Deficiencies per Year
16
12
8
4
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Census: 59
Capacity: 70
Deficiencies: 0
Sep 11, 2025
Visit Reason
The inspection was conducted as a partial, unannounced visit due to an incident at the facility.
Findings
No regulatory citations or deficiencies were identified during the inspection.
Report Facts
Total Daily Staff: 76
Waking Staff: 57
Residents Served: 59
License Capacity: 70
Residents Age 60 or Older: 59
Residents with Intellectual Disability: 1
Residents with Mobility Need: 17
Inspection Report
Follow-Up
Census: 48
Capacity: 70
Deficiencies: 4
May 7, 2024
Visit Reason
The inspection was a partial, unannounced follow-up visit conducted on 05/07/2024 to review the implementation of a previously submitted plan of correction related to medication management and administration.
Findings
The facility was found to have fully implemented the submitted plan of correction addressing multiple medication-related deficiencies, including expired medications, mislabeled medications, incomplete medication records, and failure to follow prescriber's orders. Continued compliance is required.
Deficiencies (4)
| Description |
|---|
| Expired inhaler was found in medication cart removed from its foil pouch with an open date. |
| Medications were not labeled correctly according to pharmacy labels, with discrepancies in dosage instructions. |
| Medication administration records indicated medications were administered on certain dates, but medications were not actually administered or present in the home. |
| Failure to follow prescriber's orders with multiple medications not administered as prescribed on multiple dates. |
Report Facts
License Capacity: 70
Residents Served: 48
Total Daily Staff: 72
Waking Staff: 54
Current Hospice Residents: 3
Inspection Report
Monitoring
Census: 53
Capacity: 70
Deficiencies: 10
Mar 12, 2024
Visit Reason
The visit was a monitoring inspection conducted by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing on 03/12/2024 and 03/13/2024 to review compliance and verify the implementation of a previously submitted plan of correction.
Findings
The inspection found multiple deficiencies including inadequate staffing during night shifts, improper use of glucometers across residents, incomplete and undated medical evaluations, presence of discontinued medications, medication labeling errors, medication administration record inaccuracies, failure to follow prescriber's orders, incomplete fire drill records, and missing resident medical evaluations in the home. Plans of correction were accepted and implemented with ongoing audits and staff training to ensure compliance.
Deficiencies (10)
| Description |
|---|
| Inadequate staffing on night shift with only 2 direct care staff for 54 residents including 14 with mobility needs. |
| Use of resident #1's glucometer to measure blood glucose levels of other residents, risking cross-contamination. |
| Fire drill record for 12/12/23 did not include the time of the drill. |
| Resident #5's medical evaluation was incomplete in the areas of Health Status and Cognitive Functioning. |
| Resident #6's most recent medical evaluation was undated. |
| Discontinued medications for resident #7 were still present in the home. |
| Medication label for resident #7 did not accurately reflect directions. |
| Medication administration record showed resident #7 was given medication that was not available in the home. |
| Failure to follow prescriber's orders for residents #1, #4, and #7 including missed medications and blood glucose checks. |
| Resident #6's 2023 medical evaluation was not available in the home; it was kept electronically in a former system no longer used. |
Report Facts
Residents served: 53
License capacity: 70
Staffing count: 2
Residents with mobility needs: 14
Total daily staff: 65
Waking staff: 49
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff Member A | Named in relation to improper use of glucometer and medication administration training |
Inspection Report
Follow-Up
Census: 54
Capacity: 70
Deficiencies: 15
Oct 12, 2023
Visit Reason
The inspection visit was conducted as a follow-up to verify the implementation of a previously submitted plan of correction related to renewal, complaint, and incident concerns at the facility.
Findings
The report documents multiple deficiencies related to abuse, staffing, sanitary conditions, fire safety drills, medical evaluations, medication management, assessments, and support plan signatures. The facility has taken corrective actions and implemented plans of correction, with ongoing monitoring and audits scheduled to maintain compliance.
Deficiencies (15)
| Description |
|---|
| Staff person made unauthorized charges to a resident's credit card and other abuse-related violations. |
| Insufficient staffing levels to meet residents' needs and assist with emergency evacuation. |
| Use of a deceased resident's glucometer for blood glucose measurements, violating sanitary conditions. |
| Failure to conduct fire drills during sleeping hours every six months. |
| Only stairwells were used as exit routes during fire drills, not alternate exit routes. |
| Fire drills were routinely held when additional staff were present and at times of low resident attendance. |
| Medical evaluation for a resident was not completed within required timeframes. |
| Medical evaluations for residents lacked required information such as vital signs and professional details. |
| Annual medical evaluations were not completed timely for a resident. |
| Current prescriptions were not properly maintained; discontinued medications were still present. |
| Medication records did not accurately reflect prescribed medications and dosages for a resident. |
| Failure to follow prescriber's orders due to unavailable medication supplies and inaccurate medication records. |
| Initial resident assessments were incomplete or missing required diagnoses. |
| Additional resident assessments were not updated to reflect current diagnoses. |
| Support plans were not signed by residents or assessors, nor documented reasons for lack of signatures. |
Report Facts
Residents served: 54
License capacity: 70
Staffing hours: 71
Waking staff: 53
Residents with mobility needs: 17
Residents diagnosed with mental illness: 30
Residents aged 60 or older: 54
Inspection Report
Census: 58
Capacity: 70
Deficiencies: 0
May 18, 2023
Visit Reason
The inspection was conducted as a licensing inspection triggered by an incident, with an unannounced partial inspection type.
Findings
No regulatory citations or deficiencies were identified during this inspection.
Report Facts
Total Daily Staff: 80
Waking Staff: 60
Residents Served: 58
License Capacity: 70
Residents Age 60 or Older: 57
Residents with Mobility Need: 22
Residents Diagnosed with Intellectual Disability: 1
Inspection Report
Renewal
Census: 63
Capacity: 70
Deficiencies: 15
Oct 4, 2022
Visit Reason
The inspection was conducted as a renewal visit to review compliance with licensing requirements and verify the implementation of the submitted plan of correction.
Findings
The inspection identified multiple deficiencies including improper placement of carbon monoxide detectors, missing contract signature dates, lack of an annual training plan, unlabeled poisonous materials, missing window screens, outdated food items, overdue fire extinguisher inspections, missed fire drills, incomplete evacuation during fire drills, incomplete first aid kits in transport vehicles, medication labeling and administration documentation errors, incomplete preadmission screening forms, incomplete resident assessments, and incomplete support plans. All deficiencies had plans of correction accepted and were implemented by February 18, 2023.
Deficiencies (15)
| Description |
|---|
| Carbon monoxide detectors were installed within 5 feet of fossil fuel burning air handlers, violating placement standards. |
| Resident-home contract for resident #1 lacked the date the resident signed the contract. |
| The home did not have an annual training plan for the year 2022. |
| An unlabeled 2-gallon spray bottle containing a hazardous floor cleaner was found in the housekeeping supply room. |
| Missing window screens in the northwest and northeast stairwell windows on multiple floors. |
| Outdated food items including a bag of flour and bottle of vinegar were found in the kitchenette cabinet. |
| Fire extinguishers in laundry rooms had not been inspected since June 2021. |
| An unannounced fire drill was not held during January 2022. |
| Fire drill records showed incomplete evacuation of residents during multiple drills in 2022. |
| First aid kits in two transport vehicles did not include antiseptic. |
| Medication label for resident #2 did not match prescribed dosage instructions. |
| Medication administration record for resident #4 lacked staff initials for certain medication administrations. |
| Resident #4's preadmission screening form did not include a determination that the resident's needs could be met by the home. |
| Resident #3's assessment did not indicate the need for an assistive enabler bar on the bed. |
| Resident #2's support plan did not indicate the outside services being provided. |
Report Facts
Residents Served: 63
License Capacity: 70
Total Daily Staff: 75
Waking Staff: 56
Current Hospice Residents: 2
Residents Age 60 or Older: 62
Residents with Mobility Need: 12
Residents with Physical Disability: 3
Fire Drill Resident Counts: 90
Fire Drill Resident Counts: 92
Fire Drill Resident Counts: 95
Fire Drill Resident Counts: 96
Fire Drill Resident Counts: 96
Fire Drill Resident Counts: 101
Fire Drill Resident Counts: 103
Fire Drill Resident Counts: 101
Fire Drill Resident Counts: 106
Fire Drill Evacuated Residents: 55
Fire Drill Evacuated Residents: 57
Fire Drill Evacuated Residents: 59
Fire Drill Evacuated Residents: 59
Fire Drill Evacuated Residents: 59
Fire Drill Evacuated Residents: 61
Fire Drill Evacuated Residents: 62
Fire Drill Evacuated Residents: 60
Fire Drill Evacuated Residents: 61
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Chris Hall | Maintenance Director | Made corrections to carbon monoxide detectors, inspected devices, installed window screens, and completed fire extinguisher audits. |
| Nursing Supervisor | Corrected medication label for resident #2 and educated medication technicians. | |
| Administrator | Completed audits of contracts, training plans, food audits, fire extinguisher checklists, fire drills, and preadmission screens. | |
| Housekeeping Supervisor | Corrected unlabeled poisonous material and trained housekeeping staff on handling. | |
| Medication Techs | Conducted medication cart audits. | |
| LPN | Conducted medication cart audits and educated on medication administration. |
Inspection Report
Renewal
Deficiencies: 0
Jan 12, 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.
Notice
Capacity: 70
Deficiencies: 0
Sep 28, 2021
Visit Reason
The document serves as a renewal notification and license issuance for the Personal Care Home Regency Suites/Regency at South Shore, confirming receipt of the renewal application and advising of the requirement for an annual onsite inspection within the next twelve months.
Findings
No inspection findings are reported in this document; it is an administrative license renewal notice confirming the facility's compliance and outlining future inspection requirements.
Report Facts
Maximum licensed capacity: 70
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary, Office of Long-term Living | Signed the renewal notification letter. |
Inspection Report
Renewal
Census: 59
Capacity: 70
Deficiencies: 7
Jul 19, 2021
Visit Reason
The inspection was a full, unannounced renewal inspection conducted on 07/19/2021 and 07/20/2021 to assess compliance with licensing requirements at Regency Suites/Regency at South Shore.
Findings
The inspection identified multiple deficiencies including unsigned resident contracts, missing emergency telephone numbers by resident phones, improper food storage, incomplete medication records, missing diagnoses in resident assessments, and unsigned support plans. All deficiencies had plans of correction accepted and were reported as implemented.
Deficiencies (7)
| Description |
|---|
| Resident-home contract for resident #2 was not signed by the resident. |
| No emergency telephone numbers including nearest hospital and fire department on or by the telephone in room #125 and #216. |
| Walk-in freezer in the kitchen contained an opened and unsealed bag of approximately 20 chicken patties. |
| Resident #3's medication administration record did not indicate dosage for additional insulin units according to sliding scale. |
| Resident #1's assessment did not include diagnoses of neuropathy of feet, hypertension, and urinary retention as indicated on medical evaluation. |
| Resident #2's assessment did not include diagnoses of low back pain, toxic encephalopathy, and repeated falls as indicated on medical evaluation. |
| Resident #4’s support plan was not signed by the resident nor indicated inability or refusal to sign. |
Report Facts
License Capacity: 70
Residents Served: 59
Current Residents in Hospice: 2
Residents Diagnosed with Mental Illness: 27
Residents Aged 60 or Older: 58
Residents with Mobility Need: 8
Total Daily Staff: 67
Waking Staff: 50
Personal Care Leases Audited: 59
Leases Needing Resident Signatures: 5
Nurses Auditing Medication Records: 3
Nursing Staff Auditing Support Plans: 3
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