Inspection Report
Renewal
Census: 39
Capacity: 81
Deficiencies: 16
Oct 29, 2024
Visit Reason
The inspection was conducted as part of a renewal and complaint investigation to assess compliance with 55 Pa. Code Ch. 2600 relating to Personal Care Homes.
Findings
The facility was found to have multiple deficiencies related to resident privacy, record confidentiality, storage of poisonous materials, lighting and fire safety, medication administration, and documentation. Plans of correction were accepted and implemented by March 2025. A follow-up partial inspection on 2025-03-21 found no deficiencies.
Complaint Details
The inspection included complaint investigation as indicated by the reason 'Renewal, Complaint' and multiple findings related to resident privacy, medication administration, and fire safety.
Deficiencies (16)
| Description |
|---|
| Resident records were found unlocked and accessible without proper consent. |
| No door on common bathroom 307 and bathroom stalls lacked locking devices. |
| Poisonous materials were not stored in original labeled containers. |
| An EXIT sign led to an enclosed patio without a means of egress to a public thoroughfare. |
| Rubber stripping at a door threshold was detached, posing a tripping hazard. |
| No grab bars, handrails or assist bars in men’s and women’s bathrooms near main dining room. |
| Fire safety inspection and drill were not completed annually; last was in 2022. |
| Fire drill records lacked indication of a.m. or p.m. times. |
| Evacuation times exceeded allowable limits; no written safe evacuation time specified by fire safety expert within past year. |
| Fire drills were routinely conducted at the end of the month on similar dates. |
| Resident #4 had medications in room without assessment for self-administration. |
| Non-licensed staff administered GLP-1 agonist medication to resident #5. |
| Prescription medication label for resident #5 was inconsistent with physician orders. |
| Medication record for resident #6 did not include Morphine on the November 2024 MAR. |
| Medication administration record for resident #5 was not initialed for multiple medications on 10/7/24 at 8:00 p.m. |
| Correction fluid was used on resident #7’s nursing note, which is against policy. |
Report Facts
License Capacity: 81
Residents Served: 39
Staffing Hours: 46
Waking Staff: 35
Residents Served: 42
Staffing Hours: 53
Waking Staff: 40
Fire Drill Evacuation Times: 13
Inspection Report
Renewal
Census: 39
Capacity: 81
Deficiencies: 16
Oct 29, 2024
Visit Reason
The inspection was conducted as part of a renewal and complaint investigation process, including multiple licensing inspections on 10/29/24, 11/4/24, 11/13/24, and 3/21/24, to assess compliance with 55 Pa. Code Ch. 2600 relating to Personal Care Homes.
Findings
The facility was found to be in compliance overall, with multiple deficiencies cited related to record confidentiality, privacy, poisonous materials storage, lighting, surfaces, grab bars, fire safety inspections and drills, medication administration, and record keeping. All deficiencies had plans of correction accepted and were implemented by 03/26/2025. A follow-up partial inspection on 03/21/2025 found no deficiencies.
Complaint Details
The inspection included complaint investigation as part of the renewal process. Specific complaint details are not provided, but the report notes corrections made after inspections and no deficiencies found on the 03/21/2025 follow-up partial inspection.
Deficiencies (16)
| Description |
|---|
| Resident records binder was unlocked and accessible, violating confidentiality requirements. |
| No door on common bathroom 307 and bathroom stalls lacked locking devices, violating privacy rights. |
| Spray bottle with unlabeled disinfectant found outside original container. |
| Exit sign above patio door unsafe due to no means of egress to public thoroughfare. |
| Rubber stripping detached at door threshold creating tripping hazard. |
| No grab bars or handrails in men's and women's bathrooms near main dining room. |
| Fire safety inspection and drill not completed annually; last done 8/3/22. |
| Fire drill records lacked indication of a.m. or p.m. times. |
| Evacuation times exceeded allowable 2 minutes 30 seconds in multiple fire drills. |
| Fire drills routinely held at end of month dates, not varied days/times. |
| Resident #4 self-administered medications without proper assessment. |
| Non-licensed staff administered GLP-1 agonist medication to resident #5. |
| Prescription medication label for resident #5 inconsistent with physician orders. |
| Morphine medication for resident #6 not included on medication administration record. |
| Medication administration record for resident #5 not initialed for multiple medications on 10/7/24 at 8:00 p.m. |
| Correction fluid used on resident #7's nursing note, violating record entry requirements. |
Report Facts
License Capacity: 81
Residents Served: 39
Staffing Hours: 46
Waking Staff: 35
Residents Served: 42
Staffing Hours: 53
Waking Staff: 40
Fire Drill Evacuation Times: 13
Inspection Report
Complaint Investigation
Census: 38
Capacity: 81
Deficiencies: 3
Feb 26, 2024
Visit Reason
The inspection was conducted as a complaint investigation triggered by an incident involving mistreatment or abuse of a resident, failure to submit and comply with an acceptable plan of correction, and related violations of 55 Pa. Code Chapter 2600 for Personal Care Homes.
Findings
The investigation found that a resident was found deceased outside the facility after wandering away in cold weather, indicating neglect and abuse. Additional violations included failure to properly document medication administration and lack of a current written description of services. A provisional license was issued due to these violations and an acceptable plan of correction.
Complaint Details
The complaint investigation was substantiated based on findings of resident neglect and abuse, failure to submit and comply with an acceptable plan of correction, and violations of licensing regulations.
Deficiencies (3)
| Description |
|---|
| Resident #1 was found deceased outside the home after wandering away unattended in cold weather, indicating neglect and abuse. |
| Failure to document medication administration accurately; resident's morning medications were not administered though documented as given. |
| The home did not have a current written description of services and activities provided, including criteria for admission and discharge and services not provided but arranged. |
Report Facts
License Capacity: 81
Residents Served: 38
Resident Support Staff: 50
Waking Staff: 38
Supplemental Security Income Recipients: 9
Residents 60 Years or Older: 38
Residents with Mobility Need: 12
Residents with Physical Disability: 1
Current Hospice Residents: 4
Inspection Report
Plan of Correction
Census: 51
Capacity: 81
Deficiencies: 4
Mar 30, 2023
Visit Reason
The inspection was a partial review conducted as a follow-up to verify the submitted plan of correction for the facility.
Findings
The facility had deficiencies related to building renovations and electronic locking systems on secured dementia care unit doors. The facility rescinded its request to open a secured dementia unit and disconnected all locking systems and wander guard devices. Photographic evidence was directed to be submitted to the local code enforcement official to verify corrections.
Deficiencies (4)
| Description |
|---|
| The home's most recent occupancy permit indicates 'mixed use' and does not specify use classes; keypad locking devices were added to doors without proper approval. |
| The home lacks written approval for keypad locking devices on secured dementia care unit doors. |
| The home does not have a manufacturer statement verifying the locking system will shut down and doors will open immediately upon fire alarm, power failure, or override. |
| Doors in the secured dementia care unit are only monitored by a wander guard system and lack an electronic locking system. |
Report Facts
License Capacity: 81
Residents Served: 51
Staffing: 52
Waking Staff: 39
Secured Dementia Care Unit Capacity: 12
Secured Dementia Care Unit Residents Served: 0
Hospice Current Residents: 3
Residents Receiving Supplemental Security Income: 9
Residents Age 60 or Older: 51
Residents with Mobility Need: 1
Residents with Physical Disability: 1
Inspection Report
Renewal
Census: 48
Capacity: 81
Deficiencies: 6
Dec 7, 2022
Visit Reason
The inspection was conducted as a renewal and complaint investigation for the facility Mt. Assisi Place on 12/07/2022, 12/08/2022, and 12/09/2022.
Findings
The inspection identified multiple deficiencies including expired boiler certificates, use of restraints (bedrails) without proper justification, incomplete criminal background checks for staff, incomplete orientation documentation for new staff, inadequate bedside lighting for a resident, and incomplete documentation in a resident's support plan regarding bedrails. Plans of correction were submitted and implemented by January 24, 2023.
Complaint Details
The inspection included a complaint investigation as part of the renewal process. Specific complaint substantiation status is not stated.
Deficiencies (6)
| Description |
|---|
| Certificates for multiple boilers within the home expired on 11/2/22. |
| Bilateral half-length bedrails were present at the top of the beds of residents #1, #2, and #3; residents were unable to independently use the devices. |
| A Pennsylvania criminal background check was not completed for direct care staff person A. |
| Orientation documentation was incomplete for direct care staff person C and ancillary staff person B, making it unclear if orientation was completed timely. |
| Resident #1's bedside lamp was approximately 5 feet from the bed and could not be turned on/off from bedside. |
| Resident #1's support plan did not address the need for bedrails or a plan to protect the resident from potential dangers of the bedrails. |
Report Facts
Inspection dates: 3
Residents served: 48
License capacity: 81
Staff total daily: 65
Waking staff: 49
Current hospice residents: 4
Residents receiving Supplemental Security Income: 10
Residents age 60 or older: 48
Residents with mobility need: 17
Residents with physical disability: 1
Inspection Report
Follow-Up
Census: 42
Capacity: 81
Deficiencies: 1
Feb 28, 2022
Visit Reason
The inspection was a partial, unannounced follow-up visit conducted on 02/28/2022 to review the implementation of a plan of correction related to a prior incident.
Findings
The submitted plan of correction was determined to be fully implemented. The facility was found to have addressed the abuse allegations involving two staff members, who were suspended and terminated. Staff training on resident rights was completed and increased monitoring was initiated.
Complaint Details
The visit was triggered by an incident involving allegations of abuse against staff persons A and B. The allegations were investigated by AAA and DHS. Staff persons A and B were suspended and subsequently terminated. The resident was monitored and did not report lasting distress. The complaint was substantiated.
Deficiencies (1)
| Description |
|---|
| Resident #1 was subjected to intimidation and verbal abuse by staff persons A and B, violating resident rights and abuse prevention regulations. |
Report Facts
License Capacity: 81
Residents Served: 42
Current Hospice Residents: 2
Residents 60 Years or Older: 42
Residents with Mental Illness: 3
Residents with Mobility Need: 12
Residents with Physical Disability: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Janine Wenzig | Signed letters regarding inspection results and plan of correction acceptance |
Inspection Report
Complaint Investigation
Census: 42
Capacity: 81
Deficiencies: 3
Dec 27, 2021
Visit Reason
The inspection was conducted as a complaint investigation with a provisional exit conference on 12/27/2021 at MT. ASSISI PLACE.
Findings
The inspection identified deficiencies related to incomplete resident-home contract signatures, incomplete medical evaluations missing vital signs, and incomplete resident assessments missing prescribed diet information. Plans of correction were accepted with specified completion dates.
Complaint Details
The visit was complaint-related and provisional, with a follow-up plan of correction submission due on 01/13/2022. The plan of correction was accepted.
Deficiencies (3)
| Description |
|---|
| Resident #1's resident-home contract was not signed by the resident or the home's administrator or designee; Resident #2's resident-home contract was not signed by the home's administrator or designee. |
| Resident #1's medical evaluation did not include blood pressure or temperature; these sections were blank. |
| Resident #3's most recent assessment did not include the resident's prescribed diet of mechanical soft foods as indicated on the medical evaluation. |
Report Facts
License Capacity: 81
Residents Served: 42
Current Hospice Residents: 2
Resident Support Staff: 0
Total Daily Staff: 54
Waking Staff: 41
Residents Receiving Supplemental Security Income: 13
Residents 60 Years or Older: 42
Residents Diagnosed with Mental Illness: 3
Residents with Mobility Need: 12
Inspection Report
Monitoring
Census: 50
Capacity: 81
Deficiencies: 3
Mar 15, 2021
Visit Reason
The inspection was a partial, unannounced monitoring visit conducted by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing on 03/15/2021.
Findings
The inspection identified three deficiencies: an entrapment hazard due to an unsecured enabler bar on a resident's bed, missing emergency telephone numbers by a kitchen phone, and improperly stored food (an unsealed bag of tater tots) in the walk-in freezer. Plans of correction were accepted and included staff reeducation and ongoing inspections.
Deficiencies (3)
| Description |
|---|
| The 9" x 3" opening between the rails of the uncovered, unsecured enabler bar on resident #1's bed posed an entrapment hazard due to insecure attachment allowing movement. |
| No emergency telephone numbers including nearest hospital and fire department were posted on or by the telephone in the kitchen next to the ice maker. |
| An unsealed 5 pound bag of tater tots was found in the walk-in freezer, violating food storage requirements. |
Report Facts
Residents Served: 50
License Capacity: 81
Staffing Hours - Total Daily Staff: 67
Staffing Hours - Waking Staff: 50
Current Hospice Residents: 4
Residents Receiving Supplemental Security Income: 13
Residents Diagnosed with Mental Illness: 3
Residents with Mobility Need: 17
Residents Age 60 or Older: 50
Residents Diagnosed with Intellectual Disability: 1
Residents with Physical Disability: 1
Inspection Report
Renewal
Census: 52
Capacity: 81
Deficiencies: 20
Nov 20, 2020
Visit Reason
The inspection was a renewal inspection conducted to assess compliance with 55 Pa. Code Chapter 2600 relating to Personal Care Homes.
Findings
The inspection identified multiple violations including failure to post influenza awareness posters, incomplete criminal background checks, entrapment hazards with bed enabler bars, uncovered trash receptacles, missing emergency telephone numbers, unlabeled and undated food and medications, unsecured medications, and incomplete medication records. Plans of correction were accepted and implemented for most violations.
Deficiencies (20)
| Description |
|---|
| Influenza Awareness poster was not posted as required. |
| Direct care staff had no record of Pennsylvania State Police criminal background check. |
| Unsecured and uncovered enabler bars on residents' beds posed entrapment hazards. |
| Trash receptacles in kitchens and bathrooms were uncovered. |
| Trash outside the home was not kept in covered receptacles. |
| Emergency telephone numbers were not posted on or by telephones with outside lines. |
| Resident did not have access to a source of light that can be turned on/off at bedside. |
| Unlabeled and undated leftover food items found in refrigerators. |
| No thermometers in some refrigerators and freezers. |
| Food stored in unsealed containers. |
| Emergency procedures and preparedness plan not posted in a conspicuous place. |
| Fire drill evacuation time exceeded maximum safe evacuation time and incomplete evacuation of residents. |
| Weekly menus not posted one week in advance. |
| Medications not kept in original labeled containers. |
| Medications and syringes not kept locked and accessible in resident's room. |
| Opened medications not labeled with open or expiration dates. |
| Medications not labeled with pharmacy label including resident name, medication name, date issued, dosage and instructions. |
| Medication found on floor outside of container. |
| Medication record did not accurately reflect prescribed medication administration frequency. |
| Home did not follow directions of prescriber regarding medication administration. |
Report Facts
License Capacity: 81
Residents Served: 52
Staffing Hours: 68
Waking Staff: 51
Current Residents on Hospice: 4
Residents 60 Years or Older: 52
Residents Diagnosed with Mental Illness: 3
Residents with Mobility Need: 16
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