Deficiencies per Year
8
6
4
2
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Renewal
Census: 26
Capacity: 40
Deficiencies: 4
Nov 30, 2023
Visit Reason
The inspection was conducted as a renewal and complaint investigation of the facility to assess compliance with licensing requirements and to review the submitted plan of correction.
Findings
The inspection identified multiple deficiencies including a direct care staff member lacking required documentation of a high school diploma or GED, incomplete evacuation of residents during a fire drill, incorrect posting of menus, and discrepancies in glucometer date/time settings and blood sugar readings. Plans of correction were accepted and implemented by early January 2024.
Complaint Details
The inspection included a complaint investigation component, but no substantiation status was explicitly stated in the report.
Deficiencies (4)
| Description |
|---|
| Direct care staff person did not have a high school diploma, GED, or active registry status on the Pennsylvania nurse aide registry. |
| Resident #3 was not evacuated during a fire drill conducted on 10/8/23. |
| Menus posted were not for the current week or one week in advance as required. |
| Glucometer machines showed incorrect date/time and discrepancies between glucometer readings and Medication Administration Report for Residents #1 and #2. |
Report Facts
License Capacity: 40
Residents Served: 26
Total Daily Staff: 31
Waking Staff: 23
Deficiencies cited: 4
Inspection Report
Complaint Investigation
Census: 25
Capacity: 40
Deficiencies: 0
Apr 11, 2023
Visit Reason
The inspection was conducted as a complaint investigation during an unannounced partial inspection on 04/11/2023.
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 citations were found, indicating no substantiated issues.
Report Facts
Total Daily Staff: 32
Waking Staff: 24
Residents Served: 25
License Capacity: 40
Residents Age 60 or Older: 25
Residents with Mobility Need: 7
Inspection Report
Renewal
Census: 32
Capacity: 40
Deficiencies: 5
Nov 17, 2022
Visit Reason
The inspection was conducted as a renewal and complaint investigation to review compliance and verify the submitted plan of correction.
Findings
The inspection identified several deficiencies including unlabeled batteries in the carbon monoxide alarm, uncovered trash receptacles, lint accumulation in dryers, missing vehicle registration, and medication storage and documentation issues. All deficiencies had plans of correction submitted and were implemented by January 9, 2023.
Deficiencies (5)
| Description |
|---|
| Batteries installed in the Carbon Monoxide Alarm near the kitchen were not labeled with the date they were installed. |
| Trash receptacle in the resident spa bathroom was not covered. |
| Approximately 6 inch accumulation of lint in the lint trap of dryer #2 and dryer #3. |
| The home did not have a copy of the current registration for its 2017 Toyota Bus used to transport residents. |
| Glucometer readings did not match the eMAR for Resident 1; glucometer was not calibrated to the correct date and time. Medication discrepancies found for Residents 1 and 2. |
Report Facts
Residents Served: 32
License Capacity: 40
Staffing Hours: 43
Staffing Hours: 32
Current Residents: 2
Residents Age 60 or Older: 32
Residents with Intellectual Disability: 1
Residents with Mobility Need: 11
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Named in multiple findings related to battery replacement, trash receptacle lid placement, lint cleaning, and vehicle registration handling | |
| Clinical Director | LPN | Named in medication storage and glucometer calibration deficiencies |
| Housekeeping Supervisor | Named in lint removal and dryer safety training | |
| Executive Director | Contacted owner to obtain vehicle registration |
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