Inspection Report
Renewal
Census: 67
Capacity: 123
Deficiencies: 4
Jul 7, 2025
Visit Reason
The inspection was conducted as a renewal inspection of the facility's license, with an unannounced full inspection on 07/07/2025 and 07/08/2025.
Findings
The inspection identified several deficiencies including improper storage of poisonous materials, missing emergency procedures posting, failure to meet fire drill evacuation time requirements, and routine scheduling of fire drills during sleeping hours. Plans of correction were accepted and implemented by early August 2025.
Deficiencies (4)
| Description |
|---|
| Poisonous materials were not stored in their original labeled containers; a spray bottle with purple liquid was improperly labeled. |
| Emergency procedures for the assisted living residence and local municipality were not posted in a public and conspicuous place. |
| Fire drill evacuation time exceeded the safe evacuation time specified by a fire safety expert; repeat violation noted. |
| Fire drills were routinely held during sleeping hours, which is against regulations; repeat violation noted. |
Report Facts
License Capacity: 123
Residents Served: 67
Special Care Unit Capacity: 19
Special Care Unit Residents Served: 13
Hospice Residents: 11
Residents Age 60 or Older: 67
Residents Diagnosed with Mental Illness: 5
Residents Diagnosed with Intellectual Disability: 1
Residents with Mobility Need: 29
Residents with Physical Disability: 1
Fire Drill Evacuation Time: 600
Safe Evacuation Time: 264
Inspection Report
Complaint Investigation
Census: 63
Capacity: 123
Deficiencies: 0
Apr 29, 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 complaint-related and no deficiencies were found, indicating no substantiated issues.
Report Facts
License Capacity: 123
Residents Served: 63
Special Care Unit Capacity: 19
Special Care Unit Residents Served: 13
Hospice Current Residents: 12
Resident Demographics: 0
Resident Demographics: 5
Resident Demographics: 31
Resident Demographics: 63
Resident Demographics: 1
Resident Demographics: 2
Total Daily Staff: 94
Waking Staff: 71
Inspection Report
Census: 38
Capacity: 123
Deficiencies: 0
Apr 4, 2024
Visit Reason
The inspection was a partial, unannounced licensing inspection conducted due to provisional and incident reasons.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
License Capacity: 123
Residents Served: 38
Special Care Unit Capacity: 19
Special Care Unit Residents Served: 7
Hospice Residents: 3
Resident Support Staff: 0
Total Daily Staff: 63
Waking Staff: 47
Residents Age 60 or Older: 37
Residents Diagnosed with Mental Illness: 2
Residents Diagnosed with Intellectual Disability: 1
Residents with Mobility Need: 25
Residents with Physical Disability: 2
Inspection Report
Renewal
Census: 36
Capacity: 123
Deficiencies: 30
Feb 21, 2024
Visit Reason
The inspection was conducted as a renewal, provisional licensing inspection with multiple visits from February to May 2024 to verify compliance with 55 Pa. Code Chapter 2800 relating to Assisted Living Residence.
Findings
The facility was found to be in compliance overall, but multiple deficiencies were cited including expired boiler certificates, incomplete criminal background checks, staff qualifications, fire safety training, sanitary conditions, elevator certificates, resident equipment safety, medication labeling and administration, resident abuse reporting, and record confidentiality. Plans of correction were accepted and implemented for all deficiencies.
Deficiencies (30)
| Description |
|---|
| Boiler certificates expired in January 2024. |
| Criminal background check request for staff person A was pending and final report not received. |
| Staff persons A and B did not have required high school diploma, GED, or active nurse aide registry status. |
| Staff person C had not received required fire safety orientation. |
| Ancillary staff person C did not complete required orientation within 40 hours. |
| Staff persons A and C did not receive dementia-specific training within 30 days of hire. |
| No grab bars installed in two women's restrooms on 1st floor. |
| Half bed rails on resident beds were not well-secured, posing entrapment/fall hazards. |
| No paper towels or other safe hand drying means in women's bathroom across from business office. |
| Elevator certificate expired for one elevator; no certificate for second elevator. |
| No bedside table or shelf beside resident #3's bed. |
| Beds of residents #2, #3, and #4 lacked operable bedside lighting. |
| Food stored on floor in walk-in freezer. |
| Food stored in unsealed or uncovered containers in kitchen and special care unit. |
| Outdated and unsealed food items in kitchen freezer. |
| Fire drill logs incomplete or inaccurate regarding exit routes and resident counts. |
| Evacuation times during fire drills exceeded maximum safe evacuation time specified by fire safety expert. |
| Fire drill during sleeping hours not conducted within required 6 month interval. |
| Fire drills routinely held at same time of day and week. |
| First aid kit in transport van missing thermometer, eye coverings, and tweezers. |
| Resident #6 had medication bottle without label. |
| Resident glucometers not calibrated to current date and time. |
| Half-length bed rails used on both sides of resident #1's bed; resident unable to raise/lower rails; assessment and support plan did not address use. |
| Resident #1 assessment did not include diagnoses of history of falls and muscle weakness. |
| Resident #1 support plan did not document how home will meet multiple care needs as indicated on assessment. |
| No code posted for locking mechanism on stairwell exit door next to unit 212. |
| Correction fluid used on resident #2's contract with name written over it. |
| Resident #1 was verbally and physically abused by staff covering mouth and face, causing abrasion; incident not reported timely. |
| Resident #1 medications not administered on multiple dates due to unavailability in residence. |
| Resident records left unlocked and unattended in nurses' station. |
Report Facts
License Capacity: 123
Residents Served: 36
Special Care Unit Capacity: 19
Special Care Unit Residents Served: 7
Total Daily Staff: 58
Waking Staff: 44
Deficiency Counts: 29
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Juliet Marsala | Deputy Secretary | Signed licensing letter and certificate. |
| Staff person A | Named in multiple findings including criminal background check, staff qualifications, dementia training, abuse allegation, and medication administration. | |
| Staff person B | Named in staff qualification deficiency. | |
| Staff person C | Named in fire safety, orientation, dementia training, and rights/abuse training deficiencies. | |
| RN/DON | Registered Nurse/Director of Nursing | Responsible for medication labeling correction, glucometer calibration, medication audits, and staff education. |
| Maintenance Director | Responsible for correcting boiler inspections, elevator inspections, bedrail compliance, fire drill monitoring, and facility maintenance. | |
| Executive Director | Oversaw audits, education, and corrective actions for multiple deficiencies. | |
| Business Office Manager | Responsible for auditing staff files, admissions process, and record keeping. | |
| Culinary Director | Responsible for food storage corrections and kitchen audits. | |
| Administrator | Named in plans of correction and monitoring compliance. |
Inspection Report
Renewal
Census: 36
Capacity: 123
Deficiencies: 27
Feb 21, 2024
Visit Reason
The inspection was conducted as a renewal and provisional exit conference to assess compliance with 55 Pa. Code Chapter 2800 relating to Assisted Living Residence.
Findings
The facility was found to be in compliance with the regulations after multiple inspections and corrections. Several deficiencies were identified related to health and safety laws, staff qualifications, fire safety, resident accommodations, medication management, and resident rights, with plans of correction implemented.
Deficiencies (27)
| Description |
|---|
| Boiler certificates expired in January 2024. |
| Criminal background check for staff person A was pending. |
| Direct care staff persons A and B lacked required qualifications. |
| Staff person C had not received required fire safety orientation. |
| Ancillary staff person C did not complete required 40-hour orientation. |
| Staff persons A and C did not receive dementia-specific training within 30 days of hire. |
| No grab bars in certain women's restrooms. |
| Bed rails on residents #1 and #2 beds were not well-secured, posing entrapment/fall hazards. |
| No paper towels or other safe hand drying means in women's bathroom. |
| Elevator certificates expired or missing. |
| No bedside table or shelf beside resident #3's bed. |
| Beds of residents #2, #3, and #4 lacked operable bedside lighting. |
| Food stored on floor in walk-in freezer. |
| Food stored in unsealed or uncovered containers. |
| Outdated and unsealed food in freezer. |
| Fire drill logs incomplete or inaccurate. |
| Evacuation times during fire drills exceeded maximum safe time. |
| Fire drill during sleeping hours not conducted within required 6 months. |
| Fire drills conducted at same time of day for several months. |
| First aid kit in transport van missing thermometer, eye coverings, and tweezers. |
| Resident #6 medication bottle missing label. |
| Resident #5 and #7 glucometers not calibrated to current date/time. |
| Half-length rails used on both sides of resident #1's bed without meeting regulatory criteria. |
| Resident #1 assessment missing diagnoses of history of falls and muscle weakness. |
| Resident #1 support plan incomplete regarding multiple care needs. |
| No code posted for locking mechanism on stairwell exit door next to unit 212. |
| Correction fluid used on resident #2's contract with overwritten text. |
Report Facts
Inspection dates: 6
License capacity: 123
Residents served: 36
Special Care Unit capacity: 19
Residents served in SCU: 7
Staffing hours: 58
Waking staff: 44
Residents served during follow-up: 38
Total daily staff during follow-up: 60
Waking staff during follow-up: 45
Residents served during incident monitoring: 35
Total daily staff during incident monitoring: 49
Waking staff during incident monitoring: 37
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Juliet Marsala | Deputy Secretary | Signed licensing letter and certificate of compliance. |
Inspection Report
Renewal
Census: 36
Capacity: 123
Deficiencies: 30
Feb 21, 2024
Visit Reason
The inspection visit was conducted as a renewal, provisional licensing inspection with multiple inspection dates from February to May 2024 to assess compliance with 55 Pa. Code Chapter 2800 relating to Assisted Living Residence.
Findings
The facility was found to be in compliance overall, but multiple deficiencies were cited including expired boiler certificates, incomplete criminal background checks, staff qualifications, fire safety training, sanitary conditions, elevator certificates, resident equipment safety, medication labeling and administration, resident abuse reporting, and record confidentiality. Plans of correction were accepted and implemented with follow-up inspections scheduled.
Deficiencies (30)
| Description |
|---|
| Boiler certificates expired in January 2024. |
| Criminal background check request for staff person A was still pending review. |
| Staff persons A and B did not have required high school diploma, GED, or active nurse aide registry status. |
| Staff person C had not received required fire safety orientation. |
| Ancillary staff person C did not complete required orientation on resident rights, emergency medical plan, abuse reporting, and core competencies within 40 hours. |
| Staff persons A and C did not receive dementia-specific training within 30 days of hire. |
| No grab bars installed in two women's restrooms on 1st floor. |
| Half bed rails on resident beds were not well-secured, posing entrapment/fall hazards. |
| No paper towels or other safe hand drying means in women's bathroom across from business office. |
| Elevator certificate expired for one unit; no certificate for second elevator. |
| No bedside table or shelf beside resident #3's bed. |
| Beds of residents #2, #3, and #4 lacked operable bedside lighting. |
| Food stored on floor in walk-in freezer. |
| Food stored in unsealed or uncovered containers in kitchen and special care unit. |
| Outdated and unsealed food found in kitchen freezer. |
| Fire drill logs incomplete or inaccurate regarding exit routes and resident counts. |
| Evacuation times during fire drills exceeded maximum safe evacuation time specified by fire safety expert. |
| Fire drill during sleeping hours not conducted within required 6-month interval. |
| Fire drills conducted routinely at same time of day and week. |
| First aid kit in transport van missing thermometer, eye coverings, and tweezers. |
| Medication bottle for Eliquis missing pharmacy label. |
| Resident glucometers not calibrated to current date and time. |
| Half-length bed rails used on both sides of resident #1's bed without meeting regulatory criteria. |
| Resident #1's assessment did not include diagnoses of history of falls and muscle weakness. |
| Resident #1's support plan did not document how the home will meet multiple care needs. |
| No code posted for locking mechanism on stairwell exit door next to unit 212. |
| Correction fluid used on resident #2's contract with overwritten text. |
| Resident records left unlocked and unattended in nurses' station. |
| Resident #1 was verbally and physically abused by staff covering resident's mouth and face, causing abrasion. |
| Resident #1's prescribed medications were not administered on multiple dates due to unavailability. |
Report Facts
Inspection dates: 6
License capacity: 123
Residents served: 36
Special Care Unit capacity: 19
Special Care Unit residents served: 7
Staffing hours: 58
Waking staff: 44
Deficiency counts: 30
Residents served: 38
Staffing hours: 60
Waking staff: 45
Residents served: 35
Staffing hours: 49
Waking staff: 37
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Juliet Marsala | Deputy Secretary | Signed licensing letter and certificate of compliance |
Inspection Report
Complaint Investigation
Census: 35
Capacity: 123
Deficiencies: 3
Nov 21, 2023
Visit Reason
The inspection was conducted as a complaint investigation and fine review, as indicated by the reason 'Complaint, Fine' and the unannounced partial inspection on 11/21/2023.
Findings
The inspection identified deficiencies related to sanitary conditions with a pervasive urine odor in a resident room, incomplete labeling of prescription medications, and medication storage procedures including unavailable medication for evening administration. Plans of correction were accepted and implemented by 12/26/2023.
Complaint Details
The visit was complaint-related with a fine issued. The inspection was unannounced and partial, conducted on 11/21/2023.
Deficiencies (3)
| Description |
|---|
| Strong pervasive odor of urine in room #210 and adjoining bathroom. |
| Pharmacy label for Resident #1's medication was incomplete and did not include the sliding scale portion. |
| Medication for Resident #2 was not available in the residence for evening administration, noted as a repeat violation. |
Report Facts
License Capacity: 123
Residents Served: 35
Special Care Unit Capacity: 19
Special Care Unit Residents Served: 7
Hospice Current Residents: 3
Residents Age 60 or Older: 36
Residents with Mobility Need: 18
Inspection Report
Complaint Investigation
Census: 40
Capacity: 123
Deficiencies: 21
Aug 15, 2023
Visit Reason
The inspection was conducted as a complaint investigation with provisional license and fine assessment related to violations found during licensing inspections on July 25, August 9, and August 15, 2023.
Findings
Multiple violations of 55 Pa. Code Chapter 2800 related to assisted living residence regulations were found, including mistreatment or abuse of residents, failure to submit and comply with plans of correction, and deficiencies in resident care documentation and medication administration. A provisional license was issued and fines were proposed.
Complaint Details
The inspection was complaint-related, provisional license was issued, and fines were proposed for multiple violations. The report includes repeated violations and plans of correction with deadlines.
Deficiencies (21)
| Description |
|---|
| Resident #1's supervision was inadequate, allowing the resident to leave the home unsupervised and wander outside. |
| Resident #2's resident-residence contract was not completed until after admission. |
| Resident #2's resident-residence contract was not signed by the resident. |
| Resident #2's resident-residence contract did not include a fee schedule listing allowable charges. |
| Residents #2, 3, 4, 5, and 6 did not have signed statements acknowledging receipt of resident rights and complaint procedures. |
| Residents #2, 3, 7, and 8 medical evaluations lacked immunization history or indication of tuberculin skin test within 2 years. |
| Resident #1's previous medical evaluation was undated, making it unclear if annual evaluations were completed. |
| Resident #2's and others' medical evaluations did not include required immunization or tuberculin skin test information. |
| Resident #2's albuterol nebulizer medication was discontinued but remained in the medication cart. |
| Resident #4's phenaseptic liquid medication was discontinued but remained in the medication cart. |
| Resident #3's insulin orders were clarified late and direction stickers were applied after the fact. |
| Resident #4's oxycodone medication cards were mislabeled and corrected after discovery. |
| Resident #7's simvastatin medication administration time was corrected after error was identified. |
| Resident #3's insulin administration did not follow prescribed sliding scale schedule on certain dates. |
| Resident #4's mucus relief medication was administered differently than prescribed. |
| Resident #7's hydromorphone medication was not administered as prescribed on certain dates. |
| Residents #2, 3, 4, 5, and 6 were not educated on their right to refuse medication. |
| Residents #1, 3, and 9's cognitive preadmission screenings were incomplete or not done in collaboration with required professionals. |
| Resident #3's admission record lacked documentation of agreement to admission to special care unit. |
| Resident #2's medical evaluation was not completed on the Department's standardized form. |
| Resident #3's and #7's medical evaluations were not completed on the Department's standardized form. |
Report Facts
Census: 40
Total Capacity: 123
Fine Amount: 200
Fine Amount: 120
Number of Violations: 18
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Juliet Marsala | Deputy Secretary, Office of Long-term Living | Signed letter regarding license revocation and provisional license issuance |
Inspection Report
Complaint Investigation
Census: 40
Capacity: 123
Deficiencies: 8
Jul 25, 2023
Visit Reason
The inspection was conducted as a complaint and incident investigation at Northland Heights assisted living facility.
Findings
Multiple violations related to resident abuse, neglect, failure to complete criminal background checks, inadequate staff training, and deficiencies in supplemental health services and admission support plans were found. The facility's certificate of compliance was revoked and replaced with a second provisional license due to these violations.
Complaint Details
The visit was complaint-related involving allegations of resident abuse and neglect. The complaint was substantiated based on multiple violations found during the inspection.
Severity Breakdown
II: 8
Deficiencies (8)
| Description | Severity |
|---|---|
| Resident abuse involving staff making inappropriate comments and failing to properly supervise and care for a resident. | II |
| Failure to develop and implement a plan of supervision or suspend staff involved in alleged abuse incidents. | II |
| Neglect and mistreatment of a resident including verbal abuse and improper handling during care. | II |
| Failure to complete a criminal background check for a direct care staff member prior to employment. | II |
| Direct care staff providing unsupervised assisted living services without completing required 18 hours of training. | II |
| Failure to provide or arrange supplemental health services in a manner protective of resident health and safety. | II |
| Failure to complete cognitive preadmission screening within 72 hours prior to admission to special care unit. | II |
| Failure to develop and document support or rehabilitation plans within required timeframe for residents admitted to special care unit. | II |
Report Facts
Census at Inspection: 40
Total Capacity: 123
Fines Calculated: 200
Number of Violations: 15
Inspection Report
Complaint Investigation
Census: 42
Capacity: 123
Deficiencies: 2
Jun 2, 2023
Visit Reason
The inspection was conducted as a complaint investigation with an unannounced partial inspection on June 2, 2023, to review compliance with regulations and address specific complaints.
Findings
The facility was found to have multiple violations including mistreatment or abuse of residents, failure to submit and comply with an acceptable plan of correction, and specific deficiencies such as inoperable window blinds and medication administration documentation errors. A provisional license was issued due to these violations.
Complaint Details
The inspection was complaint-driven and substantiated by findings of mistreatment or abuse of residents and failure to comply with correction plans.
Deficiencies (2)
| Description |
|---|
| The blind on the window in resident #1's living unit is inoperable and will not go up. |
| Resident #1's medication administration record documented Lidocaine Patch applied at 8:00 am, but the patch was actually applied at approximately 11:20 am. |
Report Facts
License Capacity: 123
Residents Served: 42
Special Care Unit Capacity: 19
Special Care Unit Residents Served: 2
Hospice Residents: 3
Fine per violation per day: 5
Total Fine per violation per day: 210
Number of violations listed for fines: 18
Inspection Report
Complaint Investigation
Census: 44
Capacity: 123
Deficiencies: 12
May 10, 2023
Visit Reason
The inspection was conducted as a complaint and incident investigation with unannounced partial inspections on May 10 and 11, 2023.
Findings
Multiple violations were found including failure to report incidents timely, inadequate assistance with activities of daily living (ADLs), abuse/neglect by staff, lack of proper staff training on fire safety and abuse reporting, missing or incomplete medical evaluations, improper medication storage and administration, and failure to maintain updated resident assessments and support plans.
Complaint Details
The inspection was complaint-driven, triggered by incidents involving resident mistreatment, medication errors, and failure to comply with reporting requirements. The complaint was substantiated with multiple violations found.
Deficiencies (12)
| Description |
|---|
| Failure to report an incident involving resident #1 to the Department within 24 hours and medication errors not reported. |
| Resident #2 was improperly transferred and verbally abused by staff person A, who left the resident unattended on the edge of a wheelchair. |
| Direct care staff person A did not receive required fire safety orientation training on first day of employment. |
| Direct care staff person A did not receive required orientation training within 40 hours on resident rights, emergency medical plan, abuse reporting, and safe management techniques. |
| No medical evaluation completed for resident #2 within required timeframe. |
| Resident #3's previous annual medical evaluation was overdue. |
| Medication storage violation: contaminated Furosemide tablet for resident #3. |
| Expired medication (Acetaminophen) present in the facility for resident #3. |
| Medication administration record for resident #1 missing diagnosis or purpose for Acetaminophen and Cefuroxime. |
| Failure to administer prescribed Cefuroxime medication timely to resident #1 and failure to administer Trimethoprim to resident #2 due to unavailability. |
| Resident #3's most recent assessment was overdue. |
| Quarterly support plan reviews for residents #1 and #4 were not completed timely. |
Report Facts
License Capacity: 123
Census: 44
Staffing: 60
Waking Staff: 45
Special Care Unit Capacity: 19
Special Care Unit Residents Served: 2
Hospice Residents: 2
Fines per Violation: 210
Inspection Report
Renewal
Census: 46
Capacity: 123
Deficiencies: 26
Apr 4, 2023
Visit Reason
The inspection was conducted as a renewal inspection combined with complaint and incident investigations at Northland Heights assisted living residence.
Findings
The inspection identified multiple violations including failure to timely report incidents, confidentiality breaches, incomplete resident contracts, inadequate staff qualifications and training, medication management issues, fire safety deficiencies, and incomplete resident assessments and support plans. A provisional license was issued with a requirement to correct all violations.
Deficiencies (26)
| Description | Severity |
|---|---|
| Failure to post current license inspection summaries and regulations in a conspicuous place. | — |
| Incident involving missing medication cards was not reported within 24 hours. | Repeat |
| Resident records were unlocked and accessible without proper confidentiality safeguards. | Repeat |
| Resident contracts were unsigned or missing required signatures. | Repeat |
| Quality management plan did not include review of incident reporting and staff training. | — |
| Resident medication records lacked signed statements acknowledging receipt of rights and complaint procedures. | Repeat |
| Video recording in resident living areas without proper notification or consent. | — |
| Criminal background checks and administrator qualifications were incomplete or missing. | — |
| Direct care staff lacked required qualifications and training including first aid, fire safety, and dementia-specific training. | Repeat |
| Floors, walls, ceilings, windows, doors, and other surfaces were not properly maintained or clean. | — |
| Emergency telephone numbers were not posted by telephones in resident rooms. | — |
| Resident rooms lacked bedside tables or shelves. | — |
| Refrigerator/freezer lacked thermometer; food items were improperly stored or unsealed. | Repeat |
| Insufficient emergency drinking water supply for residents. | — |
| Fire extinguishers were not inspected annually and fire drills were not properly documented or conducted as required. | Repeat |
| Residents were not evacuated to designated meeting places during fire drills and alternate exit routes were not used. | Repeat |
| Resident medical evaluations were incomplete or not current. | Repeat |
| Menus were not posted one week in advance. | — |
| Expired medications and improperly stored medications were found. | Repeat |
| Medication records lacked required information including diagnosis or purpose and discontinued medications were not removed. | Repeat |
| Medications were not administered as prescribed and some medications were unavailable for administration. | Repeat |
| Staff administering medications had not completed required annual competency training. | Repeat |
| Residents were not educated on their right to refuse or question medications. | Repeat |
| Resident assessments and support plans were not completed timely or reviewed quarterly as required. | Repeat |
| Resident support plans were unsigned or lacked documentation of refusal to sign. | — |
| Cognitive preadmission screenings and admission agreement documentation for special care unit residents were incomplete or missing. | Repeat |
Report Facts
Census: 46
Total Capacity: 123
Staffing: 62
Waking Staff: 47
Fine per violation per day: 5
Total Fine per violation: 210
Number of violations fined: 18
Emergency water supply: 11
Required emergency water supply: 138
Fire drill maximum evacuation time: 201
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Colleen Roy | President/COO | Facility leadership named in licensing and enforcement correspondence |
| Lestia Fetzer | Workload Manager | Department contact for appeals and enforcement |
| Larry Mazza | Reviewer | Reviewer of plan of correction submissions |
| Theresa Hartman | Bureau Director | Copied on licensing correspondence |
| Sheila Page | Director of Operations | Copied on licensing correspondence |
| Brent Sutherland | Regional Director | Copied on licensing correspondence |
| Staff person A | Administrator | Named in violations related to criminal background check and qualifications |
| Staff person B | Direct Care Staff | Named in violations related to qualifications, training, and medication administration |
| Staff person C | Direct Care Staff | Named in violations related to training and medication administration |
| Staff person D | Direct Care Staff | Named in violations related to training, medication administration, and dementia training |
| Staff person E | Direct Care Staff | Named in violations related to training and medication administration; noted as retired |
| Staff person F | Direct Care Staff | Named in violations related to medication administration training |
| Staff person G | Direct Care Staff | Named in violations related to medication administration training |
| Staff person H | Director of Nursing | Named in medication discontinuation violation |
Inspection Report
Follow-Up
Census: 36
Capacity: 123
Deficiencies: 5
Jan 6, 2023
Visit Reason
The inspection was conducted as a follow-up review of the submitted plan of correction for the facility following an incident.
Findings
The submitted plan of correction was determined to be fully implemented. The report details multiple prior violations related to resident assessments, medical evaluations, cognitive screenings, no objection statements, and support plans, all of which have corrective actions and audits planned or completed.
Deficiencies (5)
| Description |
|---|
| Incomplete initial assessment for resident #1, missing details on eating assistance and special dietary needs. |
| Medical evaluation for resident #1 did not indicate need for dementia-related care in a secured area. |
| Resident #1 did not have a written cognitive preadmission screening completed within 72 hours prior to admission to the special care unit. |
| Resident #1's record lacked documentation of agreement by resident or family for admission to the special care unit. |
| Resident #1's support plan was not developed, implemented, and documented within 72 hours of admission to the special care unit. |
Report Facts
License Capacity: 123
Residents Served: 36
Special Care Unit Capacity: 19
Special Care Unit Residents Served: 3
Waking Staff: 38
Total Daily Staff: 51
Residents Age 60 or Older: 36
Residents with Mobility Need: 15
Inspection Report
Complaint Investigation
Census: 32
Capacity: 123
Deficiencies: 4
Nov 1, 2022
Visit Reason
The inspection was conducted as a complaint investigation with an unannounced partial review of the facility on 11/01/2022 and 11/01/2022 off-site review, to determine compliance with regulations and verify the submitted plan of correction.
Findings
The inspection found multiple deficiencies related to incident reporting, medication management, and following prescriber's orders, including failure to report a resident death within 24 hours, presence of discontinued medications on medication carts, and missed or undocumented medication administrations. Plans of correction were accepted and implemented by 12/14/2022.
Complaint Details
The inspection was triggered by a complaint, as indicated by the inspection reason. The submitted plan of correction was reviewed and determined to be fully implemented.
Deficiencies (4)
| Description |
|---|
| Failure to report the death of Resident #1 to the Department’s assisted living residence office or complaint hotline within 24 hours. |
| Discontinued medications for Resident #1 and Resident #2 were found on the residence’s medication cart. |
| Medication administration records were not properly documented; medications were found not administered and left in a medicine cup, and refusals were not documented. |
| Failure to follow prescriber's orders including missed medication administrations, unavailable medications in the home, and missed blood glucose monitoring and insulin administration for Resident #4. |
Report Facts
License Capacity: 123
Residents Served: 32
Special Care Unit Capacity: 19
Special Care Unit Residents Served: 0
Current Hospice Residents: 1
Residents Age 60 or Older: 31
Residents Diagnosed with Mental Illness: 1
Residents Diagnosed with Intellectual Disability: 1
Residents with Mobility Need: 12
Residents Receiving Supplemental Security Income: 0
Residents with Physical Disability: 0
Total Daily Staff: 44
Waking Staff: 33
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Personal Care | Director of Personal Care | Named in relation to incident reporting and medication management deficiencies and responsible for education and audits |
| Administrator | Administrator | Named in relation to incident reporting and medication management deficiencies and responsible for education and confirmation of incident report submissions |
Inspection Report
Follow-Up
Census: 23
Capacity: 123
Deficiencies: 2
Aug 11, 2022
Visit Reason
The inspection visit on 08/11/2022 was conducted as a follow-up to review the submitted plan of correction related to an incident involving alleged resident abuse and supervision violations.
Findings
The facility was found to have fully implemented the submitted plan of correction addressing allegations of resident abuse and failure to properly supervise staff. The report notes repeated violations related to abuse reporting and supervision, with corrective actions including internal investigations, reprimands, and suspension plans.
Complaint Details
The visit was complaint-related due to an allegation of abuse involving resident #1 and direct care staff person A. The allegation was substantiated with findings of failure to report abuse timely and failure to properly supervise the staff involved.
Deficiencies (2)
| Description |
|---|
| Failure to immediately report suspected abuse of a resident and comply with reporting requirements. |
| Failure to immediately develop and implement a plan of supervision or suspend the staff person involved in the alleged abuse incident. |
Report Facts
License Capacity: 123
Residents Served: 23
Special Care Unit Capacity: 19
Total Daily Staff: 29
Waking Staff: 22
Residents Age 60 or Older: 23
Residents with Mobility Need: 6
Inspection Report
Complaint Investigation
Census: 14
Capacity: 123
Deficiencies: 4
Jun 23, 2021
Visit Reason
The inspection was conducted as a complaint investigation with an unannounced partial inspection on 06/23/2021.
Findings
The inspection found multiple violations including unlocked and unattended resident records accessible in various nursing stations, improper labeling and storage of poisonous materials, uncovered trash cans in the kitchen, and improperly stored food items. Plans of correction were accepted and implemented with staff education and physical security improvements.
Complaint Details
The inspection was complaint-driven as stated under Inspection Type: Partial and Reason: Complaint.
Deficiencies (4)
| Description |
|---|
| Resident records were unlocked, unattended, and accessible in multiple areas including nurses' stations and unlocked cabinets. |
| Poisonous materials were not stored in original, labeled containers; a spray bottle labeled 'Enzyme Cleaner' was not properly labeled. |
| Trash can in the kitchen was missing the flip section of the lid, not preventing penetration of insects and rodents. |
| Food was stored improperly; an open unsealed loaf of bread was found in a metal bin with other bread products. |
Report Facts
License Capacity: 123
Residents Served: 14
Special Care Unit Capacity: 19
Special Care Unit Residents Served: 4
Hospice Residents: 1
Residents with Mobility Need: 7
Residents 60 Years or Older: 14
Residents Diagnosed with Intellectual Disability: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Personal Care | Responsible for auditing nursing stations and educating staff on confidentiality of records. | |
| Administrator | Responsible for auditing nursing stations and educating staff on confidentiality of records. | |
| Maintenance Director | Responsible for auditing chemical storage and educating staff on proper labeling of poisons. | |
| Culinary Services Director | Responsible for auditing kitchen trash cans and food storage, and educating staff on related regulations. | |
| Chef | Responsible for auditing kitchen food storage and educating staff on proper food storage. |
Inspection Report
Complaint Investigation
Census: 14
Capacity: 123
Deficiencies: 0
Apr 30, 2021
Visit Reason
The inspection was conducted as a complaint investigation during an unannounced visit on 04/30/2021.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Complaint Details
The inspection was complaint-related, but no deficiencies or regulatory citations were found, indicating no substantiated issues.
Report Facts
Residents Served: 14
License Capacity: 123
Memory Care Capacity: 19
Memory Care Residents Served: 3
Hospice Current Residents: 1
Residents Age 60 or Older: 13
Residents Diagnosed with Mental Illness: 2
Residents with Mobility Need: 4
Inspection Report
Complaint Investigation
Census: 104
Capacity: 123
Deficiencies: 9
Mar 3, 2021
Visit Reason
The inspection was conducted as a complaint investigation following allegations of resident abuse and other regulatory concerns at the facility.
Findings
The investigation found multiple violations including resident abuse by staff, failure to immediately report abuse, lack of dignity and respect towards residents, incomplete medical evaluations, improper use of bedside rails, incomplete resident support plans, and deficiencies in preadmission screening documentation.
Complaint Details
The complaint investigation was substantiated with findings of resident abuse, failure to report abuse timely, and multiple regulatory violations related to resident care and documentation.
Deficiencies (9)
| Description |
|---|
| Failure to immediately report suspected abuse of residents and staff yelling at residents, causing distress. |
| Staff did not treat residents with dignity and respect, including yelling and name-calling. |
| Medical evaluations missing timely tuberculin skin test documentation for residents. |
| Bedside rails used without physician order or inclusion in resident support plan. |
| Resident support plans incomplete or missing documentation of copies given to residents. |
| Resident assessments missing key information such as assistance needs and fall risk. |
| Final support plans not revised timely to reflect resident needs and changes. |
| Cognitive preadmission screening incomplete and undated. |
| Non-dementia resident admitted to memory care unit without proper medical evaluation within required timeframe. |
Report Facts
Inspection dates: 4
Licensed capacity: 123
Residents served: 104
Staff total daily: 109
Waking staff: 82
Residents age 60 or older: 11
Residents with mental illness: 6
Residents with mobility need: 5
Current hospice residents: 1
Inspection Report
Renewal
Capacity: 123
Deficiencies: 0
Feb 26, 2021
Visit Reason
The document is a renewal license issued in response to the facility's renewal application to operate an Assisted Living Home, with a reminder that an annual onsite inspection will be conducted within the next twelve months.
Findings
The Department has approved the renewal application and issued a regular license. The Department will conduct an onsite inspection within the next twelve months and take enforcement action if noncompliance is found.
Report Facts
Maximum capacity: 123
Special Care Unit capacity: 19
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary | Signed the renewal license letter |
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