Inspection Report
Complaint Investigation
Census: 95
Capacity: 131
Deficiencies: 4
Sep 24, 2025
Visit Reason
The inspection was conducted as a complaint investigation with an unannounced partial review on 09/24/2025 to assess compliance with staffing and care requirements.
Findings
The facility failed to provide immediate access to requested staffing schedules, delayed documentation of total census and mobility requirements on staffing schedules for August 30 and 31, 2025, and did not meet required direct care hours for residents with mobility needs on those days. Additionally, the facility did not meet the required 75% of personal care service hours during waking hours on August 30 and 31, 2025. Corrective actions and ongoing monitoring plans were implemented.
Complaint Details
The inspection was triggered by a complaint, and the findings relate to delays in providing requested records and failure to meet staffing and care hour requirements for residents with mobility needs. The plan of correction was accepted and fully implemented by 10/21/2025.
Deficiencies (4)
| Description |
|---|
| Delayed provision of accurate staffing schedules to the Department's agent until approximately 1:30 p.m. despite request at 9:45 a.m. |
| Failure to document total census and mobility requirements on staffing schedules for August 30 and 31, 2025, resulting in non-compliance with required staffing hours. |
| Did not provide the minimum required direct care hours (2 hours per day) to residents with mobility needs on August 30 and 31, 2025. |
| Did not meet the requirement that at least 75% of personal care service hours be provided during waking hours on August 30 and 31, 2025. |
Report Facts
Residents served: 95
License capacity: 131
Residents with mobility needs: 40
Direct care hours required on 8/30/2025: 139
Direct care hours provided on 8/30/2025: 120
Direct care hours required on 8/31/2025: 138
Direct care hours provided on 8/31/2025: 137
Direct care hours during waking hours required on 8/30/2025: 104.25
Direct care hours during waking hours provided on 8/30/2025: 89.5
Direct care hours during waking hours required on 8/31/2025: 103.5
Direct care hours during waking hours provided on 8/31/2025: 99
Inspection Report
Complaint Investigation
Census: 97
Capacity: 131
Deficiencies: 1
Jul 22, 2025
Visit Reason
The inspection was conducted as a complaint investigation following an incident involving alleged resident abuse in the secured dementia care unit.
Findings
The facility failed to immediately report an alleged resident abuse incident that occurred on 05/06/2025, violating the Older Adult Protective Services Act. The home subsequently submitted a plan of correction and retrained staff on abuse reporting procedures.
Complaint Details
The complaint involved an incident on 05/06/2025 where one resident hit another on the upper arm in the secured dementia care unit. The incident was not verbally reported immediately to the local Area Agency on Aging. The Charge Supervisor failed to follow through with immediate reporting procedures and was removed from that role. The facility reported the incident to Adult Protective Services upon discovery on 05/07/2025 and submitted a plan of correction.
Deficiencies (1)
| Description |
|---|
| Failure to immediately report suspected abuse of a resident as required by the Older Adult Protective Services Act. |
Report Facts
License Capacity: 131
Residents Served: 97
Secured Dementia Care Unit Capacity: 19
Secured Dementia Care Unit Residents Served: 14
Hospice Current Residents: 10
Residents Age 60 or Older: 97
Residents with Mobility Need: 41
Inspection Report
Follow-Up
Census: 99
Capacity: 131
Deficiencies: 1
Aug 12, 2024
Visit Reason
The inspection was a partial, unannounced follow-up visit conducted due to an incident at the facility, with a focus on verifying the submitted plan of correction.
Findings
The submitted plan of correction related to a resident-to-resident abuse incident was found to be fully implemented. The facility took immediate actions to separate the residents involved, implemented 15-minute checks, reported the incident to Adult Protective Services and the Bureau of Human Services Licensing, and developed ongoing staff training and monitoring protocols to prevent future occurrences.
Deficiencies (1)
| Description |
|---|
| A resident-to-resident abuse incident occurred where one resident scratched another resident's forearm and bent the resident's wrist backwards, causing red marks. |
Report Facts
License Capacity: 131
Residents Served: 99
Secured Dementia Care Unit Capacity: 19
Secured Dementia Care Unit Residents Served: 17
Current Hospice Residents: 18
Residents Age 60 or Older: 99
Residents Diagnosed with Mental Illness: 1
Residents with Mobility Need: 40
Total Daily Staff: 139
Waking Staff: 104
Inspection Report
Census: 97
Capacity: 131
Deficiencies: 0
Jun 17, 2024
Visit Reason
The inspection was a partial, unannounced visit conducted due to an incident at the facility.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Resident Support Staff: 126
Waking Staff: 95
Residents Served in Secured Dementia Care Unit: 17
Capacity of Secured Dementia Care Unit: 19
Current Hospice Residents: 1
Residents 60 Years or Older: 97
Residents Diagnosed with Mental Illness: 1
Residents with Mobility Need: 29
Inspection Report
Renewal
Census: 97
Capacity: 131
Deficiencies: 4
May 29, 2024
Visit Reason
The inspection was conducted as a full, unannounced visit for renewal, complaint, and incident reasons at the facility.
Findings
The inspection found several deficiencies including incomplete training records, unsecured resident equipment posing hazards, damage to walls in resident bedrooms, and incomplete preadmission screening documentation. All deficiencies were corrected or addressed with plans of correction accepted and implemented.
Deficiencies (4)
| Description |
|---|
| The home's record of annual direct care staff training did not include the duration of the trainings completed during the 1/1/23 - 12/31/23 annual training year. |
| The enabler device on resident #1’s bed was unsecured and could be moved back and forth approximately 2"-3", posing an entrapment/fall hazard. |
| There were four 2" x 2" holes in the drywall behind a reclining chair in bedroom #104 and a 4" x 5" hole in the wall behind the bed in bedroom #102. |
| Resident #2's preadmission screening form did not indicate the date the form was completed; this section was blank. |
Report Facts
License Capacity: 131
Residents Served: 97
Secured Dementia Care Unit Capacity: 19
Secured Dementia Care Unit Residents Served: 17
Hospice Residents: 5
Residents Receiving Supplemental Security Income: 5
Residents Age 60 or Older: 97
Residents Diagnosed with Mental Illness: 28
Residents with Mobility Need: 29
Inspection Report
Complaint Investigation
Census: 98
Capacity: 131
Deficiencies: 2
Jan 25, 2024
Visit Reason
The inspection was conducted as a complaint and incident investigation following concerns about medication administration errors at the facility.
Findings
The investigation found that staff member A administered medications to the wrong resident, resulting in at least two medications being given incorrectly. Staff member B also administered insulin incorrectly by failing to follow the second-check protocol. Both incidents were reported, and no adverse effects were noted in the residents. Corrective actions including retraining, monitoring, and policy changes were implemented.
Complaint Details
The visit was complaint-related due to medication administration errors. The complaint was substantiated as staff member A administered medications to the wrong resident and staff member B failed to follow insulin administration protocols. Both incidents were reported to the Bureau of Human Services Licensing. Residents involved were sent to the Emergency Room for observation but had no adverse effects.
Deficiencies (2)
| Description |
|---|
| Staff member A did not confirm the identity of the resident prior to administering medications, resulting in at least two medications being administered to the wrong resident. |
| Staff member B administered insulin incorrectly by failing to have a second checker verify the medication and dosage as required by protocol. |
Report Facts
License Capacity: 131
Residents Served: 98
Secured Dementia Care Unit Capacity: 19
Secured Dementia Care Unit Residents Served: 18
Hospice Current Residents: 6
Resident with Mobility Need: 31
Total Daily Staff: 129
Waking Staff: 97
Medication Errors: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff member A | Licensed Practical Nurse | Named in medication administration error where medications were given to the wrong resident |
| Staff member B | Named in insulin administration error where second-check protocol was not followed |
Inspection Report
Complaint Investigation
Census: 94
Capacity: 131
Deficiencies: 3
Sep 28, 2023
Visit Reason
The inspection was conducted as a complaint and incident investigation at Newhaven Court at Lindwood on 09/28/2023.
Findings
The investigation found violations related to resident abuse, including staff person B leaving the secure dementia care unit abruptly and inappropriate interactions involving resident #2 with other residents. Additional assessments for resident #2 were found to be incomplete or inaccurate. The facility implemented corrective actions including staff suspension and termination, retraining, and updated resident assessments.
Complaint Details
The complaint investigation was substantiated with findings of staff misconduct and resident abuse. Staff person B was suspended and terminated the same day due to the reported incidents. The facility followed reporting protocols and notified the Area on Aging. Ongoing monitoring and training were implemented to prevent recurrence.
Deficiencies (3)
| Description |
|---|
| Violation of 42.b - Resident abuse including neglect, intimidation, physical or verbal abuse, mistreatment, and corporal punishment. |
| Violation of 42.t - Resident's right to file complaints without intimidation, retaliation, or threat of discharge. |
| Violation of 225.c - Failure to conduct additional resident assessments annually, specifically related to wandering behaviors. |
Report Facts
License Capacity: 131
Residents Served: 94
Secured Dementia Care Unit Capacity: 19
Secured Dementia Care Unit Residents Served: 18
Hospice Residents: 6
Staffing Hours - Resident Support Staff: 131
Staffing Hours - Waking Staff: 98
Resident #2 Wandering Supervision: 15
License Expiration Date: Jun 10, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff Person B | Named in findings related to resident abuse, suspension, and termination. | |
| Administrator | Administrator | Responsible for retraining managers and overseeing corrective actions. |
Inspection Report
Complaint Investigation
Census: 95
Capacity: 131
Deficiencies: 2
Aug 25, 2023
Visit Reason
The inspection was conducted as a complaint and incident investigation to review compliance with regulations and assess the facility's response to identified issues.
Findings
The facility was found to have deficiencies related to failure to update resident assessments to reflect significant changes and failure to provide a 30-day advance written notice for discharge as required by regulation. The submitted plan of correction was accepted and fully implemented.
Complaint Details
The visit was complaint-related, triggered by concerns about Resident #1's care and discharge process. The complaint was substantiated with findings of regulatory violations regarding assessment updates and discharge notice requirements.
Deficiencies (2)
| Description |
|---|
| Resident #1's assessment did not include new diagnoses and behavioral changes, and failed to document required 15-minute checks. |
| No 30-day advance written notice was provided to Resident #1 or their designated person prior to discharge, and no physician documentation justified the delay in discharge. |
Report Facts
License Capacity: 131
Residents Served: 95
Secured Dementia Care Unit Capacity: 19
Secured Dementia Care Unit Residents Served: 18
Hospice Residents: 6
Residents with Mental Illness: 1
Residents with Mobility Need: 36
Total Daily Staff: 131
Waking Staff: 98
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Executive Operations Officer | Re-educated Resident Wellness Director on assessment regulation and responsible for oversight of plan of correction implementation | |
| Resident Wellness Director | Responsible for resident assessments and compliance with regulation 2600.225.c | |
| General Area Manager | Responsible for second check to ensure physician documentation is present prior to discharge |
Inspection Report
Follow-Up
Census: 81
Capacity: 131
Deficiencies: 5
Nov 10, 2022
Visit Reason
The inspection visit on 11/10/2022 was a partial, unannounced follow-up to an incident, focusing on verifying the implementation of a submitted plan of correction.
Findings
The facility was found to have multiple medication-related deficiencies including failure to document blood glucose readings, medication administration times, refusals, and follow prescriber orders. Trained personnel were removed from insulin and blood sugar administration until retraining and re-education were completed. The Resident Wellness Director and Executive Operations Officer implemented corrective actions and ongoing monitoring to ensure compliance.
Deficiencies (5)
| Description |
|---|
| Failure to document blood glucose readings on residents' medication administration records as ordered. |
| Medication administration records were not signed off at the time medications were administered. |
| Failure to document refusals of prescribed medications and notify physicians accordingly. |
| Failure to follow prescriber's orders, including incorrect insulin administration and lack of physician notification. |
| Medication administration training course annual practicum was not properly signed by a certified Train the Trainer. |
Report Facts
License Capacity: 131
Residents Served: 81
Secured Dementia Care Unit Capacity: 16
Secured Dementia Care Unit Residents Served: 15
Current Hospice Residents: 7
Residents Age 60 or Older: 81
Residents Diagnosed with Mental Illness: 1
Residents with Mobility Need: 26
Residents with Physical Disability: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff Person A | Named in medication error finding related to insulin administration and reporting. |
Inspection Report
Follow-Up
Census: 82
Capacity: 128
Deficiencies: 1
Jun 28, 2022
Visit Reason
The inspection was a partial, unannounced follow-up visit triggered by an incident to review the submitted plan of correction for a prior abuse violation.
Findings
The report details a substantiated abuse incident where a staff member punched a resident during care. The staff member was immediately terminated, and corrective actions including staff re-education, ongoing monitoring, and resident interviews were implemented to prevent recurrence.
Deficiencies (1)
| Description |
|---|
| A staff member punched a resident in the right side of the abdomen with a closed fist during care. |
Report Facts
License Capacity: 128
Residents Served: 82
Secured Dementia Care Unit Capacity: 16
Secured Dementia Care Unit Residents Served: 15
Hospice Current Residents: 9
Residents Age 60 or Older: 82
Residents Diagnosed with Mental Illness: 1
Residents Diagnosed with Intellectual Disability: 0
Residents with Mobility Need: 27
Residents with Physical Disability: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff member B | Staff member who punched resident and was terminated | |
| Staff member A | Witnessed the abuse and removed the staff member from the resident's room | |
| Staff member C | Director of Wellness | Interviewed staff member B after the incident |
Inspection Report
Renewal
Census: 83
Capacity: 128
Deficiencies: 6
Mar 7, 2022
Visit Reason
The inspection was conducted as a renewal and complaint investigation of the facility NEWHAVEN COURT AT LINDWOOD during the dates 03/07/2022 to 03/09/2022.
Findings
The inspection identified several deficiencies including ripped lint trap screens in dryers, outdated food storage, missed monthly fire drills, lack of annual fire safety inspection by an expert, and issues with resident assessments and support plans being completed prior to admission dates. Plans of correction were accepted and implemented with specified completion dates.
Deficiencies (6)
| Description |
|---|
| The metal mesh screen in the lint trap was ripped in multiple dryers in the home. |
| An open, undated bag of carrots was found in the commercial freezer. |
| An unannounced fire drill was not conducted during the month of January 2022. |
| A fire safety inspection and fire drill has not been conducted by a fire safety expert since 2020. |
| Resident assessments were completed prior to admission dates for three residents. |
| Resident support plans were completed prior to admission dates for three residents. |
Report Facts
License Capacity: 128
Residents Served: 83
Residents in Secured Dementia Care Unit: 15
Hospice Residents: 12
Residents with Mobility Need: 33
Total Daily Staff: 116
Waking Staff: 87
Dryer B lint trap rip length: 10
Dryer A lint trap rip length front: 6
Dryer A lint trap rip length side: 6
Completion Date: Mar 10, 2022
Completion Date: Mar 29, 2022
Completion Date: Mar 15, 2022
Completion Date: Mar 7, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Safety and Maintenance Engineer | Named in lint trap deficiency and fire drill training | |
| Executive Operations Officer | Named in multiple findings including lint trap training, food safety, fire drill, and resident assessment monitoring | |
| Dining Services Director | Named in outdated food finding and correction | |
| Resident Wellness Director | Named in resident assessment and support plan findings and corrective actions |
Inspection Report
Renewal
Deficiencies: 0
Sep 15, 2021
Visit Reason
The inspection was conducted as a licensing inspection by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing on 09/15/2021.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Notice
Capacity: 128
Deficiencies: 0
Jun 10, 2021
Visit Reason
The document serves as a renewal license notification for the Personal Care Home 'Newhaven Court at Lindwood' following receipt of the renewal application dated March 16, 2021.
Findings
The Department issued a regular license in response to the renewal application and advised that an onsite annual inspection will be conducted within the next twelve months to ensure compliance with applicable regulations.
Report Facts
Maximum capacity: 128
Secure Dementia Care Unit capacity: 16
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary, Office of Long-term Living | Signed the renewal notification letter |
Inspection Report
Renewal
Census: 74
Capacity: 128
Deficiencies: 9
Mar 4, 2021
Visit Reason
The inspection was an unannounced renewal inspection conducted on 03/04/2021 and 03/05/2021 to review compliance with licensing regulations for Newhaven Court at Lindwood.
Findings
The inspection identified multiple deficiencies including breaches of resident record confidentiality, delayed contract signatures, faulty smoke detector causing fire panel trouble signals, obstructed emergency exit door, incomplete or untimely annual medical evaluations and assessments, medication administration documentation errors, and failure to follow prescriber's orders for insulin administration. Plans of correction were submitted and accepted with staff re-education and ongoing monitoring implemented.
Deficiencies (9)
| Description |
|---|
| Resident records were left unlocked and accessible with private information in multiple locations. |
| Resident-home contracts were not signed timely by residents and responsible parties. |
| Fire panel displayed trouble signal due to a disabled smoke detector that was not reset. |
| Emergency exit door latch did not fully disengage, requiring considerable force to open. |
| Resident #9's annual medical evaluation was not completed timely and lacked proper documentation. |
| Medication Administration Record for Resident #10 lacked staff initials for medication administration on multiple dates. |
| Resident #10 was administered incorrect insulin dose due to inaccurate blood glucose documentation and failure to notify physician for high readings. |
| Resident #10's most recent additional assessment was not completed timely. |
| Support plans for Residents #7 and #11 were signed but missing dates next to resident signatures. |
Report Facts
License Capacity: 128
Residents Served: 74
Secured Dementia Care Unit Capacity: 16
Secured Dementia Care Unit Residents Served: 16
Hospice Residents: 7
Staff Total Daily: 86
Staff Waking: 65
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Executive Operations Officer | Oversight and training responsibility for multiple deficiencies including confidentiality breaches, contract signatures, fire panel issues, emergency exit door repairs, and staff re-education. | |
| Resident Wellness Director | Responsible for audits, staff training, medication administration monitoring, annual medical evaluations, assessments, and support plan compliance. | |
| Safety and Maintenance Engineer | Responsible for fire panel and emergency exit door maintenance and monitoring. | |
| Marketing Department Staff | Responsible for obtaining resident contract signatures with oversight by Executive Operations Officer. |
Inspection Report
Renewal
Deficiencies: 0
Jan 7, 2021
Visit Reason
The inspection was conducted as part of the licensing inspections by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing on 01/07/2021 and 01/08/2021.
Findings
No regulatory citations were identified as a result of this inspection.
Loading inspection reports...
