Inspection Report
Complaint Investigation
Census: 63
Capacity: 70
Deficiencies: 1
Jul 31, 2025
Visit Reason
The inspection was conducted as a complaint investigation with an unannounced partial inspection on 07/31/2025 to review compliance and the submitted plan of correction.
Findings
The facility was found to have a deficiency related to the resident initial assessment form not being completed on the Department’s assessment form and missing multiple required elements. A plan of correction was directed and later implemented to ensure all required assessment content is included in resident service plans.
Complaint Details
The inspection was complaint-driven and the submitted plan of correction was fully implemented as of 09/29/2025.
Deficiencies (1)
| Description |
|---|
| Resident initial assessment was not completed on the Department’s assessment form and lacked required information including formal and informal supports, assessment dates, reasons, levels of supervision and mobility, medical, dental, dietary, sensory, mental health, social needs, and assessor details. |
Report Facts
License Capacity: 70
Residents Served: 63
Current Residents in Hospice: 9
Residents Age 60 or Older: 63
Residents with Mobility Need: 17
Residents with Physical Disability: 2
Total Daily Staff: 80
Waking Staff: 60
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Area Director of Clinical Services | In-serviced Health and Wellness Director on assessment content requirements as part of plan of correction | |
| Health and Wellness Director | Responsible for ensuring assessment content inclusion and completing quarterly service plan reviews | |
| Executive Director | Responsible for reviewing service plans and auditing new admissions for compliance |
Inspection Report
Complaint Investigation
Census: 62
Capacity: 70
Deficiencies: 0
Apr 1, 2025
Visit Reason
The inspection was conducted as a complaint investigation at the facility.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Complaint Details
The inspection was complaint-driven, but no deficiencies or citations were found, indicating no substantiated issues.
Report Facts
Residents Served: 62
License Capacity: 70
Current Hospice Residents: 7
Residents Age 60 or Older: 62
Residents with Mobility Need: 16
Total Daily Staff: 78
Waking Staff: 59
Inspection Report
Renewal
Census: 61
Capacity: 70
Deficiencies: 13
Aug 27, 2024
Visit Reason
The inspection was a full, unannounced renewal inspection conducted on 08/27/2024 and 08/28/2024, including an incident review and follow-up on plan of correction submissions.
Findings
Multiple deficiencies were identified including failure to post current license inspection summary, expired elevator inspection certification, incomplete medical evaluations, unsigned resident contracts, missing signed resident rights statements, insufficient first aid/CPR trained staff, incomplete staff orientation and training, missing emergency procedures posting, incomplete fire drill evacuation, medication records lacking diagnosis/purpose, and lack of resident education on medication refusal rights. All deficiencies had accepted plans of correction with proposed completion dates mostly by 09/30/2024 or 10/31/2024.
Deficiencies (13)
| Description |
|---|
| The residence's most recent license inspection summary dated 8/10/23 was not posted in a conspicuous and public place. |
| The residence's elevator inspection certification expired on 5/31/24. |
| Resident #5's initial medical evaluation was completed more than 60 days prior to admission. |
| Residents #2, #3, #4, and #6 did not sign the facility contract. |
| Resident #6's record did not contain a signed statement acknowledging receipt of resident rights and complaint procedures. |
| On 8/14/24 and 8/18/24, only one staff member was certified and trained in first aid and CPR for 62 residents. |
| Staff person A did not receive required orientation on fire safety and emergency preparedness topics on their first day of work. |
| Staff person A did not complete required orientation training within the first 40 hours worked on resident rights, emergency medical plan, abuse reporting, and core competencies. |
| Staff person A provided unsupervised assisted living services without completing 18 hours of required direct care training. |
| The residence’s emergency procedures were not posted in a conspicuous and public place. |
| During the fire drill on 5/21/24, only 53 out of 57 residents evacuated the building. |
| Resident #3's medication administration record did not include a diagnosis or purpose for prescribed medications. |
| Residents #1, #2, #3, #4, #5, and #6 were not educated on their right to refuse medication if they believe there may be a medication error. |
Report Facts
License Capacity: 70
Residents Served: 61
Current Residents in Hospice: 12
Residents 60 Years or Older: 61
Residents with Mobility Need: 20
Residents with Physical Disability: 1
Total Daily Staff: 81
Waking Staff: 61
Staff Certified in First Aid/CPR: 1
Residents Present During CPR Deficiency: 62
Residents Evacuated During Fire Drill: 53
Residents Present During Fire Drill: 57
Inspection Report
Renewal
Census: 61
Capacity: 70
Deficiencies: 4
Aug 2, 2023
Visit Reason
The inspection was conducted as a renewal inspection of the facility's license, with an unannounced full inspection on 08/02/2023 and an exit conference on 08/03/2023.
Findings
The inspection identified several deficiencies related to criminal background checks, expired medications, improper medication storage, and medication administration record inaccuracies. Plans of correction were submitted and determined to be fully implemented by 09/22/2023.
Deficiencies (4)
| Description |
|---|
| Staff Member A did not have a Pennsylvania State Police background check completed within the acceptable timeframe. |
| Expired narcotic medications (Lorazepam and Tramadol HCL) were found in the medication cart. |
| Loose pill found in medication cart and insulin vials lacked dates showing when medications were opened. |
| Glucometer for Resident #4 lacked calibration to the correct date and time, and discrepancies were found in medication administration record (MAR) recordings. |
Report Facts
License Capacity: 70
Residents Served: 61
Current Hospice Residents: 9
Residents Diagnosed with Mental Illness: 1
Residents with Mobility Need: 11
Total Daily Staff: 72
Waking Staff: 54
Inspection Report
Original Licensing
Deficiencies: 0
Jun 8, 2022
Visit Reason
The inspection was conducted as a licensing inspection for a newly licensed assisted living facility operated by a new legal entity.
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 status. A re-inspection will be conducted within 3 months of the license effective date.
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