Inspection Report
Follow-Up
Census: 45
Capacity: 58
Deficiencies: 3
Sep 9, 2025
Visit Reason
The inspection was a partial, unannounced visit conducted due to an incident at the facility.
Findings
The facility was found to have deficiencies related to failure to immediately report suspected resident abuse, failure to timely report a serious injury incident, and incomplete resident assessments. The submitted plan of correction was accepted and fully implemented, with ongoing audits and staff training to ensure compliance.
Deficiencies (3)
| Description |
|---|
| Failure to immediately report suspected abuse of a resident involving an incident causing bruising. |
| Failure to report a serious injury fall incident to the Department within the required 24-hour timeframe. |
| Resident assessment did not include information for hearing, communication, or olfactory needs as required. |
Report Facts
License Capacity: 58
Residents Served: 45
Secured Dementia Care Unit Capacity: 24
Secured Dementia Care Unit Residents Served: 13
Residents Age 60 or Older: 44
Residents with Mental Illness: 2
Residents with Mobility Need: 25
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Administrator | Reviewed abuse report and incident documentation; responsible for compliance and audits. |
| Wellness Director | Wellness Director | Designee involved in reviews, training, audits, and compliance related to abuse reporting and incident management. |
Inspection Report
Census: 45
Capacity: 58
Deficiencies: 0
Jun 17, 2025
Visit Reason
The inspection was a partial, announced licensing inspection conducted as an interim review of the facility.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Residents Served: 45
License Capacity: 58
Secured Dementia Care Unit Capacity: 13
Secured Dementia Care Unit Residents Served: 11
Residents Age 60 or Older: 44
Residents with Mental Illness: 2
Residents with Mobility Need: 25
Inspection Report
Census: 45
Capacity: 58
Deficiencies: 0
Jun 10, 2025
Visit Reason
The inspection was conducted as a partial, unannounced visit due to an incident at the facility on 06/10/2025 and 06/11/2025.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
License Capacity: 58
Residents Served: 45
Secured Dementia Care Unit Capacity: 13
Secured Dementia Care Unit Residents Served: 11
Resident Support Staff: 0
Total Daily Staff: 67
Waking Staff: 50
Residents Age 60 or Older: 45
Residents with Mobility Need: 22
Inspection Report
Renewal
Census: 41
Capacity: 58
Deficiencies: 4
May 8, 2025
Visit Reason
The inspection was conducted as a renewal inspection of the facility's license, with an unannounced full inspection on 05/08/2025 and a follow-up plan of correction submission.
Findings
The inspection identified several deficiencies including unlabeled and undated leftover food, uncovered food storage, missing rabies vaccination documentation for a dog on site, and an inaccurate glucometer reading transcription. Plans of correction were accepted and implemented by 06/03/2025 with policies updated and staff training conducted to ensure compliance.
Deficiencies (4)
| Description |
|---|
| Unlabeled and undated leftover food in a Styrofoam cup found in the kitchenette refrigerator. |
| Uncovered open cardboard container of pretzel bites found in the kitchenette refrigerator. |
| Missing wellness or rabies vaccination information for a small chihuahua type dog present in the facility. |
| The 8 a.m. glucometer reading for Resident 1 on 5/6/25 was 96 but transcribed in the Medication Administration Record as 98. |
Report Facts
License Capacity: 58
Residents Served: 41
Secured Dementia Care Unit Capacity: 13
Secured Dementia Care Unit Residents Served: 11
Hospice Residents: 2
Residents 60 Years or Older: 52
Residents Diagnosed with Mental Illness: 2
Residents with Mobility Need: 22
Total Daily Staff: 63
Waking Staff: 47
Inspection Report
Follow-Up
Census: 37
Capacity: 58
Deficiencies: 2
Oct 23, 2024
Visit Reason
The visit was an unannounced partial inspection conducted as a follow-up to verify the implementation of a previously submitted plan of correction.
Findings
The facility was found to have fully implemented the plan of correction related to fire alarm false alarms and resident support plan documentation for evacuation needs and mobility. Compliance with applicable health and safety laws was addressed, including replacement of faulty smoke detectors and updating resident evacuation plans.
Deficiencies (2)
| Description |
|---|
| Violation due to second false alarm since 07/29/2023, resulting in a monetary fine for violation of Moosic Borough’s Chapter 72, section 72-2 B (2), relating to Alarms. |
| Resident support plan did not document evacuation needs properly; resident required verbal cueing to safely evacuate during fire drills but plan stated 'N/A'. |
Report Facts
License Capacity: 58
Residents Served: 37
Secured Dementia Care Unit Capacity: 12
Residents Served in Dementia Unit: 6
Waking Staff: 37
Total Daily Staff: 49
False Alarm Date: 2
Inspection Report
Census: 39
Capacity: 58
Deficiencies: 0
Sep 19, 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
License Capacity: 58
Residents Served: 39
Secured Dementia Care Unit Capacity: 12
Secured Dementia Care Unit Residents Served: 5
Total Daily Staff: 53
Waking Staff: 40
Resident Support Staff: 0
Residents 60 Years or Older: 58
Residents with Mobility Need: 14
Inspection Report
Complaint Investigation
Census: 35
Capacity: 58
Deficiencies: 16
Sep 4, 2024
Visit Reason
The inspection was conducted as a complaint, provisional, and incident investigation with an unannounced full licensing inspection on September 4, 2024.
Findings
The facility was found to have multiple deficiencies including issues with record confidentiality, compliance with laws, contract signatures, staff training, emergency telephone postings, food labeling and storage, medical evaluations, medication labeling and availability, resident rights education, support plan accuracy, and key-locking device instructions. All deficiencies had plans of correction accepted and were verified as implemented by October 30, 2024.
Complaint Details
The inspection was complaint-related, provisional, and incident-based, with a follow-up plan of correction submission required. The complaint was substantiated as deficiencies were found and corrected.
Deficiencies (16)
| Description |
|---|
| Medication administration records were left unattended on a medication cart, violating record confidentiality. |
| Carbon monoxide detector batteries were not dated as required by law. |
| Resident contracts were not signed by residents. |
| Staff person did not complete required training within 40 scheduled working hours. |
| Emergency telephone numbers were not posted near a telephone in Willow House. |
| Unlabeled and undated food items found in kitchen refrigerator and freezer. |
| Refrigerators in Oak and Willow sections lacked thermometers. |
| Resident medical evaluation form was not completed timely. |
| Resident medical evaluation missing height and pulse rate. |
| First aid kit in facility vehicle lacked a thermometer. |
| Medication label for Resident #1 did not match medication administration record. |
| Over-the-counter medications in medication carts were not labeled with resident names. |
| PRN medication for Resident #6 was not available in the home at time of inspection. |
| Resident education on right to refuse or question medications was not documented for Residents #2 and #4. |
| Resident #2's support plan did not reflect need for verbal cuing during emergency evacuation. |
| Electronic lock gate in secured dementia unit courtyard lacked posted operating instructions. |
Report Facts
License Capacity: 58
Residents Served: 35
Residents Served in Secured Dementia Care Unit: 5
Staffing Hours: 46
Waking Staff: 35
Residents with Mobility Need: 11
Deficiency Count: 16
Inspection Report
Complaint Investigation
Census: 35
Capacity: 58
Deficiencies: 16
Sep 4, 2024
Visit Reason
The inspection was conducted as a full, unannounced visit due to complaint, provisional, and incident reasons.
Findings
The inspection identified multiple deficiencies including record confidentiality breaches, compliance with health and safety laws, contract signature issues, staff training deficiencies, emergency telephone number postings, food labeling and storage violations, medical evaluation documentation issues, medication labeling and availability problems, resident rights education gaps, support plan inaccuracies, and missing instructions for key locking devices. All deficiencies had plans of correction accepted and were implemented by late October 2024.
Complaint Details
The inspection was complaint-related, provisional, and incident-based as stated in the inspection information section.
Deficiencies (16)
| Description |
|---|
| Medication administration records left unattended on medication cart. |
| Carbon monoxide detector batteries not dated or changed as required. |
| Resident contracts not signed by residents. |
| Staff person did not complete required emergency medical plan and reportable incidents training within 40 hours. |
| Emergency telephone numbers not posted near phone in Willow House. |
| Unlabeled and undated food items in kitchen refrigerator and freezer. |
| Refrigerators in Oak and Willow sections lacked thermometers. |
| Resident medical evaluation form not completed timely. |
| Resident medical evaluation missing height and pulse rate. |
| First aid kit in facility vehicle missing thermometer. |
| Resident medication label did not match medication administration record. |
| Over the counter medications not labeled with resident's name. |
| Prescribed PRN medications not available in the home at time of inspection. |
| Resident education on right to refuse or question medications not documented. |
| Resident support plan did not reflect need for verbal cuing during emergency evacuation. |
| Instructions for operating electronic lock on secured dementia unit gate not posted. |
Report Facts
License Capacity: 58
Residents Served: 35
Secured Dementia Care Unit Capacity: 35
Secured Dementia Care Unit Residents Served: 5
Total Daily Staff: 46
Waking Staff: 35
Residents 60 Years or Older: 35
Residents Diagnosed with Mental Illness: 1
Residents with Mobility Need: 11
Inspection Report
Census: 35
Capacity: 58
Deficiencies: 0
Aug 7, 2024
Visit Reason
The inspection was conducted as a licensing inspection by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing, triggered by an incident.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Residents Served: 35
License Capacity: 58
Secured Dementia Care Unit Capacity: 12
Secured Dementia Care Unit Residents Served: 5
Current Hospice Residents: 1
Residents Age 60 or Older: 35
Residents with Mental Illness: 1
Residents with Mobility Need: 10
Inspection Report
Follow-Up
Census: 30
Capacity: 58
Deficiencies: 6
Jul 2, 2024
Visit Reason
The inspection was a partial, unannounced follow-up visit triggered by an incident to review the submitted plan of correction and verify compliance.
Findings
The facility was found to have multiple violations related to resident abuse reporting, staff sleeping on duty, treatment of residents with dignity and respect, awake staff requirements, and incomplete resident support plans. The submitted plan of correction was fully implemented and compliance was maintained.
Deficiencies (6)
| Description |
|---|
| Failure to immediately report suspected abuse of a resident, specifically staff sleeping in a resident's bed overnight. |
| Failure to immediately develop and implement a plan of supervision or suspend staff involved in alleged abuse. |
| Failure to report the incident or condition to the Department within 24 hours as required. |
| Resident was treated without dignity and respect when staff fell asleep in resident's bed overnight. |
| Direct care staff were not awake at all times during shifts when residents were present; staff was observed sleeping on duty. |
| Resident support plan did not document required medical and behavioral care services or plans to meet these needs. |
Report Facts
Residents served: 30
License capacity: 58
Residents served in secured dementia care unit: 6
Capacity of secured dementia care unit: 12
Current hospice residents: 3
Staffing hours - Total Daily Staff: 46
Staffing hours - Waking Staff: 35
Inspection Report
Follow-Up
Census: 32
Capacity: 58
Deficiencies: 3
May 9, 2024
Visit Reason
The inspection was a partial, unannounced follow-up visit conducted on 05/09/2024 to review the submitted plan of correction related to an incident and fine.
Findings
The submitted plan of correction was determined to be fully implemented as of the inspection date. The report details incidents involving resident abuse and treatment violations, as well as deficiencies related to support plan signatures, all of which had corrective actions directed and implemented.
Deficiencies (3)
| Description |
|---|
| Resident was pushed by another resident causing a fall and injury, violating abuse prevention requirements. |
| Resident was hit on the head with a small plant by another resident, violating treatment with dignity and respect requirements. |
| Initial RASP support plans for residents were not signed by the person who completed the assessments. |
Report Facts
License Capacity: 58
Residents Served: 32
Residents Served in Secured Dementia Care Unit: 12
Current Hospice Residents: 4
Resident Mobility Need: 15
Total Daily Staff: 47
Waking Staff: 35
Inspection Report
Complaint Investigation
Census: 36
Capacity: 58
Deficiencies: 20
Feb 16, 2024
Visit Reason
The inspection was conducted as a complaint investigation with a provisional, incident, and interim reason on 02/16/2024.
Findings
Multiple violations were found including failure to post inspection summaries, confidentiality breaches, lack of quality management meetings, privacy violations, inadequate staff training, medication administration errors, fire safety deficiencies, and incomplete resident assessments and support plans. Plans of correction were directed for all violations with deadlines mostly set for 04/27/2024.
Complaint Details
The complaint investigation included incidents of resident aggression, medication errors, failure to report incidents timely, and deficiencies in resident care plans and staff training. Several repeat violations were noted from previous inspections.
Deficiencies (20)
| Description |
|---|
| The home did not have the License inspection summary reports dated 5/31/23 and 11/27/23 posted conspicuously in the home as required. |
| The LIS dated 8/18/23 was posted with the privacy coding sheet attached to it, revealing confidential resident information. |
| The home did not have documentation that a Quality management meeting was held to review the topics required under this regulation in 2023. |
| Resident #1 was recorded falling in a hallway where cameras are not permitted to record. |
| No staff present with current First aid/CPR training during specified shifts. |
| Staff persons did not have required 40-hour orientation training within 40 scheduled working hours. |
| Staff person C did not have 12 hours of documented annual training for 2023. |
| Staff person C did not have required training topics included in annual training for 2023. |
| Hot water temperature in resident room Willow #1 bathroom measured 124.1°F, exceeding the 120°F limit. |
| First aid kit was missing tweezers, a thermometer, and a CPR breathing shield. |
| The home did not conduct a required sleeping hour fire drill six months after the last drill in June 2023. |
| Cigarette butts observed on the ground mixed with dried leaves in the outdoor designated smoking area. |
| Staff persons administering medications without being certified to do so. |
| Resident #2 did not receive the 1pm dose of Tylenol 500 mg as ordered; medication was found in a cup later. |
| Pharmacy label on Resident #3's insulin pen did not match the prescribed dosage. |
| Resident #2's ordered medication Dextromethorphan ER was not available when needed. |
| Resident #2's medication administration record had incorrect staff initials and missing sliding scale insulin documentation. |
| Resident #2 had an incident of aggression not documented in the support plan. |
| Residents requiring secure dementia care were not residing in a secure dementia area at the time of inspection. |
| Staff person C did not receive 6 hours of dementia-related training during the 2023 training year. |
Report Facts
License Capacity: 58
Residents Served: 36
Staffing Hours - Total Daily Staff: 41
Staffing Hours - Waking Staff: 31
Correction Dates: 2024
Fine Amounts: 108
Fine Amounts: 180
Fine Amounts: 180
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff Person C | Named in findings related to medication administration without certification, lack of required training hours, and dementia training deficiencies. | |
| Staff Person E | Named in medication administration without certification and medication error findings. | |
| Staff Person F | Named in medication administration without certification. | |
| Staff Person G | Named in medication administration without certification. | |
| Wellness Director | Responsible for multiple corrective actions including medication administration training, audits, privacy training, and incident reporting. | |
| Administrator | Responsible for compliance oversight, training, audits, and corrective action implementation. | |
| Business Office Manager | Responsible for staff training compliance and medication administration oversight. | |
| Director of Maintenance | Responsible for fire drill compliance and privacy camera removal. |
Inspection Report
Complaint Investigation
Census: 36
Capacity: 58
Deficiencies: 19
Feb 16, 2024
Visit Reason
The inspection was a complaint investigation conducted on February 16, 2024, to review compliance with regulations and address multiple complaints and incidents at Oakwood Terrace.
Findings
The inspection identified numerous violations including failure to post inspection summaries, confidentiality breaches, inadequate quality management meetings, privacy violations, lack of CPR trained staff on certain shifts, incomplete staff training, hot water temperature exceeding limits, missing first aid kit items, failure to conduct required fire drills, unsafe smoking area conditions, medication administration and documentation errors, incomplete medical evaluations, and deficiencies in resident support plans and assessments.
Complaint Details
The complaint investigation included incidents of resident falls, medication errors, abuse allegations, privacy violations, and failure to report incidents timely. Several repeat violations were noted from prior inspections.
Deficiencies (19)
| Description |
|---|
| The home did not have the License inspection summary reports dated 5/31/23 and 11/27/23 posted conspicuously. |
| The LIS dated 8/18/23 was posted with privacy coding sheet attached, revealing confidential resident information. |
| The home did not have documentation that a Quality management meeting was held to review required topics in 2023. |
| Resident #1 fell backwards in hallway; camera footage was reviewed showing recording in common areas, which is prohibited. |
| No staff present with current First aid/CPR training during specified shifts on multiple dates. |
| Staff persons did not have required training within 40 hours of hire and annual training requirements were not met. |
| Hot water temperature in resident bathroom measured 124.1°F, exceeding the 120°F limit. |
| First aid kit missing tweezers, thermometer, and CPR breathing shield. |
| Sleeping hour fire drill not conducted within required 6-month interval. |
| Cigarette butts observed in outdoor designated smoking area, creating fire hazard. |
| Multiple staff administering medications without proper certification or incomplete medication administration observations. |
| Resident #2 did not receive ordered Tylenol 1pm dose; medication found in drawer but MAR was initialed. |
| Resident #3 insulin pen label did not match prescribed dosage. |
| Resident #2 medication (Dextromethorphan ER) not available when needed. |
| Medication records had errors including wrong medication initialed and incomplete documentation of insulin units. |
| Resident #2 missed doses of Tylenol and Eliquis due to medication not being on hand. |
| Resident #9's support plan not updated to reflect aggression incident and care needs. |
| Residents with secured dementia care DMEs not residing in secure unit at time of inspection. |
| Staff person C did not receive required 6 hours dementia training during 2023. |
Report Facts
License Capacity: 58
Residents Served: 36
Staffing Hours: 41
Waking Staff: 31
Secure Dementia Care Unit Capacity: 13
Residents Served in Secure Unit: 0
Fine Amounts: 468
Correction Timeframes: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Juliet Marsala | Deputy Secretary | Signed enforcement and licensing letters. |
| Wellness Director | Named in multiple findings related to medication errors, staff training, incident reporting, and quality management. | |
| Administrator | Named in multiple findings related to compliance, incident reporting, staff training, and quality management. | |
| Business Office Manager | Responsible for staff training compliance and medication administration oversight. | |
| Director of Maintenance | Responsible for fire drill compliance, hot water temperature, and smoking area maintenance. | |
| Staff Person A | Witnessed resident abuse incident. | |
| Staff Person C | Named in medication administration and training deficiencies. | |
| Staff Person E | Named in medication administration deficiencies. | |
| Staff Person F | Named in medication administration deficiencies. | |
| Staff Person G | Named in medication administration deficiencies. |
Inspection Report
Complaint Investigation
Census: 36
Capacity: 58
Deficiencies: 19
Feb 16, 2024
Visit Reason
The inspection was conducted as a complaint investigation with a provisional, incident, and interim reason, including a full unannounced inspection on 02/16/2024.
Findings
Multiple deficiencies were found including failure to post inspection summaries, confidentiality breaches, lack of quality management meetings, privacy violations, inadequate staff training including CPR and abuse reporting, medication administration errors, unsafe hot water temperature, incomplete first aid kits, failure to conduct required fire drills, smoking area hazards, and incomplete or inaccurate resident assessments and support plans.
Complaint Details
The complaint investigation included incidents of resident-to-resident abuse, failure to report incidents timely, medication errors, and deficiencies in resident care plans and staff training. Substantiation status is not explicitly stated.
Deficiencies (19)
| Description |
|---|
| The home did not have the License inspection summary (LIS) reports dated 5/31/23 and 11/27/23 posted conspicuously in the home as required. |
| The LIS dated 8/18/23 was posted with the privacy coding sheet attached to it, revealing confidential resident information. |
| The home did not have documentation that a Quality management meeting was held to review required topics in 2023. |
| Resident #1 fell backwards in a hallway that was recorded by a camera, violating privacy regulations. |
| No staff present with current First aid/CPR training during multiple shifts. |
| Staff persons did not have required orientation and annual training hours. |
| Hot water temperature in resident room Willow #1 bathroom measured 124.1°F, exceeding the 120°F limit. |
| First aid kit missing tweezers, thermometer, and CPR breathing shield. |
| No sleeping hour fire drill conducted within required 6-month period. |
| Cigarette butts observed in outdoor designated smoking area. |
| Staff administering medications without proper certification and insufficient medication administration observations. |
| Resident #2 did not receive prescribed Tylenol 500 mg dose at 1pm; medication found in medication cart later. |
| Resident #3's insulin pen label did not match prescribed dosage. |
| Resident #2's prescribed medication Dextromethorphan ER was not available when needed. |
| Medication administration errors including wrong medication initials on MAR and incomplete documentation of sliding scale insulin units. |
| Resident #2 and #9 did not receive prescribed medications due to unavailability; medication errors not reported to prescriber or resident. |
| Resident #9's support plan not updated to reflect incident of aggression and related care interventions. |
| Resident #4 through #8 had documentation indicating need for secured dementia care but were not residing in secured unit at time of inspection. |
| Staff person C did not receive required 6 hours of dementia-related training during 2023. |
Report Facts
License Capacity: 58
Residents Served: 36
Staffing Hours: 41
Waking Staff: 31
Deficiency Counts: 17
Fine Amounts: 108
Fine Amounts: 180
Fine Amounts: 180
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Juliet Marsala | Deputy Secretary | Signed enforcement and licensing letters. |
| Wellness Director | Named in multiple findings related to medication administration, staff training, incident reporting, and quality management. | |
| Administrator | Named in multiple findings related to compliance, incident reporting, staff training, and quality management. | |
| Business Office Manager | Named in findings related to staff training and medication administration. | |
| Director of Maintenance | Named in findings related to privacy camera removal, hot water temperature, and smoking area maintenance. | |
| Staff Person A | Witnessed resident abuse incident. | |
| Staff Person C | Named in findings related to medication administration and training deficiencies. | |
| Staff Person E | Named in medication administration deficiencies. | |
| Staff Person F | Named in medication administration deficiencies. | |
| Staff Person G | Named in medication administration deficiencies. |
Inspection Report
Complaint Investigation
Census: 36
Capacity: 58
Deficiencies: 19
Feb 16, 2024
Visit Reason
The inspection was a full, unannounced visit conducted on 02/16/2024 as a provisional, incident, and interim inspection to review compliance with Personal Care Homes regulations.
Findings
Multiple deficiencies were found including failure to post inspection summaries, confidentiality breaches, lack of quality management meetings, privacy violations, inadequate staff training including CPR and abuse reporting, medication administration errors, fire safety violations, and incomplete resident assessments and support plans.
Complaint Details
The complaint investigation conducted on 02/07/2024 found multiple violations including failure to report serious incidents timely, abuse incidents, confidentiality breaches, incomplete assessments and support plans, and medication errors. Follow-up submissions and enforcement actions were ongoing.
Deficiencies (19)
| Description |
|---|
| The home did not have the License inspection summary (LIS) reports dated 5/31/23 and 11/27/23 posted conspicuously in the home as required. |
| The LIS dated 8/18/23 was posted with the privacy coding sheet attached to it, revealing confidential resident information. |
| The home did not have documentation that a Quality management meeting was held to review required topics in 2023. |
| Resident #1 fell backwards in a hallway that was recorded by a camera, violating privacy regulations. |
| No staff present with current First Aid/CPR training during multiple shifts. |
| Staff persons did not have required annual training hours or training on required topics. |
| Hot water temperature in resident room Willow #1 bathroom measured 124.1°F, exceeding the 120°F limit. |
| First aid kit was missing tweezers, a thermometer, and a CPR breathing shield. |
| The home did not conduct a required fire drill during sleeping hours within the last 6 months. |
| Cigarette butts observed in the outdoor designated smoking area. |
| Multiple staff administering medications without proper certification or training. |
| Resident #2 did not receive prescribed Tylenol 500 mg dose at 1pm; medication was found in medication cart later. |
| Resident #3's insulin pen label did not match the prescribed dosage. |
| Resident #2's medication Dextromethorphan ER was not available when needed. |
| Resident #2's medication administration records had incorrect staff initials and missing documentation of sliding scale insulin units. |
| Resident #2 did not receive prescribed Tylenol and Eliquis doses due to medication not being on hand. |
| Resident #9's support plan was not updated to reflect an incident of aggression and did not include a plan to address behaviors. |
| Resident #4-8 had documentation indicating need for secured dementia care but were not residing in a secure unit at inspection time. |
| Staff person C did not receive 6 hours of dementia-related training during 2023. |
Report Facts
License Capacity: 58
Residents Served: 36
Staffing Hours: 41
Waking Staff: 31
Deficiency Counts: 19
Correction Dates: 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Juliet Marsala | Deputy Secretary | Signed enforcement and licensing letters related to the facility. |
| Wellness Director | Named in multiple findings related to medication administration, staff training, incident reporting, and quality management. | |
| Administrator | Named in multiple findings related to compliance oversight, staff training, incident reporting, and quality management. | |
| Business Office Manager | Named in findings related to staff training and medication administration compliance. | |
| Director of Maintenance | Named in findings related to privacy camera removal and maintenance of smoking area. |
Inspection Report
Census: 37
Capacity: 58
Deficiencies: 0
Dec 4, 2023
Visit Reason
The inspection was conducted as a partial, unannounced visit for complaint and monitoring reasons.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Total Daily Staff: 58
Waking Staff: 44
Residents Served: 37
License Capacity: 58
Current Residents in Hospice: 7
Residents Age 60 or Older: 37
Residents with Mobility Need: 21
Inspection Report
Follow-Up
Census: 37
Capacity: 58
Deficiencies: 1
Nov 27, 2023
Visit Reason
The inspection visit on 11/27/2023 was a partial, unannounced follow-up to review the submitted plan of correction related to an incident.
Findings
The submitted plan of correction was determined to be fully implemented, with continued compliance required. The report details a repeated violation involving resident-to-resident altercation and outlines corrective actions including updated resident assessments and increased supervision.
Deficiencies (1)
| Description |
|---|
| Resident became argumentative with another resident, escalating to an attempt to shove and hit with a walker. Repeat violation from 3/30/23. |
Report Facts
License Capacity: 58
Residents Served: 37
Current Hospice Residents: 7
Residents Age 60 or Older: 37
Residents with Mobility Need: 21
Inspection Report
Enforcement
Census: 48
Capacity: 58
Deficiencies: 8
Aug 18, 2023
Visit Reason
The inspection was conducted as a licensing inspection by the Pennsylvania Department of Human Services, Bureau of Human Services Licensing, including a follow-up enforcement review related to violations found during inspections on May 31, 2023, and August 18, 2023.
Findings
Multiple violations were found related to medical evaluations, medication labeling and administration, storage procedures, prescriber order compliance, and resident assessments. The facility's certificate of compliance was revoked and replaced with a first provisional license contingent on correction of violations. Directed plans of correction were issued with deadlines for compliance.
Severity Breakdown
Class III: 8
Deficiencies (8)
| Description | Severity |
|---|---|
| The DME for Resident #1 was not signed by the physician who completed the evaluation; Resident #2's DME did not indicate ability to self-administer medications. | Class III |
| Resident #4's prescribed Lispro Insulin Kwik pen medication was not dated or initialed when opened. | Class III |
| A bottle of Calcium Citrate + Vitamin D for Resident # Maureen Coren was not properly labeled with the resident's name. | Class III |
| Resident #5 glucometer readings were inconsistent with MAR documentation; Resident #6's prescribed Nystatin cream was not available though MAR indicated administration. | Class III |
| Resident #6's Metformin HCL medication was not initialed on the MAR to indicate administration on 8/2/23 at 8:00pm. | Class III |
| Resident #3's Pre-Admission Screening form did not indicate if the home can meet the resident's needs. | Class III |
| Initial assessments (RASP) for Residents #2 and #3 were not dated to indicate completion. | Class III |
| Resident #1's last annual RASP was dated 5/3/22; an annual RASP had not been completed (repeated violation). | Class III |
Report Facts
License Capacity: 58
Residents Served: 48
Staffing Hours: 74
Waking Staff: 56
Fine per Violation per Day: 3
Fine Calculated per Violation: 144
Mandated Correction Days: 15
Inspection Report
Renewal
Census: 44
Capacity: 58
Deficiencies: 21
May 31, 2023
Visit Reason
The inspection was a renewal and incident-related visit conducted on May 31, 2023, to assess compliance with licensing regulations and investigate incidents at Oakwood Terrace.
Findings
The inspection identified multiple violations including failure to post current licenses, delayed incident reporting, lack of quality management plan documentation, abuse incident involving residents, privacy concerns with video recording, staff qualification and training deficiencies, medication management issues, incomplete medical evaluations and assessments, and food storage violations. Plans of correction were accepted for all findings with various implementation statuses.
Deficiencies (21)
| Description |
|---|
| Failure to post the most recent Licensing Inspection Summaries and regulation book in a conspicuous place. |
| Delayed reporting of a narcotic administration incident to the Department. |
| Lack of documentation of an annual quality management plan review within the past 12 months. |
| Resident #2 was physically abused by Resident #3 resulting in a fractured hip. |
| No signs posted to inform residents or visitors of video recording in common hallways and entrances. |
| Direct care staff person C lacked documentation of required education and training within required timeframes. |
| Direct care staff persons E and F did not receive required annual training topics for 2022. |
| Food stored in unsealed containers in the walk-in freezer. |
| Local fire department notification letter did not indicate licensed capacity and resident mobility status was inaccurate. |
| Resident #4 lacked a medical evaluation within 60 days prior or 30 days after admission. |
| Resident #3's medical evaluation did not include immunization history or medication self-administration ability. |
| Residents #2 and #5 did not have annual medical evaluations completed in 2022. |
| Weekly menus were not posted in a conspicuous and public place at time of inspection. |
| Resident #5 had expired medication and Resident #6 had discontinued medication left in the medication cart. |
| Failure to follow safe storage and administration procedures for medications; missing PRN medications and inaccurate glucometer readings documentation. |
| Medication Administration Records for residents #3, #5, and #6 lacked diagnosis or purpose for medications. |
| Resident #3 was missing prescribed medication (Nystatin cream). |
| Staff person F did not receive required diabetic training through a Department-approved program. |
| Pre-admission screening form for Resident #1 did not indicate the name of the admitting Personal Care Home. |
| Resident #4 did not have an initial resident assessment completed within 15 days of admission; Resident #3's initial assessment was late. |
| Resident #5 did not have an annual resident assessment completed until after the due date. |
Report Facts
License Capacity: 58
Residents Served: 44
Staffing Hours: 87
Waking Staff: 65
Residents with Mobility Need: 43
Residents Age 60 or Older: 43
Current Residents on Hospice: 9
Fine Per Resident Per Day: 3
Fine Calculated: 144
Mandated Correction Days: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff Person B | Failed to initial narcotic administration and did not follow proper medication procedures. | |
| Staff Person A | Provided information about video recording in common areas. | |
| Staff Person C | Lacked documentation of education, training, and initial direct care training; scheduled for retraining. | |
| Staff Person F | Did not receive required annual training and diabetic training; scheduled for completion. | |
| Resident #1 | Subject of narcotic administration incident and pre-admission screening form violation. | |
| Resident #2 | Victim of abuse resulting in fractured hip. | |
| Resident #3 | Perpetrator of abuse; medication and medical evaluation deficiencies noted. | |
| Resident #4 | Missing medical evaluation and initial resident assessment within required timeframes. | |
| Resident #5 | Medication and annual medical evaluation deficiencies. | |
| Resident #6 | Medication management deficiencies including discontinued medication left on cart. | |
| Administrator | Administrator | Responsible for oversight, education, and implementation of corrective actions. |
| Wellness Director | Wellness Director | Involved in medication management, incident reporting, and staff training. |
| QA RN | Quality Assurance Registered Nurse | Responsible for quality management plan and staff education. |
| HR Director | Human Resources Director | Responsible for staff hiring documentation and training compliance. |
| Dietary Director | Dietary Director | Responsible for food storage compliance and staff education. |
Inspection Report
Follow-Up
Census: 41
Capacity: 58
Deficiencies: 6
Mar 30, 2023
Visit Reason
The visit was a partial, unannounced inspection conducted due to an incident at the facility.
Findings
The submitted plan of correction was determined to be fully implemented. Deficiencies involved timely reporting of incidents, treatment of residents with dignity, annual medical evaluations, prohibition of restraints, additional assessments, and support plan signatures.
Deficiencies (6)
| Description |
|---|
| Failure to report an incident to the Department's personal care home complaint hotline within 24 hours. |
| Resident was not treated with dignity and respect, resulting in hospitalization. |
| Annual medical evaluation documentation was not current for a resident. |
| Prohibited use of restraint by wrapping a resident's hood around their wheelchair handle. |
| Resident did not have a current additional assessment (RASP) updated as required. |
| Support plan signatures were missing for a resident's RASP. |
Report Facts
License Capacity: 58
Residents Served: 41
Current Hospice Residents: 5
Residents Age 60 or Older: 39
Total Daily Staff: 82
Waking Staff: 62
Inspection Report
Follow-Up
Census: 38
Capacity: 58
Deficiencies: 2
Jan 18, 2023
Visit Reason
The inspection was a partial, unannounced follow-up visit 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 abuse reporting and resident abuse incidents. The report details two repeat violations involving failure to report abuse timely and physical abuse by a staff member, both of which have been addressed with staff coaching, suspension, termination, and ongoing quality assurance measures.
Complaint Details
The visit was related to an incident complaint. The plan of correction was accepted and fully implemented. The report does not explicitly state substantiation status but indicates corrective actions were taken.
Deficiencies (2)
| Description |
|---|
| Failure to report an incident of abuse within 24 hours as required. |
| Resident was physically abused by a staff member who hit the resident multiple times and made inappropriate verbal statements. |
Report Facts
License Capacity: 58
Residents Served: 38
Current Hospice Residents: 5
Number of times resident was hit: 5
Inspection Report
Follow-Up
Census: 45
Capacity: 58
Deficiencies: 4
Nov 3, 2022
Visit Reason
The inspection was a partial, unannounced follow-up visit 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 resident abuse reporting, incident reporting, and updating resident support plans. The violations involved delayed reporting of resident abuse and incomplete updates to resident support plans, all of which were corrected by the follow-up date.
Deficiencies (4)
| Description |
|---|
| Failure to immediately report suspected abuse of a resident to the local area agency on aging. |
| Failure to submit an incident report to the Department within 24 hours regarding resident abuse. |
| Resident abuse resulting in physical injury (broken right humerus) due to resident pushing another resident. |
| Resident support plan (RASP) not updated to reflect current aggressive behaviors and management strategies. |
Report Facts
License Capacity: 58
Residents Served: 45
Secured Dementia Care Unit Capacity: 13
Secured Dementia Care Unit Residents Served: 0
Hospice Residents: 7
Resident Mobility Need: 26
Resident Age 60 or Older: 45
Resident Abuse Incident Date: 1
Inspection Report
Renewal
Census: 42
Capacity: 58
Deficiencies: 7
Aug 23, 2022
Visit Reason
The inspection was conducted as a renewal and incident review of the Oakwood Terrace facility on 08/23/2022 and 08/24/2022.
Findings
The submitted plan of correction was found to be fully implemented. Several deficiencies were identified related to soap dispensers, locking devices, fire drill scheduling, medication storage and labeling, prescriber order compliance, and resident record content, all of which were addressed with corrective actions and accepted plans of correction.
Deficiencies (7)
| Description |
|---|
| An unlabeled bar of soap was found in the shared shower room located on the pine house area of the facility. |
| The home had a pad lock used to lock the exterior patio exit gate near the Pine house patio, preventing immediate egress in an emergency. |
| Fire drills were routinely conducted during the last week of each month, not on different days and times as required. |
| Resident #1’s medication was not dated when opened. |
| Resident #1’s blood glucose record indicated a reading on a date/time when the glucometer had no reading; the glucometer was not available in an emergency. |
| Resident #1’s medication was not dated when opened, violating prescriber order compliance. |
| Records of Residents #2 and #3 did not indicate any identifiable marks if any. |
Report Facts
License Capacity: 58
Residents Served: 42
Current Residents: 5
Total Daily Staff: 75
Waking Staff: 56
Inspection Report
Routine
Deficiencies: 0
Jun 13, 2022
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 were identified as a result of this inspection.
Inspection Report
Routine
Deficiencies: 0
May 25, 2022
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 were identified as a result of this inspection.
Inspection Report
Follow-Up
Census: 39
Capacity: 58
Deficiencies: 5
Apr 7, 2022
Visit Reason
The inspection was a partial, unannounced follow-up visit triggered by an incident to review the submitted plan of correction and verify compliance.
Findings
The facility was found to have multiple deficiencies including failure to timely report incidents, inadequate staffing levels for resident needs, medication administration errors, and incomplete resident support plans. The submitted plan of correction was determined to be fully implemented as of the follow-up.
Deficiencies (5)
| Description |
|---|
| Failure to report incidents to the Department within 24 hours as required, including medication errors and resident elopements. |
| Resident neglect and inadequate supervision resulting in elopements and delayed awareness of missing residents. |
| Inadequate staffing levels during night shifts to meet the needs of residents, including those requiring two-person assist and one-on-one supervision. |
| Medication administration errors including failure to initial medication administration record and administering medications twice in error. |
| Resident support plans (RASPs) not updated to reflect hourly and 15-minute checks being completed by staff. |
Report Facts
License Capacity: 58
Residents Served: 39
Residents with Mobility Needs: 33
Hospice Residents: 6
Staffing Levels: 2
Staffing Levels: 3
Incident Reporting Delay: 27
Inspection Report
Complaint Investigation
Census: 41
Capacity: 58
Deficiencies: 1
Mar 8, 2022
Visit Reason
The inspection was conducted as a complaint investigation to review compliance with regulatory requirements at Oakwood Terrace.
Findings
The facility failed to complete a resident's regularly scheduled CBC blood work required to maintain medication refills for Clonzapine. A plan of correction was submitted and determined to be fully implemented.
Complaint Details
The visit was complaint-related. The submitted plan of correction was fully implemented as of the inspection date.
Deficiencies (1)
| Description |
|---|
| The home failed to complete resident #1's regularly scheduled CBC blood work order required to maintain Clonzapine medication refills. |
Report Facts
License Capacity: 58
Residents Served: 41
Current Residents in Hospice: 8
Total Daily Staff: 79
Waking Staff: 59
Inspection Report
Renewal
Census: 39
Capacity: 58
Deficiencies: 10
Dec 1, 2021
Visit Reason
The inspection was conducted as a renewal inspection of the facility's license.
Findings
The inspection identified multiple deficiencies including unsigned resident contracts, improper food storage, obstructed egress due to a maglock on a door, incomplete medical evaluations, missing weekly menus, medication administration and storage issues, and documentation errors. Plans of correction were accepted for all deficiencies with follow-up documentation and audits required.
Deficiencies (10)
| Description |
|---|
| Resident-home contracts for two residents were not signed by the residents. |
| Unsealed bag of Sysco green peas and a busted bag of green peas found in the walk-in freezer. |
| Rear exit door in the Pines unit contained a maglock preventing egress. |
| Resident #3's medical evaluation did not include blood pressure or temperature. |
| The home's menu for the week following 11/28/2021 was not posted. |
| Medication training paperwork errors and delays in annual practicum completion for multiple staff persons. |
| Loose medication of hydrochlorothiazide 12.5mg found in medication cart drawer. |
| Medications prescribed to Resident #1 were not available in the home on 12/1/2021. |
| Correction tape was used on Resident #2's contract. |
| Medication Administrator Record (MAR) for Resident #1 had incorrect transcription of blood glucose test results. |
Report Facts
License Capacity: 58
Residents Served: 39
Current Hospice Residents: 8
Residents with Mobility Need: 18
Total Daily Staff: 57
Waking Staff: 43
Inspection Report
Follow-Up
Census: 38
Capacity: 58
Deficiencies: 1
Nov 18, 2021
Visit Reason
The inspection was a follow-up visit to verify the implementation of a previously submitted plan of correction related to an incident at the facility.
Findings
The submitted plan of correction was determined to be fully implemented. The incident involved inappropriate behavior between residents, and corrective actions including resident separation, monitoring, staff education, and behavior checks were completed.
Deficiencies (1)
| Description |
|---|
| Resident #1 was observed placing a hand on resident #2's breast, constituting abuse. |
Report Facts
License Capacity: 58
Residents Served: 38
Current Residents in Hospice: 1
Staffing Hours - Total Daily Staff: 76
Staffing Hours - Waking Staff: 57
Plan of Correction Completion Date: Dec 30, 2021
Plan of Correction Follow-Up Date: Jan 3, 2022
Inspection Report
Renewal
Deficiencies: 0
Nov 4, 2021
Visit Reason
The inspection visits on 10/20/2021 and 11/04/2021 were conducted as part of the licensing inspections by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing.
Findings
No regulatory citations were identified as a result of these inspections.
Inspection Report
Complaint Investigation
Census: 40
Capacity: 58
Deficiencies: 3
Aug 27, 2021
Visit Reason
The inspection was conducted as a complaint and incident investigation with an unannounced partial inspection on 08/27/2021.
Findings
The facility was found to have deficiencies related to delayed incident reporting, incomplete medical evaluation documentation, and incomplete preadmission screening forms. Plans of correction were accepted and implemented to address these issues.
Complaint Details
The visit was complaint-related and incident-based. The complaint involved failure to timely report an incident involving a resident's hospitalization and death. The complaint was substantiated with findings of delayed incident reporting and documentation deficiencies.
Deficiencies (3)
| Description |
|---|
| The home did not send an incident report to the department’s regional office within 24 hours after a resident's death and period of non-responsiveness. |
| Resident's medical evaluation form was missing height, weight, pulse, blood pressure, and temperature information. |
| The preadmission screening form did not indicate if the home had determined that they can meet the needs of the resident. |
Report Facts
License Capacity: 58
Residents Served: 40
Secured Dementia Care Unit Capacity: 13
Secured Dementia Care Unit Residents Served: 0
Hospice Current Residents: 9
Residents Age 60 or Older: 40
Residents with Mobility Need: 18
Total Daily Staff: 58
Waking Staff: 44
Inspection Report
Complaint Investigation
Census: 40
Capacity: 58
Deficiencies: 2
Aug 10, 2021
Visit Reason
The inspection was conducted as a complaint investigation with an unannounced partial inspection on 08/10/2021.
Findings
Two deficiencies were identified: one involving an incomplete medical evaluation form missing the physician's signature and license number, and another where a resident's support plan was not updated to reflect hospice care. Both deficiencies were accepted with plans of correction implemented.
Complaint Details
The inspection was triggered by a complaint, and the visit was a partial unannounced inspection to follow up on the complaint.
Deficiencies (2)
| Description |
|---|
| Resident's medical evaluation form was incomplete; physician's signature and professional license number were missing. |
| Resident's support plan was not updated to reflect placement on hospice care. |
Report Facts
License Capacity: 58
Residents Served: 40
Current Residents on Hospice: 10
Residents with Mobility Need: 20
Total Daily Staff: 60
Waking Staff: 45
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Michele Moskalczyk | Signed the letter confirming plan of correction implementation |
Inspection Report
Follow-Up
Census: 31
Capacity: 58
Deficiencies: 5
Mar 9, 2021
Visit Reason
The visit was conducted as a follow-up to verify the implementation of the submitted plan of correction related to previous deficiencies at Oakwood Terrace.
Findings
The submitted plan of correction was determined to be fully implemented. The facility was found to have addressed issues related to resident abuse reporting, incident reporting, medical evaluations, and support plan updates. Continued compliance must be maintained.
Deficiencies (5)
| Description |
|---|
| Failure to immediately report suspected resident abuse incidents to the Area Agency on Aging. |
| Failure to report an incident of resident hitting to the Department’s regional office within 24 hours. |
| Resident abuse involving altercation causing a resident to suffer a right femur fracture. |
| Resident #2’s medical evaluation did not include height and weight. |
| Support plan for resident #1 was not updated to reflect behavioral changes and aggressive incidents. |
Report Facts
License Capacity: 58
Residents Served: 31
Total Daily Staff: 46
Waking Staff: 35
Current Residents on Hospice: 8
Residents Age 60 or Older: 31
Residents with Mobility Need: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Michele Moskalczyk | Human Services Licensing Supervisor | Signed the letter confirming plan of correction implementation. |
Inspection Report
Renewal
Census: 27
Capacity: 58
Deficiencies: 3
Oct 6, 2020
Visit Reason
The inspection was conducted as a provisional licensing inspection on October 6, 2020, to assess compliance with 55 Pa. Code Chapter 2600 relating to Personal Care Homes, leading to the issuance of a regular license.
Findings
The facility was found to be in compliance after corrections were made following the inspection. Deficiencies included missing diagnosis or purpose on medication records, outdated resident support plans reflecting health declines, and incomplete admission support plans for the secured dementia care unit. Plans of correction were accepted and implemented.
Deficiencies (3)
| Description |
|---|
| Medication records did not list diagnosis or purpose for many residents' medications. |
| Resident support plan for resident #4 was not updated to reflect health decline and care needs. |
| Resident #5 did not have a completed assessment within 72 hours of admission to the secured dementia care unit. |
Report Facts
License Capacity: 58
Residents Served: 27
Secured Dementia Care Unit Capacity: 10
Secured Dementia Care Unit Residents Served: 4
Hospice Residents: 3
Resident Mobility Need: 5
Total Daily Staff: 32
Waking Staff: 24
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Michael Semian | Executive Director | Named as facility administrator and referenced in licensing correspondence. |
| Ann O'Haire | Lead Inspector | Conducted the on-site inspection on October 6, 2020. |
| Gerald Dumas | Department Representative | Participated in the on-site inspection on October 6, 2020. |
| Jamie Buchenauer | Deputy Secretary | Signed the licensing letter and certificate of compliance. |
| Michele Moskalczyk | Lead Reviewer | Reviewed follow-up document submissions related to the inspection. |
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