Inspection Reports for Paradise Manor
206 EAST LINCOLN AVENUE,, HATFIELD, PA, 19440
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
58.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
1151% worse than Pennsylvania average
Pennsylvania average: 4.7 deficiencies/yearDeficiencies per year
80
60
40
20
0
Census
Latest occupancy rate
48% occupied
Based on a June 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 24
Capacity: 50
Deficiencies: 6
Date: Jun 12, 2025
Visit Reason
The inspection was a partial, unannounced visit conducted due to a complaint and incident involving resident safety and privacy concerns.
Complaint Details
The visit was triggered by a complaint and incident involving resident abuse and privacy violations. The complaint was substantiated as evidenced by the detailed findings and corrective actions.
Findings
The inspection found multiple deficiencies including resident abuse, privacy violations, incomplete medical evaluations, improper medication handling, unlabeled OTC medications, and incomplete resident assessments. The facility submitted plans of correction which were accepted and later implemented.
Deficiencies (6)
Resident was subjected to abuse when another resident entered their room uninvited and inappropriately touched them.
Violation of resident privacy due to surveillance footage showing unauthorized entry into resident rooms and recording of interior areas.
Resident's medical evaluation did not include all medical diagnoses.
Multiple pills were pre-poured into a medication cup more than 2 hours before scheduled administration.
OTC medications and CAM were found not labeled with the resident's name.
Resident assessment did not indicate the degree of assistance needed in doing laundry.
Report Facts
License Capacity: 50
Residents Served: 24
Current Hospice Residents: 2
Residents 60 Years or Older: 22
Residents Diagnosed with Mental Illness: 5
Residents Diagnosed with Intellectual Disability: 3
Residents Receiving Supplemental Security Income: 1
Total Daily Staff: 24
Waking Staff: 18
Inspection Report
Complaint Investigation
Census: 25
Capacity: 50
Deficiencies: 3
Date: Jun 5, 2025
Visit Reason
The inspection was conducted as a complaint investigation with an unannounced partial inspection on 06/05/2025.
Complaint Details
The inspection was triggered by a complaint, and the visit was an unannounced partial inspection on 06/05/2025.
Findings
The inspection found deficiencies related to medication storage, incomplete resident assessments, and illegible record entries. The facility submitted a plan of correction which was accepted and fully implemented by 07/29/2025.
Deficiencies (3)
Medication was not discarded according to pharmacy and manufacturer instructions, remaining on the cart past the discard date.
Resident assessment did not include behavioral, cognitive, social, and recreational needs; pages were blank.
Entries in a resident’s record were not permanent, legible, dated, or signed properly; staff wrote over the date on the resident’s assessment.
Report Facts
License Capacity: 50
Residents Served: 25
Total Daily Staff: 25
Waking Staff: 19
Current Hospice Residents: 1
Residents Receiving Supplemental Security Income: 1
Residents Age 60 or Older: 22
Residents Diagnosed with Mental Illness: 5
Residents Diagnosed with Intellectual Disability: 3
Residents with Mobility Need: 0
Residents with Physical Disability: 0
Inspection Report
Follow-Up
Census: 23
Capacity: 37
Deficiencies: 4
Date: May 12, 2025
Visit Reason
The visit was a follow-up review conducted on May 12, 2025, to assess the implementation of the plan of correction submitted for the March 17 and April 10, 2025 inspections at Paradise Manor.
Findings
The submitted plan of correction for prior violations was determined to be not implemented. Several deficiencies related to house rules, resident rights, privacy, and sanitary conditions were noted, with corrective actions proposed but not fully completed as of the follow-up date.
Deficiencies (4)
House rules requiring residents to obtain special permission to have a car were not compliant; rules were updated to require a valid driver's license.
House rules restricting residents from entering other residents' rooms without permission were clarified to mean permission from the resident occupying the room.
House rules allowing management to inspect or search residents' personal items were revised to limit inspection to furniture brought in from outside.
Sanitary condition deficiency: communal ladies restroom lacked an electric hand dryer, towel, or paper towels to dry hands; paper towels were replaced on site.
Report Facts
License Capacity: 37
Residents Served: 23
Total Daily Staff: 23
Waking Staff: 17
Inspection Report
Census: 23
Deficiencies: 0
Date: Apr 30, 2025
Visit Reason
The inspection was conducted due to a change in legal entity for the facility.
Findings
No regulatory citations or deficiencies were identified during the inspection.
Report Facts
Residents Served: 23
Total Daily Staff: 23
Waking Staff: 17
Resident Support Staff: 0
Receive Supplemental Security Income: 1
Are 60 Years of Age or Older: 21
Diagnosed with Mental Illness: 5
Diagnosed with Intellectual Disability: 3
Have Mobility Need: 0
Have Physical Disability: 0
Inspection Report
Plan of Correction
Census: 22
Capacity: 37
Deficiencies: 5
Date: Mar 25, 2025
Visit Reason
The inspection was a follow-up review conducted on March 25, 2025, to determine if the submitted plan of correction for violations found during the January 15 and February 11, 2025 inspections was implemented.
Findings
The facility was found to have not implemented the submitted plan of correction for previous violations. Specific deficiencies included failure to timely report an incident involving a resident and staff altercation, hazardous bedside mobility device, incomplete medication administration records, failure to report medication refusals to prescribers, and incomplete support plan revisions.
Deficiencies (5)
Failure to report an incident involving a resident physically pushing staff to the Department within 24 hours.
Resident's bedside mobility device had an uncovered opening measuring 12 inches by 5 inches, posing a hazard.
Medication administration records for resident #2 did not include initials of staff administering Diazepam on specified dates.
Failure to document and report medication refusals by resident #3 to the prescriber within 24 hours as required.
Resident #2's support plan did not include the use of a bedside mobility device observed attached to the bed frame.
Report Facts
License Capacity: 37
Current Residents: 22
Staffing: 22
Waking Staff: 17
Medication Administration Missing Initials: 3
Medication Refusal Period: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Named as responsible staff for training and corrective actions related to incident reporting, medication administration, and support plan revisions. | |
| Resident Care Coordinator | Responsible for auditing medical records, checking rooms for hazardous devices, and ensuring compliance with medication refusal reporting. | |
| Med Techs | Responsible for medication administration and reporting refusals. |
Inspection Report
Follow-Up
Census: 19
Capacity: 37
Deficiencies: 2
Date: Dec 5, 2024
Visit Reason
The inspection was a follow-up review conducted on December 19, 2024 and January 14, 2025 to assess the implementation of the plan of correction submitted for the December 5, 2024 inspection at Paradise Manor.
Findings
The submitted plan of correction for medication record and following prescriber's orders violations identified on December 5, 2024 was found to be not fully implemented as of the follow-up dates. Deficiencies related to incomplete medication administration records and failure to follow prescriber directions persisted.
Deficiencies (2)
Medication record did not list prescribed medications correctly for multiple residents, including incorrect dosages and administration times.
Failure to administer prescribed medications as ordered, including missed doses and incorrect timing.
Report Facts
License Capacity: 37
Residents Served: 19
Staffing: 19
Waking Staff: 14
Inspection Report
Renewal
Census: 21
Capacity: 37
Deficiencies: 16
Date: Jul 2, 2024
Visit Reason
The inspection was conducted for renewal and provisional monitoring purposes, including follow-up on plans of correction and enforcement.
Findings
The facility was found to have multiple violations related to hot water temperature, food storage, refrigeration, training, sanitary conditions, furniture and equipment, medication administration, and documentation. Plans of correction were submitted with some deficiencies not yet implemented as of the report date.
Deficiencies (16)
Hot water temperature at the bathroom sink in room 10 measured 131.5 degrees Fahrenheit, exceeding the maximum allowed 120°F.
Twelve 5-gallon bottles of water were stored on the floor in the dining area.
The temperature in the refrigerator was 46.0 degrees Fahrenheit and the attached freezer did not have a thermometer.
A box of spaghetti in the dry storage area was opened and unsealed.
Multiple food items including lunch meats, cheeses, and other foods were unlabeled and undated in the walk-in refrigerator and dry storage area.
Direct care staff person A did not receive required training on meeting residents' needs as described in assessment and support plans during training year 2023.
The women's restroom across from bedroom #11 had no paper towels available for hand drying.
The exit door on the third floor was secured with a deadbolt that did not function correctly, and kitchen refrigerator and freezer doors were secured with deadbolt locks that could be pushed open by the air system blower.
Two unlabeled inhalers were found next to the nightstand in resident #1's room; resident #1 is unable to self-administer medications.
Resident #1's medication administration record failed to indicate the site of medication administration and did not list two inhalers found in the resident's room as current medications.
Resident #1's assessment did not include evaluation of the need and use of an oxygen machine.
Resident #1's prescription medication was not in the original box and lacked proper labeling including resident's name, medication name, issuance date, dosage, administration instructions, and prescriber's name and title.
Resident #1 possessed a medication not prescribed by an authorized healthcare provider.
Resident #2 refused to take scheduled doses of insulin but the refusal was not reported to the resident's doctor as required.
Resident #2 and #3's blood sugar checks were not performed or recorded as prescribed.
Prescription medications, OTC medications, CAM and syringes were found unlocked, unattended, and accessible in resident #1's room.
Report Facts
License Capacity: 37
Census: 21
Fine Amount: 63
Fine Per Resident Per Day: 3
Mandated Correction Timeframe: 15
Number of Violations: 16
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Resident Care Coordinator | Resident Care Coordinator | Named as responsible staff for multiple findings including medication administration, assessments, and training. |
| Med Techs | Med Techs | Named as responsible staff for medication-related deficiencies and training. |
| Housekeeping | Housekeeping | Named as responsible staff for sanitary conditions and medication storage violations. |
| Maintenance Director | Maintenance Director | Named as responsible staff for hot water temperature correction and ongoing monitoring. |
| Cook/Chef | Cook/Chef | Named as responsible staff for food storage and refrigeration violations. |
| Administrator | Administrator | Named as responsible for training and oversight of corrective actions. |
Inspection Report
Renewal
Census: 21
Capacity: 37
Deficiencies: 16
Date: Jul 2, 2024
Visit Reason
The inspection was conducted as part of a renewal and provisional licensing process, including monitoring and follow-up on previous violations and plans of correction.
Findings
Multiple violations were found related to hot water temperature, food storage, refrigeration, training, sanitary conditions, furniture and equipment maintenance, medication administration, and documentation. Plans of correction were submitted with some implemented and others pending.
Deficiencies (16)
Hot water temperature at the bathroom sink in room 10 measured 131.5 degrees Fahrenheit, exceeding the maximum allowed 120°F.
Twelve 5-gallon bottles of water were stored on the floor in the dining area.
The temperature in the refrigerator was 46.0 degrees Fahrenheit and the attached freezer did not have a thermometer.
A box of spaghetti in the dry storage area was opened and unsealed.
Multiple food items including lunch meats, cheeses, and other foods were unlabeled and undated in the walk-in refrigerator and dry storage area.
Direct care staff person A did not receive required training on meeting the needs of residents as described in the preadmission screening form, assessment tool, medical evaluation, and support plan during training year 2023.
The women's restroom across from bedroom #11 had no paper towels available for hand drying.
The exit door on the third floor was secured with a deadbolt that did not function correctly, and kitchen refrigerator and freezer doors were secured with deadbolt locks that could be pushed open by the air system blower.
Resident #1's medication administration record failed to indicate the site of medication administration and included medications not listed on the record.
Resident #2 has not had their blood glucose checked at bedtime as prescribed.
Resident #1's assessment did not include an evaluation of the need and use of an oxygen machine.
Resident #1's medication was not in the original box and lacked proper labeling including resident's name, medication name, prescription date, dosage, administration instructions, and prescriber's name and title.
Resident #1 possessed a medication not prescribed by an authorized healthcare provider.
Resident #2 refused to take scheduled doses of insulin and the refusal was not reported to the physician as required.
Resident #2 and #3's blood sugar checks were not performed as prescribed.
Prescription medications, OTC medications, CAM and syringes were not kept locked in an area or container in Resident #1's room.
Report Facts
License Capacity: 37
Census: 21
Fine Amount: 63
Fine Per Resident Per Day: 3
Correction Timeframe: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Resident Care Coordinator | Resident Care Coordinator | Named as responsible staff for multiple plans of correction including medication record updates, oxygen assessment, and medication monitoring |
| Med Techs | Med Techs | Named as responsible staff for medication administration training, reporting refusals, and following prescriber's orders |
| Housekeeping | Housekeeping | Named as responsible staff for sanitary conditions and medication reporting in resident rooms |
| Maintenance Director | Maintenance Director | Named as responsible staff for hot water temperature correction and ongoing monitoring |
| Cook/Chef | Cook/Chef | Named as responsible staff for food storage and refrigeration corrections and ongoing monitoring |
| Administrator | Administrator | Named as responsible for training staff and overseeing plans of correction |
Inspection Report
Monitoring
Census: 21
Capacity: 37
Deficiencies: 19
Date: Jul 2, 2024
Visit Reason
The inspection was conducted for provisional monitoring and renewal provisional reasons, including follow-up on plan of correction submissions and enforcement document submissions.
Findings
Multiple violations were found related to hot water temperature, food storage, refrigerator/freezer temperatures, training topics, sanitary conditions, furniture and equipment maintenance, medication administration, staff support plans, fire drill records, and medication security. Plans of correction were submitted with some implemented and others pending.
Deficiencies (19)
Hot water temperature at the bathroom sink in room 10 measured 131.5 degrees Fahrenheit, exceeding the maximum allowed 120°F.
Twelve 5-gallon bottles of water were stored on the floor in the dining area.
The temperature in the refrigerator was 46.0 degrees Fahrenheit and the attached freezer did not have a thermometer.
A box of spaghetti in the dry storage area was opened and unsealed.
There were multiple unlabeled and undated food items in the walk-in refrigerator and dry storage area.
The women's restroom across from bedroom #11 had no paper towels available for hand drying.
The exit door on the third floor was secured with a deadbolt that did not function correctly, and refrigerator/freezer doors were secured with deadbolt locks that could be pushed open by the air system blower.
Resident #1's medication administration record failed to indicate the site of medication administration and did not list two inhalers found next to the nightstand as current medications.
Direct care staff person A did not receive required training on meeting residents' needs as described in the preadmission screening form, assessment tool, medical evaluation, and support plan during training year 2023.
The home's staff training plan did not specify which staff persons are required to complete specific trainings.
The fire drill record lacked inclusion of the year for drills conducted on multiple dates.
Prescription medications, OTC medications, CAM, and syringes were not kept locked in an area or container; two unlabeled inhalers were found unlocked and unattended in resident #1's room.
Resident #1's medication was not in the original box and lacked labeling including resident's name, medication name, issuance date, dosage, administration instructions, and prescriber's name and title.
Resident #1 possessed a medication not prescribed by an authorized healthcare provider.
Resident #2 refused to take scheduled insulin doses and the refusal was not reported to the prescriber as required.
Resident #2 and #3's blood sugar checks were not performed or recorded as prescribed.
Resident #2 and #3's prescriptions were not followed properly, including timing and documentation of blood sugar checks.
Resident #2 and #3's prescriptions were not followed properly, including timing and documentation of blood sugar checks.
Resident #1's assessment did not include evaluation of the need and use of an oxygen machine.
Report Facts
License Capacity: 37
Census: 21
Fine Amount: 63
Fine Per Resident Per Day: 3
Deficiency Counts: 17
Inspection Report
Plan of Correction
Census: 21
Capacity: 37
Deficiencies: 7
Date: Jan 18, 2024
Visit Reason
The inspection was a follow-up review of the submitted plan of correction to verify compliance after a prior partial inspection related to medication administration and storage violations.
Findings
The facility was found to have multiple medication-related deficiencies including unlicensed staff administering medications, discontinued medications left in the home, improper medication storage, incomplete controlled substance count sheets, incomplete medication records, failure to follow prescriber's orders, and failure to report medication errors. The submitted plan of correction was accepted and fully implemented by April 15, 2024.
Deficiencies (7)
Unlicensed staff administered prescription medication that should be administered only by licensed professionals.
Discontinued medications were found in the home's medication cart.
Prescription medications and inhalers were not stored properly, including opened and undated inhalers and unsealed medication packs.
Controlled substance count sheets were incomplete or missing for several medications.
Medication administration records lacked diagnosis or purpose for PRN medications and did not include number of units for administration.
Failure to follow prescriber's orders, including administering medication not present and missing vital sign checks.
Medication error was not immediately reported to the resident, designated person, and prescriber.
Report Facts
License Capacity: 37
Residents Served: 21
Total Daily Staff: 21
Waking Staff: 16
Deficiencies cited: 7
Inspection Report
Complaint Investigation
Census: 21
Capacity: 37
Deficiencies: 4
Date: Jan 17, 2024
Visit Reason
The inspection was conducted as a complaint and incident investigation with unannounced partial inspections on 01/17/2024 and 02/02/2024, followed by plan of correction submissions and reviews.
Complaint Details
The inspection was complaint-driven, triggered by incidents including unsecured weapons and resident self-harm. The complaint was substantiated as deficiencies were found and plans of correction were required.
Findings
The inspection identified multiple deficiencies including failure to provide required personal hygiene assistance, unsecured weapons in a resident's room, failure to assist a resident in securing medical care resulting in self-harm behavior, and incomplete resident assessments. Plans of correction were submitted and accepted with training and implementation dates provided.
Deficiencies (4)
Resident did not receive required assistance with hair grooming and nail care as indicated in the assessment and support plan.
Unsecured, unattended knives were found in a resident's room, violating firearms and weapons safety requirements.
Failure to assist a resident in securing medical care for depression and pain, resulting in self-harm behavior on January 12, 2024.
Resident assessment did not include required supervision and safety measures; resident engaged in self-harm with accessible knife.
Report Facts
License Capacity: 37
Residents Served: 21
Staffing Hours: 21
Waking Staff: 16
Residents 60 Years or Older: 18
Residents Diagnosed with Mental Illness: 9
Residents Diagnosed with Intellectual Disability: 2
Residents Receiving Supplemental Security Income: 1
Inspection Report
Enforcement
Census: 21
Capacity: 37
Deficiencies: 40
Date: Oct 19, 2023
Visit Reason
This document is an enforcement inspection report for Paradise Manor, a personal care home, detailing multiple inspections and follow-ups related to compliance with state regulations.
Complaint Details
Complaint investigation related to allegations of abuse, medication errors, inadequate staffing, improper resident care, and regulatory noncompliance. Some allegations were substantiated including staff striking a resident, failure to report abuse, and improper medication administration.
Findings
The report identifies numerous deficiencies including medication administration errors, inadequate staffing, failure to follow prescriber orders, improper storage of medications and food, lack of proper resident assessments, failure to report abuse, and issues with resident rights and safety. Several corrective actions and training plans were proposed, with some deficiencies noted as not implemented by the last follow-up.
Deficiencies (40)
Resident #1 tried to hit staff and the incident was not reported to the department.
No carbon monoxide detector near the kitchen gas stove.
Direct care staff did not receive required medication self-administration and safe management training.
Resident room #5 had a bed enabler that was not covered and did not meet size requirements.
First aid kit in the medication room lacked a breathing shield.
No grab bar, hand rail or assist bar in the shower in resident room #103.
Lint accumulation in the lint trap of one of the dryers.
Resident medical evaluations missing required elements such as physical exam, dietary needs, immunization history, and mobility assessment.
Staff person B administered medications without current recertification.
Medication administration records missing diagnosis or purpose for medications for several residents.
Medication administration records missing staff initials for administered medications.
Refusals of medication by resident not reported to prescriber within 24 hours.
Medications not administered as prescribed including incorrect timing and missing medications.
Staff person B administered medications without current medication administration course completion.
Resident support plans missing documentation of medical, dental, vision, hearing, mental health or behavioral care services.
Resident records were unlocked and accessible with resident personal information exposed.
Fines assessed for violations related to medication storage and administration.
Staff person C did not receive required fire safety orientation on first day.
Staff persons C, F, G, and H did not complete required rights/abuse and job function orientation within required hours.
Resident 7 actively dying on hospice was not evacuated during fire drills and staffing was insufficient for safe evacuation.
Resident 7's assessment and support plan did not address exclusion from evacuation during fire drills due to active dying status.
Resident 2 was discharged against their will without 30-day notice.
Resident 3's medication administration record missing diagnosis or purpose for multiple medications.
Medication cart was unlocked, unattended, and accessible in common area.
Medications stored improperly including expired, discontinued, or not discarded per manufacturer instructions.
Glucometers not calibrated correctly and blood sugar logs not accurately recorded.
Medication errors not reported to resident, designated person, or prescriber.
Resident 9 restricted to common area and denied access to bedroom except during naps and sleep.
Insufficient direct care staffing hours to meet resident mobility needs and waking hour requirements.
Home lacked dietary aides and used minor volunteers for food service.
Staff contact list not current with names, addresses, and phone numbers.
Emergency telephone numbers not posted by telephone in first floor wing.
Food safety violations including uncovered food, food stored on floor, leftover food reused, unsealed containers, dented cans.
Portable space heater observed in fireplace in common area.
Resident 8 medical evaluation not completed within required timeframe.
Resident 5, 9, 10 medical evaluations missing required information including immunization history and cognitive functioning.
Resident 6 assessment missing mobility needs and ability to self-administer medications.
Resident 7 participated in support plan development but did not sign the plan.
Resident support plans were locked and inaccessible to direct care staff.
Narcotics declining inventory log entries were illegible and written over without notation.
Report Facts
Fine Per Resident Per Day: 5
Fine Per Resident Per Day: 5
License Capacity: 37
Residents Served: 21
Total Daily Staff: 22
Waking Staff: 17
Residents Served: 22
Total Daily Staff: 24
Waking Staff: 18
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff person B | Medication Administration Technician | Named in medication administration and certification deficiencies |
| Staff person C | Direct Care Staff | Named in medication administration, abuse observation, and training deficiencies |
| Staff person D | Administrator | Named in abuse reporting and resident discharge deficiencies |
| Resident Care Coordinator | Named in multiple training, assessment, and compliance deficiencies | |
| Assistant Resident Care Coordinator | Named in multiple training, assessment, and compliance deficiencies | |
| Administrator | Named in multiple training, compliance, and enforcement actions | |
| Chef | Named in food safety and dietary deficiencies | |
| Maintenance | Named in safety and housekeeping deficiencies |
Inspection Report
Enforcement
Census: 21
Capacity: 37
Deficiencies: 46
Date: Oct 19, 2023
Visit Reason
The inspection was conducted as an enforcement action following multiple prior inspections and complaint investigations, focusing on compliance with regulations related to Personal Care Homes.
Complaint Details
The complaint investigation revealed multiple violations including abuse, neglect, medication errors, inadequate staffing, failure to follow prescriber orders, and failure to provide adequate care and services to residents. Specific incidents included physical abuse of a resident by staff, resident aggression not addressed, and improper medication administration and documentation.
Findings
The facility was found to have numerous deficiencies including medication administration errors, inadequate staffing, failure to follow prescriber orders, improper storage of medications and food, lack of proper resident assessments and support plans, failure to report abuse, and issues with staff training and orientation. Several residents were affected by these deficiencies, including medication errors and neglect of dietary and health needs.
Deficiencies (46)
Failure to report an incident involving a resident attempting to hit staff and police involvement.
No carbon monoxide detector near the kitchen gas stove.
Direct care staff did not receive required medication self-administration and safe management training.
Resident room bed equipped with an enabler that is not covered and of improper size.
First aid kit missing a breathing shield.
No grab bar, hand rail or assist bar in the shower in resident room #103.
Accumulation of lint in the lint trap of a clothes dryer.
Incomplete medical evaluations for several residents missing key components such as physical exam, dietary needs, immunization history, and mobility assessment.
Medication administration by uncertified staff and failure to complete recertification.
Medication administration records missing diagnosis or purpose for prescribed medications.
Medication administration records missing staff initials for administered medications.
Failure to report resident refusals of medication to prescriber within 24 hours.
Failure to follow prescriber's orders for medication administration times and availability of medications.
Staff person administered medications without current certification.
Lack of current weekly activity calendar posted in a public place.
Resident assessments missing mobility needs, supervision needs, medical diagnoses, and behavioral assessments.
Resident support plans missing documentation of medical, dental, vision, hearing, mental health or behavioral care services and required signatures; support plans inaccessible to direct care staff.
Resident records contained illegible entries and overwritten narcotics inventory logs.
Failure to provide immediate access to records to Department agents.
Failure to immediately report suspected resident abuse to appropriate agencies.
Lack of sufficient staffing to safely evacuate all residents including those actively dying on hospice.
Failure to address resident exclusion from evacuation during fire drills in assessment and support plan.
Failure to maintain confidentiality of resident records; unlocked file drawers accessible with resident information visible.
Direct care staff did not receive orientation on fire safety and emergency preparedness topics on first day of work.
Direct care staff and volunteers did not complete required training on resident rights, emergency medical plan, abuse reporting, and reportable incidents within 40 hours of work.
Ancillary staff and volunteers did not receive general orientation to specific job functions prior to working.
Direct care staff hired did not complete required initial direct care training including demonstration and competency test before providing unsupervised ADL services.
Poisonous materials stored next to food items in kitchen.
Unsanitary conditions observed including volunteer pouring punch back into serving pitcher and dirty air conditioner vents.
Emergency telephone numbers not posted by telephone in first floor wing.
Resident with dementia restricted to common area when awake, denied access to bedroom except for naps and sleep.
Food stored uncovered or on the floor in kitchen; leftover food poured back into serving pitcher; opened and unsealed food containers; dented cans present.
Portable space heater observed in fireplace in common area.
Resident medical evaluations not completed within required timeframes or missing required information.
Resident assessments missing required elements including behavioral, cognitive, supervision, medical diagnoses, and mobility needs.
Resident support plans missing signatures and not accessible to direct care staff.
Resident discharged without 30-day advance written notice.
Medication administration records contained illegible entries and overwritten narcotics inventory logs.
Medication cart unlocked and unattended in common area.
Discontinued medications not removed from medication cart.
Glucometers not calibrated for correct time; blood sugar logs not accurately recorded; medication counts inaccurate.
Medications not available in home as prescribed.
Medication errors not reported to resident, designated person, or prescriber.
Resident not receiving prescribed blood sugar checks and insulin as ordered.
Resident refused meals and was not offered adequate food to meet nutritional requirements; physician not notified timely.
Resident with aggressive behavior not managed with positive interventions; resident sent to hospital and told not to return.
Report Facts
License Capacity: 37
Residents Served: 21
Staffing Hours: 24
Waking Staff Hours: 18
Fine Amount: 210
Census at Inspection: 21
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff person B | Medication Administration Technician | Named in medication administration and abuse findings. |
| Staff person C | Direct Care Staff | Named in abuse and medication administration findings. |
| Staff person D | Administrator | Named in abuse and medication administration findings. |
| Resident Care Coordinator | Named in multiple findings related to training, assessments, and care plans. | |
| Assistant Resident Care Coordinator | Named in multiple findings related to training, assessments, and care plans. | |
| Administrator | Named in multiple findings related to training, enforcement, and oversight. | |
| Staff person A | Direct Care Staff | Named in abuse and medication administration findings. |
| Staff person F | Volunteer | Named in training and orientation findings. |
| Staff person G | Volunteer | Named in training and orientation findings. |
| Staff person H | Direct Care Staff | Named in training and orientation findings. |
Inspection Report
Enforcement
Census: 21
Capacity: 37
Deficiencies: 45
Date: May 22, 2023
Visit Reason
The inspection was conducted as a renewal and incident investigation to assess compliance with regulations for Paradise Manor.
Complaint Details
Complaint investigation conducted on 2023-06-13 with follow-up on 2023-08-02 and 2023-10-19. Multiple substantiated violations including abuse, medication errors, inadequate staffing, and failure to meet resident care needs.
Findings
Multiple violations were found including failure to report incidents, lack of required training, medication administration errors, inadequate staffing, improper food handling, and deficiencies in resident care and documentation.
Deficiencies (45)
Failure to report an incident involving a resident attempting to hit staff and police involvement.
No carbon monoxide detector near the kitchen gas stove.
Direct care staff did not receive required medication self-administration and safe management training.
Resident room bed enabler was not covered.
First aid kit missing a breathing shield.
No grab bar, hand rail or assist bar in the shower in resident room #103.
Lint accumulation in dryer lint trap.
Incomplete medical evaluations for multiple residents missing key elements such as physical exam, dietary needs, immunization history, and mobility assessment.
Medication administration by uncertified staff and failure to complete recertification.
Medication administration records missing diagnosis or purpose for prescribed medications.
Medication administration records missing staff initials for administered medications.
Failure to report medication refusals to prescriber within 24 hours.
Medications administered not following prescriber's orders.
Staff administered medications without current Department-approved certification.
Failure to document medication errors and prescriber response in resident records.
Failure to post signage indicating video surveillance in the home.
Staff person did not receive required fire safety orientation on first day.
Failure to provide immediate access to records to Department agents.
Failure to immediately report suspected resident abuse to Area Agency on Aging.
Failure to maintain confidentiality of resident records; unlocked and unattended files accessible.
Failure to provide quarterly itemized account of financial transactions to residents and designated persons.
Failure to keep copy of quarterly financial account in resident records.
Insufficient staffing to provide safe evacuation of residents receiving hospice care, including overnight shifts.
Resident assessment and support plan did not address exclusion from evacuation during fire drills due to active dying status.
Resident physically abused by staff and other resident; aggressive behavior not adequately addressed.
Resident restricted to common area due to dementia, denied access to bedroom except for naps and sleep.
Failure to maintain dietary aides; volunteers used instead.
Failure to maintain current list of staff names, addresses, and phone numbers including substitutes and volunteers.
Volunteers and staff did not receive required orientation and training on resident rights, emergency plans, abuse reporting, and job functions.
Direct care staff hired did not complete required initial direct care training and competency testing before unsupervised ADL services.
Poisonous materials stored next to food items in kitchen.
Unsanitary conditions observed including volunteer pouring punch back into serving pitcher and dirty air conditioner vents.
Emergency telephone numbers not posted by telephone in first floor wing.
Food stored uncovered or on floor; dented cans present.
Portable space heater observed in common area fireplace.
Medical evaluations missing required elements including immunization history, medication self-administration ability, and cognitive functioning.
Resident special dietary needs not met; dietary alternatives not provided; resident missed meals without adequate food offered.
Resident refused to eat or drink continuously without timely notification to physician and designated person.
Medication cart left unlocked and unattended in common area.
Discontinued medications not removed from home.
Medication records missing required information and documentation errors.
Medications not administered as prescribed; insulin administered despite blood sugar levels requiring hold.
Medication errors not immediately reported to resident, designated person, and prescriber.
Resident discharged without 30-day advance written notice.
Entries in resident records not permanent, legible, dated, or signed; narcotics log illegible with overwritten entries.
Report Facts
Deficiencies cited: 59
Census at inspection: 21
Total licensed capacity: 37
Staffing hours: 22
Waking staff hours: 17
Staffing hours: 24
Waking staff hours: 18
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff person B | Named in medication administration and abuse findings. | |
| Staff person C | Named in medication administration and abuse findings. | |
| Staff person D | Named in abuse and record access findings. | |
| Staff person A | Named in abuse and medication administration findings. | |
| Staff person F | Volunteer | Named in orientation and training deficiencies. |
| Staff person G | Volunteer | Named in orientation and training deficiencies. |
| Staff person H | Named in orientation and training deficiencies. | |
| Resident Care Coordinator | Named in training and corrective action plans. | |
| Assistant Resident Care Coordinator | Named in training and corrective action plans. | |
| Administrator | Named in multiple corrective action plans and trainings. |
Inspection Report
Enforcement
Census: 21
Capacity: 37
Deficiencies: 40
Date: May 22, 2023
Visit Reason
The inspection was conducted as a renewal and incident investigation visit to assess compliance with 55 Pa. Code Chapter 2600 relating to Personal Care Homes.
Complaint Details
Complaint investigation conducted on 2023-06-13 with follow-up on multiple dates. Allegations included resident abuse, neglect, improper medication administration, insufficient staffing, and failure to provide adequate care and services. Several violations were substantiated including physical abuse, neglect, and failure to follow prescribed care plans.
Findings
Multiple violations were found including failure to report incidents, non-compliance with health and safety laws, inadequate staff training, medication administration errors, improper storage of medications and food, resident abuse, insufficient staffing, and failure to maintain proper resident records and support plans.
Deficiencies (40)
Failure to report an incident involving resident aggression to the department.
No carbon monoxide detector near the kitchen gas stove.
Direct care staff did not receive required medication self-administration and safe management training.
Resident room bed equipped with an uncovered enabler.
First aid kit missing a breathing shield.
No grab bar, hand rail or assist bar in the shower in resident room #103.
Accumulation of lint in the lint trap of a clothes dryer.
Incomplete medical evaluations for residents, missing key components such as physical exam, dietary needs, immunization history, and mobility assessment.
Medication administration by staff not properly certified or recertified.
Medication administration records missing diagnosis or purpose for medications.
Medication administration records missing staff initials for administered medications.
Failure to report medication refusals to prescriber within 24 hours.
Medications not administered according to prescriber's orders.
Staff person administered medications without current recertification.
Failure to document medication errors and prescriber response in resident records.
Failure to report medication errors to resident, designated person, and prescriber.
Lack of immediate access to resident and staff records by Department agents.
Failure to immediately report suspected resident abuse to Area Agency on Aging.
Failure to maintain confidentiality of resident records; unlocked and unattended files accessible with resident information exposed.
Failure to provide itemized quarterly financial accounts to residents and designated persons.
Insufficient staffing to provide safe evacuation of residents including those actively dying on hospice.
Resident assessment and support plans not current or lacking required information related to hospice care and exclusion from evacuation.
Resident abuse incidents including physical abuse and neglect, failure to provide medications and care as prescribed.
Failure to provide at least 2 hours per day of personal care services to residents with mobility needs.
Less than 75% of personal care service hours provided during waking hours.
Use of minor volunteers instead of dietary aides for food service.
Lack of current staff contact list including substitute personnel and volunteers.
Volunteers and staff did not receive required orientation and training on fire safety, resident rights, abuse reporting, and job functions.
Poisonous materials stored next to food items in kitchen.
Unsanitary conditions observed including volunteer pouring punch back into serving pitcher and dirty air conditioner vents.
Emergency telephone numbers not posted by telephone in first floor wing.
Resident with dementia restricted to common area and denied access to bedroom except during naps and sleep.
Food stored uncovered or on the floor, and use of dented cans.
Outdated or spoiled food and dented cans found in kitchen.
Use of prohibited portable space heater in common area fireplace.
Resident medical evaluations missing required components or not completed timely.
Resident assessments missing required information including mobility needs, behavioral needs, and self-administration ability.
Resident support plans missing required signatures and not accessible to direct care staff.
Resident discharged without 30-day advance written notice.
Illegible entries in resident records including narcotics inventory logs.
Report Facts
Fine Per Resident Per Day: 5
Calculated Fine Per Day: 105
License Capacity: 37
Residents Served: 21
Total Daily Staff: 22
Waking Staff: 17
Residents Served: 22
Total Daily Staff: 24
Waking Staff: 18
Residents Served: 21
Total Daily Staff: 21
Waking Staff: 16
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff person B | Medication Administration Technician | Named in findings related to medication administration errors and failure to complete recertification. |
| Staff person C | Med Tech | Named in findings related to medication administration and documentation errors. |
| Staff person D | Administrator | Named in findings related to resident abuse reporting and refusal to accept resident back. |
| Resident Care Coordinator | Named in multiple findings related to training, documentation, and compliance. | |
| Assistant Resident Care Coordinator | Named in multiple findings related to training, documentation, and compliance. | |
| Administrator | Named in multiple findings related to training, oversight, and compliance. | |
| Chef | Named in findings related to food safety, storage, and dietary needs. | |
| Maintenance | Named in findings related to facility maintenance, safety, and compliance. |
Inspection Report
Monitoring
Census: 20
Capacity: 37
Deficiencies: 0
Date: Jan 11, 2023
Visit Reason
The inspection was conducted as a monitoring visit to the facility.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
License Capacity: 37
Residents Served: 20
Total Daily Staff: 20
Waking Staff: 15
Residents Age 60 or Older: 19
Residents Diagnosed with Mental Illness: 7
Residents Receiving Supplemental Security Income: 1
Inspection Report
Renewal
Census: 15
Capacity: 37
Deficiencies: 12
Date: Apr 29, 2022
Visit Reason
The inspection was an unannounced full renewal inspection conducted on 04/29/2022 to assess compliance with licensing requirements.
Findings
The inspection identified multiple deficiencies including sanitary conditions, trash management, bathroom ventilation, surface maintenance, furniture and equipment repair, combustible storage, medical evaluation documentation, smoking area safety, medication storage, and assessment documentation. All deficiencies had plans of correction accepted and were either corrected on site or directed for follow-up.
Deficiencies (12)
Sink in the bathroom of a resident's bedroom was filthy with a yellow substance that looked like dirt.
Trash outside the home included pieces of wood, bricks, old bikes, and tires outside of dumpsters.
Bathroom in a resident's room lacked operable window or ventilation fan; fan was inoperable.
Ceiling in hall on first floor had brown water stains; rugs on second-floor ramp had holes and lost black lines.
Sink in bathroom in a resident's bedroom became clogged and water would not drain.
Combustible and flammable materials stored near heat sources in enclosed boiler room.
Resident medical evaluations did not include medication lists for two residents.
Designated smoking area did not have fire resistant furniture; wooden furniture was moved to smoking area.
Prescription medications in blister cards had torn foil backs covered with tape.
Medication lock box count discrepancy and incorrect blood glucose levels documented on MAR for residents.
Resident's preadmission screening form did not include determination that needs could be met by the home.
Resident assessments were not completed within required 15 days of admission.
Report Facts
License Capacity: 37
Residents Served: 15
Total Daily Staff: 15
Waking Staff: 11
Deficiencies cited: 12
Directed Completion Date: May 30, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Resident Care Coordinator | Named in medication storage and medical evaluation findings. | |
| Assistant Resident Care Coordinator | Named in medical evaluation and assessment findings. | |
| Administrator | Responsible for training and oversight related to multiple deficiencies including sanitary conditions, maintenance, medication storage, and documentation. |
Inspection Report
Renewal
Census: 18
Capacity: 37
Deficiencies: 29
Date: Apr 26, 2021
Visit Reason
The inspection was an unannounced full renewal inspection conducted to review compliance with licensing regulations and verify the submitted plan of correction.
Findings
The facility had multiple deficiencies including failure to post the current license inspection summary, missing criminal background checks, unqualified direct care staff, lack of CPR-trained staff during certain shifts, sanitary issues, hot water temperature violations, improper food storage and labeling, missing emergency procedure submissions, locked exit doors, outdated furnace inspection, incomplete medical evaluations and assessments for residents, medication administration errors, and incomplete support plans.
Deficiencies (29)
License Inspection Summary was not posted in a conspicuous and public place in the home.
The home does not have a criminal background check for staff member A.
Direct care staff person A does not have a high school diploma, GED, or active registry status on the Pennsylvania nurse aide registry.
No staff persons present who were certified in obstructed airway techniques and CPR during multiple shifts when 18 residents were present.
Staff person A did not receive orientation on fire safety and emergency preparedness topics on first day of work.
Staff person A did not complete required orientation training within 40 scheduled working hours.
Direct care staff person A began providing unsupervised ADL services without completing required training including demonstration of job duties, passing competency test, and initial direct care staff training topics.
The home does not have a staff training plan for 2020 and 2021.
Sticky floor and strong urine smell in second floor men's bathroom.
Hot water temperature exceeded 120°F in multiple bathrooms and resident bedroom sinks.
Soap dispenser was missing in second floor women's bathroom.
No paper towels, mechanical hand dryer or other sanitary means of hand drying in second floor women's bathroom.
Multiple food items in dry storage area were not labeled or dated, including hamburger buns, hoagie rolls, coffee cake, cereals, and bread.
Multiple food items in dry storage area were opened and not sealed, including Cheerios and shredded wheat.
Written emergency procedures had not been sent to the Borough of Hatboro since 2/13/20.
Exit door on first floor near rooms was locked, obstructing egress.
Last furnace inspection was conducted on 7/2/18, not annually as required.
Medical evaluation for resident #1 was not completed within 60 days prior to admission or within 30 days after admission.
Medical evaluation for resident #2 was not documented on a form specified by the Department.
Resident #3's glucometer was not calibrated to the correct date and time; discrepancies in blood sugar readings and medication administration records were noted.
Medication administration records for resident #1 showed administration of Lorazepam Tab 1 MG on dates when medication was not available in the home.
Medication error involving resident #1 was not reported to the resident, designated person, or prescriber.
Staff person A administers medications without successfully completing the Department-approved medication administration course.
Resident #5’s preadmission screening form did not include a determination that the resident's needs can be met by the services provided by the home.
Assessments were not completed for residents #1 and #5 within 15 days of admission.
Resident #2’s assessment did not include evaluation of telephone use, personal possessions care, correspondence, social activities, prosthetic device use, and clothing.
Resident #2’s support plan did not document how the need for orientation to time, place, and person will be met.
Resident #2’s support plan was not signed by the assessor.
Resident #2 participated in support plan development but did not sign it; no notation of refusal or inability to sign was documented.
Report Facts
Residents Served: 18
License Capacity: 37
Total Daily Staff: 18
Waking Staff: 14
Repeat Violations: 3
Hot Water Temperature: 122
Hot Water Temperature: 125.7
Hot Water Temperature: 124.3
Notice
Capacity: 37
Deficiencies: 0
Date: Apr 16, 2021
Visit Reason
The document serves as a renewal notification and issuance of a regular license for Paradise Manor, a Personal Care Home, following receipt of the renewal application dated March 23, 2021.
Findings
The Department advises that an onsite inspection will be conducted within the next twelve months to ensure compliance with applicable regulations. No findings or deficiencies are reported in this document.
Report Facts
Total licensed capacity: 37
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary | Signed the renewal notification letter |
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