Inspection Report
Complaint Investigation
Census: 99
Capacity: 115
Deficiencies: 6
Jun 3, 2025
Visit Reason
The inspection was conducted as a complaint and incident investigation at Newhaven Court at Clearview, including review of a submitted plan of correction.
Findings
Multiple deficiencies were found including resident abuse incidents, medication administration errors, failure to follow prescriber's orders, and incomplete support plan documentation and revisions. The submitted plan of correction was determined to be fully implemented as of the follow-up review.
Complaint Details
The visit was complaint-related, investigating allegations of resident abuse and medication errors. The abuse allegation was not reported timely to the local Area Agency on Aging.
Deficiencies (6)
| Description |
|---|
| Resident abuse incident involving physical altercation and delayed reporting to the local Area Agency on Aging. |
| Medications were removed from original containers more than 2 hours in advance of scheduled administration. |
| Medications were not administered at the correct time and documentation errors on medication administration records (MAR). |
| Failure to follow prescriber's orders with multiple residents not receiving prescribed medications as directed. |
| Resident support plan was not signed and no notation of refusal or inability to sign was documented. |
| Resident support plan was not updated to address changes in ambulation and aggressive behavior. |
Report Facts
License Capacity: 115
Residents Served: 99
Secured Dementia Care Unit Capacity: 18
Secured Dementia Care Unit Residents Served: 18
Current Hospice Residents: 9
Residents Age 60 or Older: 99
Residents Diagnosed with Mental Illness: 1
Residents with Mobility Need: 32
Inspection Report
Follow-Up
Census: 98
Capacity: 115
Deficiencies: 2
Apr 15, 2025
Visit Reason
The inspection visit on 04/15/2025 was a partial, unannounced follow-up inspection triggered by an incident to verify the implementation of a previously submitted plan of correction.
Findings
The facility was found to have fully implemented the submitted plan of correction related to deficiencies in assistance with activities of daily living and medication administration. The report details corrective actions including enhanced resident supervision, staff training, and ongoing audits to prevent future errors.
Deficiencies (2)
| Description |
|---|
| Inadequate supervision and assistance with transfers for a resident who sustained multiple falls, resulting in hospitalization and rehab services. |
| Medication administration error where staff administered medication at the wrong time, not following prescriber's orders. |
Report Facts
Residents Served: 98
License Capacity: 115
Secured Dementia Care Unit Capacity: 18
Secured Dementia Care Unit Residents Served: 17
Hospice Current Residents: 9
Residents Age 60 or Older: 95
Residents with Mental Illness: 1
Residents with Mobility Need: 31
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Resident Wellness Director/Designee | Responsible party for enhanced resident supervision and staff training on ADL assistance | |
| Executive Operations Officer/Designee | Responsible party for staff training on medication administration and ongoing medication audits |
Inspection Report
Complaint Investigation
Census: 100
Capacity: 115
Deficiencies: 0
Jan 14, 2025
Visit Reason
The inspection was conducted as a complaint and incident investigation during an unannounced partial licensing inspection.
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
License Capacity: 115
Residents Served: 100
Memory Care Capacity: 18
Memory Care Residents Served: 18
Hospice Current Residents: 7
Residents Age 60 or Older: 100
Residents Diagnosed with Mental Illness: 1
Residents with Mobility Need: 31
Resident Support Staff: 0
Total Daily Staff: 131
Waking Staff: 98
Inspection Report
Renewal
Census: 86
Capacity: 115
Deficiencies: 9
Jul 25, 2024
Visit Reason
The inspection was conducted as a renewal licensing inspection to assess compliance with 55 Pa. Code Chapter 2600 relating to Personal Care Homes.
Findings
The facility was found to be in compliance with regulations after corrections were made following inspections on July 27, 2024, and October 16, 2024. Several deficiencies related to staff training, fire safety, medication labeling, and storage procedures were identified and addressed with plans of correction.
Deficiencies (9)
| Description |
|---|
| Direct care staff did not complete required training on meeting resident needs and safe management techniques during the 2023 training year. |
| Direct care staff did not complete required annual fire safety training during the 2023 training year. |
| A 6 ounce bottle of nail polish remover labeled as extremely flammable was unsecured and accessible to residents. |
| Fire drill records did not document evacuation time in minutes and seconds on multiple dates. |
| Residents were unable to evacuate within the safe evacuation time during a fire drill and the drill was not recorded. |
| Fire drills were routinely held at the end of each month rather than on different days and times. |
| Medication labels for Resident #1 did not match prescribed dosages and frequencies. |
| Medications for Resident #2 were not documented on the July 2024 Medication Administration Record. |
| Medications prescribed for Resident #1 were not available in the home. |
Report Facts
License Capacity: 115
Residents Served: 86
Residents Served in Secure Dementia Care Unit: 17
Capacity of Secure Dementia Care Unit: 18
Current Hospice Residents: 12
Total Daily Staff: 122
Waking Staff: 92
Residents Served: 96
Current Hospice Residents: 13
Total Daily Staff: 134
Waking Staff: 101
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Juliet Marsala | Deputy Secretary | Signed licensing letter and report cover letter. |
Inspection Report
Renewal
Census: 86
Capacity: 115
Deficiencies: 9
Jul 25, 2024
Visit Reason
The inspection was conducted as a renewal licensing inspection of Newhaven Court at Clearview to assess compliance with 55 Pa. Code Chapter 2600 relating to Personal Care Homes.
Findings
The facility was found to be in compliance with applicable regulations after inspections on July 27, 2024, and October 16, 2024, with several deficiencies noted related to staff training, fire safety, medication labeling, and storage procedures, all of which had plans of correction submitted and accepted.
Deficiencies (9)
| Description |
|---|
| Direct care staff did not complete required training on meeting resident needs and safe management techniques during the 2023 training year. |
| Direct care staff did not complete required annual fire safety training during the 2023 training year. |
| A 6 ounce bottle of nail polish remover labeled as extremely flammable was unsecured and accessible to residents. |
| Fire drill records did not document evacuation time in minutes and seconds on multiple dates. |
| Residents were unable to safely evacuate within the specified time during a fire drill and the drill was not recorded properly. |
| Fire drills were routinely held at the end of each month rather than on different days and times as required. |
| Medication labels did not match physician orders for multiple medications for Resident #1. |
| Medications prescribed for Resident #2 were not documented on the July 2024 Medication Administration Record. |
| Medications prescribed for Resident #1 (Ondansetron and Nystatin Cream) were not available in the home. |
Report Facts
License Capacity: 115
Residents Served: 86
Residents Served in Secure Dementia Care Unit: 17
Capacity of Secure Dementia Care Unit: 18
Current Hospice Residents: 12
Total Daily Staff: 122
Waking Staff: 92
Residents Served: 96
Current Hospice Residents: 13
Total Daily Staff: 134
Waking Staff: 101
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Juliet Marsala | Deputy Secretary | Signed licensing letter and report cover letter. |
Inspection Report
Complaint Investigation
Census: 91
Capacity: 115
Deficiencies: 13
Sep 25, 2023
Visit Reason
The inspection was conducted as a complaint and incident investigation with multiple inspection dates from September 25, 2023 to March 26, 2024, to evaluate compliance with 55 Pa. Code Chapter 2600 relating to Personal Care Homes.
Findings
The facility was found to have multiple violations including resident neglect and abuse related to frequent falls with injuries, failure to provide adequate supervision and assistance to residents at risk of falls, confidentiality breaches, financial management deficiencies, training record issues, environmental safety concerns, and medication labeling errors. A provisional license was issued due to these violations with required plans of correction.
Complaint Details
The inspection was complaint-driven, triggered by allegations of neglect and abuse related to resident falls and injuries, as well as other regulatory compliance concerns.
Deficiencies (13)
| Description |
|---|
| Resident #1 experienced 38 falls with multiple injuries due to lack of fall precautions and inadequate assistance despite physical therapy recommendations. |
| Resident #2 suffered a fatal injury from a fall resulting in a right femoral neck fracture and death due to complications. |
| Multiple residents (e.g., #8, #9, #10, #11, #12, #13, #14) experienced numerous unwitnessed falls with injuries due to inadequate assistance and supervision contrary to their Resident Assessment and Support Plans (RASP). |
| Resident records containing confidential information were found unlocked and unattended in a public area. |
| Residents #6 and #7 did not receive quarterly itemized accounts of financial transactions as required. |
| The home's record of direct care staff training for fire safety lacked documentation of the trainer's name and source. |
| Uncovered trash receptacles were found in the kitchen and outside the home, posing sanitation risks. |
| Emergency telephone numbers were not posted on or by multiple telephones in the home. |
| Several resident rooms had operable windows without screens. |
| Food items were stored in open and unsealed containers in the kitchen. |
| A visitor caused a small fire on a second-floor balcony by improperly discarding a lit cigarette in a potted plant outside the designated smoking area. |
| Resident #6's insulin medication label did not match the prescribed dosage, posing a medication error risk. |
| Resident #14's assessment was not updated to reflect significant changes in condition requiring assistance with transfers, balance, gait, bathing, and dressing. |
Report Facts
License Capacity: 115
Residents Served: 91
Secured Dementia Care Unit Capacity: 18
Residents Served in SDCU: 18
Number of Falls: 115
Unwitnessed Falls: 106
Falls Resulting in Injury: 31
Staffing Hours: 128
Waking Staff: 96
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Juliet Marsala | Deputy Secretary | Signed the letter regarding the provisional license and enforcement actions. |
Inspection Report
Complaint Investigation
Census: 91
Capacity: 115
Deficiencies: 15
Sep 25, 2023
Visit Reason
The inspection was conducted as a complaint and incident investigation with multiple inspection dates from September 25, 2023 to March 26, 2024, to assess compliance with 55 Pa. Code Chapter 2600 relating to Personal Care Homes.
Findings
The inspection found multiple violations including resident neglect and abuse related to frequent falls with injuries, failure to provide adequate supervision and assistance to residents at risk of falls, confidentiality breaches, incomplete financial transaction reporting, inadequate staff training records, improper trash management, missing emergency telephone postings, unsecured windows, improper food storage, smoking policy violations, incomplete menus, medication labeling errors, and failure to update resident assessments after significant condition changes.
Complaint Details
The visit was complaint-related, triggered by allegations of neglect and abuse involving multiple residents experiencing frequent falls and injuries, including a resident death due to fall-related injury. The investigation included multiple inspection dates and follow-up reviews.
Deficiencies (15)
| Description |
|---|
| Resident #1 experienced multiple falls with injuries due to lack of fall precautions and inadequate assistance despite physical therapy recommendations. |
| Resident #2 suffered a fatal injury from a fall due to inadequate supervision and assistance. |
| Confidential resident records were found unlocked and accessible to unauthorized persons. |
| Residents #6 and #7 did not receive quarterly financial transaction accounts as required. |
| Multiple residents experienced numerous falls resulting in injuries due to failure to provide required assistance and supervision. |
| Staff training records for fire safety lacked documentation of trainer name and source. |
| Trash receptacles in kitchens and bathrooms were uncovered, allowing penetration of insects and rodents. |
| Trash was improperly stored outside the home in uncovered receptacles. |
| Emergency telephone numbers were not posted on or by multiple telephones in the home. |
| Windows in multiple resident rooms lacked screens. |
| Food items were stored open and unsealed in the kitchen. |
| A visitor caused a small fire by smoking in a non-designated area and improperly discarding a cigarette. |
| Weekly menus were not posted one week in advance as required. |
| Resident #6's medication label did not match prescribed dosage. |
| Resident #14's assessment was not updated to reflect significant changes in condition and care needs. |
Report Facts
License Capacity: 115
Residents Served: 91
Secured Dementia Care Unit Capacity: 18
Residents Served in SDCU: 18
Number of Falls: 115
Unwitnessed Falls: 106
Falls Resulting in Injury: 31
Staffing Hours: 128
Waking Staff: 96
Inspection Report
Renewal
Census: 91
Capacity: 115
Deficiencies: 8
Mar 2, 2022
Visit Reason
The inspection was conducted as a renewal inspection of the facility's license, including a full unannounced review from 03/02/2022 to 03/09/2022.
Findings
The inspection identified multiple deficiencies including insufficient CPR/First Aid trained staff, unsecured bed enabler bars posing entrapment hazards, lack of operable bedside lamps for some residents, inconsistent smoking policy, medication labeling errors, uncalibrated glucometers, and delayed admission support plan completion. Plans of correction were accepted and implemented with target completion dates mostly by 03/25/2022.
Deficiencies (8)
| Description |
|---|
| Insufficient staff trained in first aid and certified in obstructed airway techniques and CPR present during specified dates and times. |
| Enabler bars on beds of residents #1 through #7 were not secured, posing an entrapment hazard. |
| Residents #6 and #8 did not have access to operable bedside lamps; one lamp was unplugged. |
| The home’s smoking policy was inconsistent between the policy and home rules, prohibiting resident smoking but allowing staff designated smoking areas. |
| Pharmacy labels for residents #3, #9, and #10 medications were incorrect or missing dosage instructions. |
| Staff person administered insulin without completing required Department-approved diabetes education within past 12 months. |
| Resident #13’s admission support plan was completed late, after admission to the secured dementia care unit. |
| Resident #6’s prescribed medication was not available in the home; glucometers for residents #9 and #11 were not calibrated to the correct date. |
Report Facts
Residents Served: 91
License Capacity: 115
Total Daily Staff: 128
Waking Staff: 96
Residents with Mobility Need: 37
Residents in Secured Dementia Care Unit: 17
Deficiencies Cited: 8
Notice
Capacity: 115
Deficiencies: 0
Apr 16, 2021
Visit Reason
The document serves as a renewal notification and certificate of compliance for the Personal Care Home 'Newhaven Court at Clearview'. It informs the facility that the Department will conduct an onsite inspection 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 in response to the renewal application and advises that enforcement action will be taken if noncompliance is found during future inspections.
Report Facts
Maximum capacity: 115
Secure Dementia Care Unit capacity: 18
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary, Office of Long-term Living | Signed the renewal notification letter. |
Inspection Report
Renewal
Deficiencies: 0
Apr 6, 2021
Visit Reason
The inspection was conducted as a 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: 74
Capacity: 115
Deficiencies: 5
Mar 11, 2021
Visit Reason
The inspection was conducted as a renewal visit to review compliance with licensing requirements at Newhaven Court at Clearview.
Findings
The facility was found to have deficiencies related to medication storage and administration, including missing prescribed medications and incorrect insulin dosing. The submitted plan of correction was determined to be fully implemented.
Deficiencies (5)
| Description |
|---|
| Resident #1's prescribed Albuterol Sulfate HFA 90 mcg was not available in the home on 3/12/21. |
| Resident #1's Co-Enzyme Q 10mg medication was not administered from 3/2/21 through 3/11/21 due to unavailability. |
| Resident #1's Quetiapine Fumarate 100 mg medication was not administered from 7:00 PM on 3/9/21 through 9:00 AM on 3/12/21 due to unavailability. |
| Resident #2's Ferrous Sulfate 325 mg medication was not administered from 3/5/21 through 3/12/21 due to unavailability. |
| Resident #3 received 4 units of insulin on 3/5/21 instead of the prescribed 3 units according to the sliding scale and blood glucose reading. |
Report Facts
License Capacity: 115
Residents Served: 74
Medication Administration Errors: 4
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