Inspection Reports for Providence Place Senior Living of Lancaster
PA, 17603
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Inspection Report
Plan of Correction
Census: 99
Capacity: 125
Deficiencies: 4
Jul 31, 2025
Visit Reason
The inspection was a partial, unannounced incident-related review conducted on 07/31/2025 to evaluate compliance with licensing requirements and the submitted plan of correction.
Findings
The facility was found to have multiple deficiencies including failure to timely report a medication administration incident, unsanitary resident room conditions, unlocked medications accessible to residents, and failure to follow prescriber’s medication orders. Plans of correction were accepted and implemented by 09/29/2025.
Deficiencies (4)
| Description |
|---|
| Failure to report a medication administration incident to the Department within 24 hours. |
| Resident room smelled of urine and had a urine bottle partially filled and hanging on the resident’s walker. |
| Unlocked, unattended, and accessible wound care gel observed in resident medicine cabinet without assessment for self-administration. |
| Resident was not administered prescribed medications at scheduled times (4:00pm, 5:00am, and 7:00am). |
Report Facts
License Capacity: 125
Residents Served: 99
Special Care Unit Capacity: 44
Special Care Unit Residents Served: 39
Current Hospice Residents: 10
Total Daily Staff: 146
Waking Staff: 110
Residents Age 60 or Older: 99
Residents with Mobility Need: 47
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director | Provided education to Licensed Practical Nurses, Medication Techs, Director of Nursing, and Connections Director regarding incident reporting, sanitary conditions, medication storage, and medication administration. | |
| Director of Nursing | Responsible for timely reporting of incidents and monitoring compliance with prescriber’s orders. | |
| Connections Director | Responsible for timely reporting of incidents and monitoring compliance with prescriber’s orders. | |
| LPN/Shift Lead MT | Licensed Practical Nurse / Shift Lead Medication Technician | Received counseling and education on medication administration and compliance. |
Inspection Report
Follow-Up
Census: 72
Capacity: 125
Deficiencies: 2
Mar 20, 2025
Visit Reason
The inspection was conducted as a follow-up review of the submitted plan of correction for the facility, triggered by an incident.
Findings
The review determined that the submitted plan of correction was fully implemented. Two deficiencies were noted related to support plan signatures and preadmission screening documentation, both of which had corrective actions accepted and implemented.
Deficiencies (2)
| Description |
|---|
| Resident support plans were developed but not signed and dated by the resident or resident’s designee. |
| Preadmission screening forms were completed but did not include the date each was completed; one resident's screening was not completed in collaboration with a physician or geriatric assessment team. |
Report Facts
License Capacity: 125
Residents Served: 72
Special Care Unit Capacity: 44
Special Care Unit Residents Served: 29
Current Hospice Residents: 12
Residents Age 60 or Older: 72
Residents with Mobility Need: 39
Residents with Physical Disability: 1
Staffing Hours - Total Daily Staff: 111
Staffing Hours - Waking Staff: 83
Inspection Report
Renewal
Census: 74
Capacity: 125
Deficiencies: 11
Oct 29, 2024
Visit Reason
The inspection was conducted as a full, unannounced review for renewal, complaint, and incident reasons at Providence Place of Lancaster.
Findings
Multiple deficiencies were identified including unlocked poisonous materials accessible to residents, missing emergency telephone numbers, improper food storage, lint accumulation in dryer, obstructed egress, incomplete fire drill records, failure to evacuate to designated meeting places during fire drills, unlocked medications in resident rooms, disorganized medication storage, incomplete medication records, and failure to follow prescriber's orders. All deficiencies had accepted plans of correction and were implemented by December 4, 2024.
Deficiencies (11)
| Description |
|---|
| Unlocked and unattended room with poisonous materials accessible to residents in the Connections Special Care Unit. |
| No emergency telephone numbers posted on or by the telephone in bedroom 24. |
| Food stored in opened and unsealed containers in cooler and walk-in freezer. |
| Accumulation of lint in the lint trap of the dryer in the west hallway laundry room. |
| Chair and piano blocked egress from the residence’s main dining room. |
| Fire drill records missing information on problems encountered and time of day for drills conducted on 10/21/24, 6/15/24, and 5/23/24. |
| Residents did not evacuate to designated meeting place during fire drills on 10/21/24 and 6/15/24. |
| Unlocked and accessible medications in Resident 1 and Resident 2's bedrooms; residents not assessed to self-administer. |
| Loose pill and inhaler without indication of opening date found in medication carts. |
| Medication administration record missing diagnosis or purpose for prescribed medications for Resident 4. |
| Resident 4 did not receive prescribed medication as ordered; medication given only twice instead of three times. |
Report Facts
License Capacity: 125
Residents Served: 74
Special Care Unit Capacity: 55
Special Care Unit Residents Served: 26
Hospice Current Residents: 5
Residents with Mobility Need: 36
Residents Age 60 or Older: 74
Staff Total Daily: 110
Staff Waking: 83
Inspection Report
Follow-Up
Census: 78
Capacity: 125
Deficiencies: 6
Oct 17, 2024
Visit Reason
The visit was a partial, unannounced inspection conducted due to an incident, with a follow-up on the submitted plan of correction to verify full implementation.
Findings
The inspection found multiple deficiencies including failure to immediately report suspected resident abuse, breaches in record confidentiality with unsecured medication bottles, inadequate assistance with IADLs as per resident support plans, unlocked medications accessible to residents, incomplete annual assessments, and missing cognitive preadmission screening for a special care unit resident. The submitted plan of correction was determined to be fully implemented.
Deficiencies (6)
| Description |
|---|
| Failure to immediately report suspected resident abuse to the local Area Agency on Aging. |
| Resident records confidentiality breached by leaving empty medication bottles with prescription labels unlocked and unattended. |
| Residents did not receive required assistance with IADLs and supervision as indicated in their assessment and support plans. |
| Prescription medication was left unlocked, unattended, and accessible on the medication cart. |
| Annual written assessments for residents were not completed on time. |
| Written cognitive preadmission screening was not completed within 72 hours prior to admission to a special care unit. |
Report Facts
License Capacity: 125
Residents Served: 78
Special Care Unit Capacity: 44
Special Care Unit Residents Served: 30
Current Hospice Residents: 6
Total Daily Staff: 108
Waking Staff: 81
Inspection Report
Complaint Investigation
Census: 84
Capacity: 125
Deficiencies: 3
Mar 13, 2024
Visit Reason
The inspection was conducted as a complaint and incident investigation at Providence Place of Lancaster on 03/13/2024.
Findings
The inspection found multiple deficiencies including unlocked poisonous materials accessible to residents in the secured dementia unit, incomplete preliminary support plans lacking necessary medical care documentation, and failure to complete additional written assessments following significant resident condition changes. The submitted plan of correction was fully implemented by 04/01/2024.
Complaint Details
The inspection was complaint-driven and included incident investigation. The submitted plan of correction was accepted and fully implemented.
Deficiencies (3)
| Description |
|---|
| Unlocked poisonous materials (Arm and Hammer toothpaste and Degree deodorant) accessible to residents in the secured dementia unit. |
| Preliminary support plan did not include care services needed to meet resident's medical condition of asthma and hypoxia respiratory failure. |
| Failure to complete additional written assessment after resident sustained injury from unwitnessed fall and prescribed neck brace and therapy. |
Report Facts
License Capacity: 125
Residents Served: 84
Special Care Unit Capacity: 44
Special Care Unit Residents Served: 32
Hospice Residents: 11
Resident Mobility Need: 40
Resident Physical Disability: 1
Total Daily Staff: 124
Waking Staff: 93
Inspection Report
Renewal
Census: 89
Capacity: 125
Deficiencies: 10
Nov 29, 2023
Visit Reason
The inspection was conducted as a renewal and incident review of the Providence Place of Lancaster facility on 11/29/2023 and 11/30/2023.
Findings
The inspection identified multiple deficiencies including abuse/neglect incidents, unlocked poisonous materials, sanitary condition issues, combustible storage violations, presence of a portable space heater, incomplete self-administer medication assessments, unlocked medication carts, improper medication storage, failure to follow prescriber orders, and incomplete admission support plans. Plans of correction were submitted and accepted with completion dates in December 2023.
Deficiencies (10)
| Description |
|---|
| Abuse/Neglect: Resident 2 sustained injury from Resident 1 pushing; inappropriate touching and kissing of Resident 3 by staff member. |
| Poisonous materials unlocked and accessible to residents in secured dementia unit. |
| Pungent odor of urine detected in resident room #210. |
| Combustible and flammable materials stored near heat sources and hot water heaters. |
| Unplugged portable space heater stored in lobby. |
| Resident 8 not assessed by qualified professional for ability to self-administer medications. |
| Medication cart unlocked, unattended, and accessible in secured dementia unit near apartment 111. |
| Loose pills found in medication carts not properly stored. |
| Medication not administered to Resident 7 as prescribed due to unavailability. |
| Initial support plans not completed timely for Residents 1, 4, and 6 admitted to special care unit. |
Report Facts
Residents served: 89
License capacity: 125
Special care unit capacity: 44
Special care unit residents served: 39
Current hospice residents: 6
Residents with mobility need: 44
Residents aged 60 or older: 89
Residents with physical disability: 1
Paint cans stored near hot water heaters: 6
Medication cart unlocked incidents: 1
Loose pills found: 5
Inspection Report
Follow-Up
Census: 101
Capacity: 125
Deficiencies: 3
Oct 12, 2023
Visit Reason
The inspection visit occurred as a follow-up to review the submitted plan of correction for the facility following an incident.
Findings
The report found multiple deficiencies related to abuse/neglect, support plan signatures, and preadmission screening documentation. The facility implemented corrective actions including additional staff training, audits, and monitoring to ensure compliance.
Deficiencies (3)
| Description |
|---|
| A verbal and physical altercation occurred between residents resulting in injury, with inadequate supervision and safety measures. |
| Resident 2’s annual support plan was signed but not dated in the required section. |
| Resident 1 and Resident 5’s written cognitive preadmission screenings were incomplete or missing required information. |
Report Facts
Residents Served: 101
License Capacity: 125
Special Care Unit Capacity: 44
Special Care Unit Residents Served: 35
Hospice Current Residents: 5
Residents Age 60 or Older: 100
Residents with Mobility Need: 35
Inspection Report
Complaint Investigation
Census: 61
Capacity: 125
Deficiencies: 2
Nov 4, 2021
Visit Reason
The inspection was conducted as a complaint investigation following an allegation related to resident abuse and dietary needs.
Findings
The facility failed to immediately report an allegation of theft by a resident to the appropriate authorities and served residents diets that did not meet prescribed mechanical soft/chopped requirements.
Complaint Details
The complaint involved an allegation of theft made by Resident #1 to Staff Member A on 10/17/21, which was not reported immediately by the facility. The complaint was substantiated with corrective actions implemented.
Deficiencies (2)
| Description |
|---|
| Failure to report suspected resident abuse (theft allegation) to the local area agency on aging or the Department. |
| Residents were served food inconsistent with their prescribed mechanical soft/chopped diets. |
Report Facts
License Capacity: 125
Residents Served: 61
Special Care Unit Capacity: 44
Special Care Unit Residents Served: 21
Residents 60 Years or Older: 82
Inspection Report
Complaint Investigation
Census: 61
Capacity: 125
Deficiencies: 2
Nov 4, 2021
Visit Reason
The inspection was conducted as a complaint investigation following an unannounced partial inspection on 11/04/2021.
Findings
Two deficiencies were identified: failure to immediately report an allegation of resident abuse (theft) and failure to meet residents' prescribed special dietary needs by serving incorrect food consistency.
Complaint Details
The visit was complaint-related, triggered by an allegation of theft made by Resident #1 to Staff Member A. The allegation was initially not reported by the residence but was later reported to DHS and the Area Agency on Aging by the Executive Director.
Deficiencies (2)
| Description |
|---|
| Failure to immediately report suspected abuse of a resident (theft allegation) to the local area agency on aging or the Department. |
| Residents prescribed mechanical soft/chopped diets were served food that was not chopped, violating dietary requirements. |
Report Facts
License Capacity: 125
Residents Served: 61
Special Care Unit Capacity: 44
Special Care Unit Residents Served: 21
Residents Age 60 or Older: 82
Total Daily Staff: 61
Waking Staff: 46
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director | Named in relation to reporting the abuse allegation and staff education on abuse and neglect reporting. | |
| Dining Director | Named in relation to verifying and correcting residents' special dietary needs and educating dietary staff. | |
| LPN Shift Lead nurse | LPN Shift Lead nurse | Involved in verifying residents' diets for accuracy. |
Notice
Capacity: 125
Deficiencies: 0
Oct 5, 2021
Visit Reason
The document is a renewal license notification letter confirming receipt of the renewal application and advising that an annual onsite inspection will be conducted within the next twelve months.
Findings
No inspection findings are reported in this document; it serves as a license renewal confirmation and notification of upcoming inspection requirements.
Report Facts
Maximum licensed capacity: 125
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary, Office of Long-term Living | Signed the renewal notification letter |
| Richard Barley | Chief Operating Officer | Recipient of the renewal notification letter |
Notice
Capacity: 125
Deficiencies: 0
Jul 14, 2021
Visit Reason
The document serves as a notification of approval for a revised license increasing the Special Care Unit capacity from 40 to 55 at Providence Place of Lancaster.
Findings
The Department granted approval for the requested capacity increase for the Special Care Unit, with the license expiration date remaining unchanged.
Report Facts
Licensed capacity: 125
Special Care Unit capacity: 55
Previous Special Care Unit capacity: 40
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary | Signed the approval letter for the revised license |
Inspection Report
Original Licensing
Capacity: 125
Deficiencies: 0
Jan 12, 2021
Visit Reason
Licensing inspection of a newly licensed assisted living facility to assess compliance with regulations and issue a new license.
Findings
The facility was found to be in substantial compliance with applicable regulations, but the licensing inspector was unable to complete a full inspection due to the new legal entity operating the home. A re-inspection will be conducted within 3 months.
Report Facts
Maximum capacity: 125
Special Care Unit capacity: 40
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary | Signed letter regarding licensing inspection findings |
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