Residents Served: 44
Residents Served in Secured Dementia Care Unit: 24
Staffing Hours: 68
Waking Staff: 51
Residents Served: 39
Staffing Hours: 57
Waking Staff: 43
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Juliet Marsala | Deputy Secretary | Signed the letter regarding the issuance of the second provisional license. |
Inspection Report
Renewal
Census: 46
Capacity: 106
Deficiencies: 6
May 10, 2023
Visit Reason
The inspection was conducted as a renewal inspection combined with complaint, incident, and monitoring reasons, including a full unannounced inspection on May 10 and 11, 2023.
Findings
The inspection identified multiple violations including lack of a valid boiler certificate, delayed resident refund issuance, resident abuse by staff, improper refrigerator/freezer temperatures, failure to submit emergency procedures annually, and incomplete medication administration documentation. Plans of correction were accepted for all violations with some implemented and others pending as of July 10, 2023.
Deficiencies (6)
| Description |
|---|
| Boiler 372312B did not have a valid Certificate of Boiler or Pressure Vessel Operation issued by the PA Department of Labor and Industry. |
| Resident refund was not issued within 30 days of discharge. |
| Resident was physically abused by staff member resulting in skin tear and bruising. |
| Walk-in freezer temperatures exceeded required limits, recorded at 6 and 12 degrees Fahrenheit. |
| Written emergency procedures were not submitted annually to the local emergency management agency in 2022. |
| Medication administration record did not include initials of staff administering medication on specified dates. |
Report Facts
Census at Inspection: 46
Total Licensed Capacity: 106
Fine Per Resident Per Day: 5
Calculated Fine Per Day: 230
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Juliet Marsala | Deputy Secretary, Office of Long-term Living | Signed the enforcement letter regarding license revocation and provisional license issuance |
Inspection Report
Complaint Investigation
Census: 50
Capacity: 106
Deficiencies: 6
Mar 13, 2023
Visit Reason
The inspection was conducted as a complaint and incident investigation regarding alleged resident abuse at the facility.
Findings
The investigation found that a staff person was witnessed smacking a resident on their hands and legs, and the facility failed to timely report the abuse, place the staff on suspension or supervision, and notify the resident and their designated person. Corrective actions including training, reporting, and monitoring were implemented and accepted.
Complaint Details
The complaint involved an allegation that Staff Person B physically abused Resident 1 by smacking their hands and legs. The facility delayed reporting the incident to the Department of Human Services, delayed placing the staff on suspension or supervision, and delayed notifying the resident and their designated person. Staff Person B was eventually placed on administrative leave and terminated after investigation.
Deficiencies (6)
| Description |
|---|
| Failure to immediately report suspected abuse of a resident to the appropriate authorities. |
| Failure to immediately develop and implement a plan of supervision or suspend the staff person involved in the alleged abuse. |
| Failure to immediately submit a plan of supervision or notice of suspension of the affected staff person to the Department. |
| Failure to immediately notify the resident and the resident’s designated person of a report of suspected abuse. |
| Failure to report the incident or condition to the Department within 24 hours as required. |
| Resident was physically abused by staff, including smacking hands and legs and forceful handling. |
Report Facts
License Capacity: 106
Residents Served: 50
Secured Dementia Care Unit Capacity: 39
Secured Dementia Care Unit Residents Served: 17
Staffing Hours - Total Daily Staff: 78
Staffing Hours - Waking Staff: 59
Residents Age 60 or Older: 50
Residents with Mobility Need: 28
Inspection Report
Follow-Up
Census: 45
Capacity: 106
Deficiencies: 1
Feb 6, 2023
Visit Reason
The inspection visit on 02/06/2023 was a partial, unannounced follow-up to review the submitted plan of correction related to an incident at the facility.
Findings
The submitted plan of correction was determined to be fully implemented. The investigation found a staff member made an inappropriate comment to a resident, resulting in the staff member's resignation and subsequent staff training on resident rights and customer service.
Deficiencies (1)
| Description |
|---|
| Staff person A made an inappropriate comment to a resident, indicating a lack of patience and causing the resident to feel uncomfortable receiving care from that staff member. |
Report Facts
License Capacity: 106
Residents Served: 45
Residents in Secured Dementia Care Unit Capacity: 39
Residents Served in Secured Dementia Care Unit: 15
Current Hospice Residents: 8
Residents Age 60 or Older: 45
Residents with Mobility Need: 25
Residents with Physical Disability: 1
Total Daily Staff: 70
Waking Staff: 53
Inspection Report
Complaint Investigation
Census: 45
Capacity: 106
Deficiencies: 3
Jan 25, 2023
Visit Reason
The inspection was conducted as a complaint investigation following concerns raised about resident care and treatment at Sunrise Senior Living of Exton.
Findings
The inspection found violations related to abuse, treatment of residents, and assessment documentation. Specific issues included neglect in managing a resident's stage 3 pressure ulcer and urinary tract infection leading to resident death, disrespectful treatment of another resident, and incomplete initial assessments.
Complaint Details
The visit was complaint-related, investigating allegations of neglect and mistreatment of residents. The complaint was substantiated based on findings of neglect leading to resident death and disrespectful treatment of another resident.
Deficiencies (3)
| Description |
|---|
| Failure to manage a resident's stage 3 pressure ulcer and urinary tract infection, resulting in septic shock and death. |
| Resident was treated without dignity and respect, including refusal to accommodate reasonable requests. |
| Resident's initial assessment did not include stage 3 pressure ulcer or use of Texas catheter. |
Report Facts
Census at Inspection: 45
Total Licensed Capacity: 106
Fine Per Resident Per Day: 5
Calculated Fine Per Day: 230
Inspection Report
Renewal
Census: 60
Capacity: 106
Deficiencies: 5
Mar 3, 2022
Visit Reason
The inspection was conducted as a renewal review of the facility's license, including unannounced full inspections on 03/03/2022, 03/04/2022, and 03/07/2022.
Findings
The inspection identified multiple deficiencies including failure to timely report an incident, direct care staff providing unsupervised ADL services before completing required training, missing lightbulb in a resident's bedside lamp, outdated/unlabeled food items, and incomplete support plan signatures. Plans of correction were submitted and accepted, with ongoing monitoring and education implemented.
Deficiencies (5)
| Description |
|---|
| Failure to report an incident involving resident #1 being sent to the hospital due to intractable vomiting within 24 hours as required. |
| Direct care staff person A provided unsupervised ADL services before completing and passing the Department-approved direct care training and competency test. |
| The bedside lamp in a resident's room was missing a lightbulb. |
| Unlabeled and undated liquid containers including pitchers of lemonade, cranberry juice, and cartridges of tea and flavored water found in the server's reach-in refrigerator. |
| Support plan signature forms for residents #2, #3, #4, #5, and #6 lacked staff or family signatures. |
Report Facts
Inspection dates: 3
Resident census served: 60
Licensed capacity: 106
Capacity of secured dementia care unit: 39
Residents served in secured dementia care unit: 23
Residents with mobility need: 34
Residents aged 60 or older: 60
Residents in hospice: 14
Total daily staff: 94
Waking staff: 71
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Resident Care Director | Named in relation to training and auditing care plan meeting signatures | |
| Executive Director | Named in relation to identifying incidents, providing education, and overseeing plans of correction | |
| Dining Service Coordinator | Named in relation to removing outdated food and auditing kitchen | |
| Reminiscence Coordinator | Named in relation to auditing rooms for operable lamps and care plan meetings | |
| Business Office Coordinator | Named in relation to auditing direct care staff training records |
Notice
Capacity: 106
Deficiencies: 0
Sep 16, 2021
Visit Reason
This document serves as a renewal notification and license issuance for the Personal Care Home 'Sunrise of Exton' following receipt of the renewal application dated September 14, 2021.
Findings
The Department advises that an onsite annual inspection will be conducted within the next twelve months to ensure compliance with Title 55, PA Code, Chapter 2600. Enforcement actions may follow if noncompliance is found.
Report Facts
Maximum licensed capacity: 106
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary, Office of Long-term Living | Signed the renewal notification letter |
Inspection Report
Census: 62
Capacity: 106
Deficiencies: 0
Aug 25, 2021
Visit Reason
The inspection was conducted as a licensing inspection by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing, with an unannounced partial inspection due to an incident.
Findings
No regulatory citations or deficiencies were identified as a result of the inspection conducted on 08/25/2021 and subsequent dates.
Report Facts
Residents Served: 62
License Capacity: 106
Staffing Hours: 87
Waking Staff: 65
Secured Dementia Care Unit Capacity: 39
Secured Dementia Care Unit Residents Served: 23
Residents with Mobility Need: 25
Residents with Physical Disability: 1
Inspection Report
Follow-Up
Census: 65
Capacity: 106
Deficiencies: 2
Jul 21, 2021
Visit Reason
The inspection was conducted as a follow-up to verify the implementation of a previously submitted plan of correction related to citations found during prior licensing inspections on 07/21/2021, 07/22/2021, 07/23/2021, and 08/02/2021.
Findings
The submitted plan of correction was determined to be fully implemented and acceptable. The facility was found to have deficiencies related to delayed reporting of suspected resident abuse and incomplete cognitive preadmission screening for a resident admitted to the secured dementia care unit.
Deficiencies (2)
| Description |
|---|
| Failure to immediately report suspected abuse of a resident; the allegation was reported late to the department, law enforcement, and local area agency on aging. |
| A written cognitive preadmission screening was not completed within 72 hours prior to admission to the secured dementia care unit for a resident. |
Report Facts
Licensed Capacity: 106
Residents Served: 65
Capacity of Secured Dementia Care Unit: 39
Residents Served in Secured Dementia Care Unit: 26
Inspection Report
Follow-Up
Census: 61
Capacity: 106
Deficiencies: 6
Mar 9, 2021
Visit Reason
The visit was a full, unannounced inspection conducted on 03/09/2021 and 03/10/2021 to review the facility's compliance and verify that the previously submitted plan of correction was fully implemented.
Findings
The inspection found several deficiencies including failure to post the current licensing inspection summary and emergency telephone numbers, obstruction of egress routes, and discrepancies in medication administration records related to glucometer readings for Resident #1. The submitted plan of correction was determined to be fully implemented.
Deficiencies (6)
| Description |
|---|
| The home did not have a copy of the current licensing inspection summary and the pink chapter book posted in a conspicuous and public place. |
| No emergency telephone numbers were posted on or by the telephones in resident bedrooms. |
| A rocking chair was blocking the exit from the sun port on the opposite side of the smoking room. |
| The glucometer reading for Resident #1 on 3/4/21 at 10:17AM was 241 but was documented in the Medication Administration Record as 243. |
| The medication administration record for Resident #1 contained blood sugar readings not found on any glucometer, indicating blood sugar checks were not performed as prescribed on specific dates. |
| Resident #1 did not have blood sugar checks on 3/1/21 AM, 3/7/21 PM, and 3/8/21 AM as prescribed. |
Report Facts
Residents Served: 61
License Capacity: 106
Secured Dementia Care Unit Capacity: 39
Secured Dementia Care Unit Residents Served: 22
Hospice Current Resident Count: 12
Residents Age 60 or Older: 61
Residents with Mental Illness: 1
Residents with Mobility Need: 28
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Shawn Parker | Signed the letter confirming plan of correction implementation | |
| Resident Care Director | Notified and involved in addressing medication record discrepancies and glucometer audits | |
| Executive Director | Responsible for implementing and monitoring plans of correction and education | |
| Maintenance Coordinator | Removed obstruction blocking egress route and conducted routine checks | |
| Activity Coordinator | Assisted in auditing emergency phone postings |
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