Deficiencies per Year
16
12
8
4
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Complaint Investigation
Census: 72
Capacity: 104
Deficiencies: 0
Aug 6, 2025
Visit Reason
The inspection was conducted as a complaint investigation during an unannounced partial licensing inspection of the facility.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Complaint Details
The inspection was complaint-related, but no deficiencies or citations were found, indicating no substantiated issues.
Report Facts
Total Daily Staff: 90
Waking Staff: 68
Residents Served: 72
License Capacity: 104
Current Hospice Residents: 13
Residents Age 60 or Older: 72
Residents with Mental Illness: 1
Residents with Intellectual Disability: 1
Residents with Mobility Need: 18
Residents with Physical Disability: 2
Inspection Report
Follow-Up
Census: 82
Capacity: 104
Deficiencies: 1
Apr 22, 2025
Visit Reason
The inspection was conducted as a follow-up to review the submitted plan of correction for an incident at the facility.
Findings
The submitted plan of correction was fully implemented and compliance was maintained. The facility took immediate action including staff suspension and termination, retraining, and implementation of weekly audits to ensure adherence to resident care requirements.
Deficiencies (1)
| Description |
|---|
| Failure to check on a resident every two hours as required by the resident’s assessment and support plan. |
Report Facts
Residents Served: 82
License Capacity: 104
Current Residents in Hospice: 13
Residents Age 60 or Older: 88
Residents with Mobility Need: 22
Residents with Physical Disability: 2
Residents Diagnosed with Intellectual Disability: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director | Retrained staff and responsible for ongoing training and weekly audits | |
| Director of Health and Wellness | Retrained staff and responsible for ongoing training and weekly audits |
Inspection Report
Census: 86
Capacity: 104
Deficiencies: 0
Mar 5, 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
Residents Served: 86
License Capacity: 104
Current Hospice Residents: 10
Residents Age 60 or Older: 85
Residents with Mobility Need: 18
Residents with Physical Disability: 4
Residents Diagnosed with Mental Illness: 1
Residents Diagnosed with Intellectual Disability: 1
Residents Receiving Supplemental Security Income: 0
Inspection Report
Complaint Investigation
Census: 88
Capacity: 104
Deficiencies: 3
Jan 31, 2025
Visit Reason
The inspection was conducted as a complaint investigation to review compliance with regulations and verify the submitted plan of correction for the facility.
Findings
The inspection found deficiencies related to failure to provide a 30-day written advance notice for rate changes, missing initial resident assessments within 15 days of admission, and missing resident support plans within 30 days of admission. The facility submitted and implemented plans of correction addressing these issues.
Complaint Details
The visit was complaint-related as indicated by the inspection reason. The submitted plan of correction was reviewed and determined to be fully implemented as of 01/31/2025.
Deficiencies (3)
| Description |
|---|
| Failure to provide resident with a 30-day written statement of the increase in rate from care level 2 to care level 4. |
| Resident initial assessment was not completed within 15 days of admission and could not be located. |
| Resident support plan was not completed within 30 days of admission and could not be located. |
Report Facts
Residents Served: 88
License Capacity: 104
Current Residents in Hospice: 7
Residents Age 60 or Older: 88
Residents with Mobility Need: 15
Residents with Physical Disability: 3
Residents Diagnosed with Mental Illness: 1
Residents Diagnosed with Intellectual Disability: 1
Inspection Report
Follow-Up
Census: 87
Capacity: 104
Deficiencies: 6
Jan 9, 2025
Visit Reason
The inspection visit was conducted as a follow-up to verify the implementation of a previously submitted plan of correction related to an incident at the facility.
Findings
The facility was found to have multiple deficiencies including failure to submit an approved plan of supervision for a staff member after an abuse allegation, neglect of a resident requiring incontinence care, unqualified direct care staff, missing annual medical evaluations, unsecured medication carts, and incomplete resident assessment support plans. The facility implemented corrective actions including staff training, audits, and tracking systems to address these issues.
Deficiencies (6)
| Description |
|---|
| Failure to submit an approved plan of supervision for a staff member after an abuse allegation. |
| Resident found in bed covered in dried urine and feces due to missed incontinence checks every 2 hours. |
| Direct care staff member had a non-US college diploma without a waiver from the Department. |
| Resident did not have an annual medical evaluation completed in 2024. |
| Unsecured and unattended medication cart observed in hallway near resident room. |
| Resident's most recent Resident Assessment Support Plan was not completed timely. |
Report Facts
License Capacity: 104
Residents Served: 87
Total Daily Staff: 101
Waking Staff: 76
Current Hospice Residents: 8
Residents Diagnosed with Mental Illness: 1
Residents with Mobility Need: 14
Residents with Physical Disability: 3
Inspection Report
Complaint Investigation
Census: 82
Capacity: 104
Deficiencies: 1
Oct 17, 2024
Visit Reason
The inspection was conducted as a complaint investigation with an unannounced partial review on 10/17/2024.
Findings
The facility was found to have a deficiency related to the malfunctioning of a pressure air mattress used by a resident, which was not working properly for 2-4 hours on 10/8/2024. The facility submitted a plan of correction which was accepted and implemented.
Complaint Details
The inspection was complaint-related as stated under Inspection Information with reason 'Complaint'.
Deficiencies (1)
| Description |
|---|
| Pressure air mattress used by a resident was found not working properly for 2-4 hours on 10/8/2024. |
Report Facts
License Capacity: 104
Residents Served: 82
Current Hospice Residents: 8
Inspection Report
Census: 85
Capacity: 104
Deficiencies: 0
Oct 9, 2024
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 as a result of this inspection.
Report Facts
Total Daily Staff: 95
Waking Staff: 71
Current Residents: 9
Residents Served: 85
License Capacity: 104
Inspection Report
Complaint Investigation
Census: 90
Capacity: 104
Deficiencies: 1
Sep 11, 2024
Visit Reason
The inspection was conducted as a complaint investigation with unannounced partial inspections on 09/11/2024 and 09/16/2024 to review compliance and the submitted plan of correction.
Findings
The facility was found to have deficiencies related to incomplete documentation in resident support plans, specifically failing to document medical, dental, vision, hearing, mental health, or behavioral care services and actions to address resident behaviors. The submitted plan of correction was accepted and deemed fully implemented.
Complaint Details
The visit was complaint-related as indicated by the inspection reason. The submitted plan of correction was accepted and fully implemented as of 10/23/2024.
Deficiencies (1)
| Description |
|---|
| Resident care needs and actions to address these needs were not documented in the resident assessment and support plan dated 4/29/2024. |
Report Facts
License Capacity: 104
Residents Served: 90
Current Residents in Hospice: 11
Residents Age 60 or Older: 90
Residents with Mobility Need: 8
Residents with Physical Disability: 2
Total Daily Staff: 98
Waking Staff: 74
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Health and Wellness | Named in plan of correction for updating resident support plans and auditing assessments | |
| Executive Director | Named in plan of correction for re-educating staff and monitoring compliance |
Inspection Report
Renewal
Census: 89
Capacity: 104
Deficiencies: 13
Jul 23, 2024
Visit Reason
The inspection was an unannounced full renewal inspection conducted on 07/23/2024 and 07/24/2024 to review compliance with licensing requirements.
Findings
The inspection found multiple deficiencies related to medication administration, resident personal equipment, exterior hazards, fire safety notifications, combustible storage, hearing impairment accommodations, fire drill documentation, self-administration assessments, medication records, follow prescriber's orders, medication error reporting and documentation, and support plan documentation. All deficiencies had accepted plans of correction with specified completion dates and were noted as implemented by 09/16/2024.
Deficiencies (13)
| Description |
|---|
| Medication not administered to Resident #6 on 7/19/24 and error not reported to the Department. |
| Resident #1's bed enabler bar was not covered, posing a risk of injury. |
| Exterior walkway sections broken or raised, posing tripping hazards. |
| Resident #2 immobility not initially included in fire department notification. |
| Combustible towel found behind washer and dryer near exhaust vent. |
| Resident #3 unable to hear fire alarm at night after removing hearing aids. |
| Fire drill logs incorrectly counted staff conducting drills in staffing numbers. |
| Resident #8 had medication at bedside without proper self-administration assessment. |
| Medication record discrepancies for Resident #4 and documentation errors for Resident #9. |
| Resident #4 insulin doses not administered per sliding scale orders on multiple occasions. |
| Medication error for Resident #6 not reported to prescriber. |
| Resident #7 medication refusal not documented with physician response. |
| Support plans for Residents #1 and #5 did not document specific needs, risks, and safe use of bedside enabler bars. |
Report Facts
License Capacity: 104
Residents Served: 89
Current Hospice Residents: 9
Total Daily Staff: 99
Waking Staff: 74
Inspection Report
Follow-Up
Census: 84
Capacity: 104
Deficiencies: 2
Dec 13, 2023
Visit Reason
The inspection was a partial, unannounced follow-up visit conducted on 12/13/2023 to review the facility's plan of correction related to a prior incident.
Findings
The submitted plan of correction was determined to be fully implemented. The inspection addressed a resident abuse report involving a verbal altercation and failure to report suspected abuse, and deficiencies in documenting medical/behavioral support plans for a resident with mental health concerns and wander guard use.
Deficiencies (2)
| Description |
|---|
| Failure to immediately report suspected abuse of a resident following a verbal altercation and allegations of being hit by staff. |
| Resident support plan was not updated to document medical, dental, vision, hearing, mental health or other behavioral care services, including suicidal ideations and use of a wander guard. |
Report Facts
License Capacity: 104
Residents Served: 84
Current Hospice Residents: 4
Total Daily Staff: 88
Waking Staff: 66
Inspection Report
Renewal
Census: 84
Capacity: 104
Deficiencies: 6
Jun 6, 2023
Visit Reason
The inspection was conducted as a renewal review of the facility's license by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing on 06/06/2023 and 06/07/2023.
Findings
The facility was found to have several deficiencies including uncovered trash receptacles, food stored on the floor, missing thermometers in refrigerators/freezers, outdated fire extinguisher inspection, lack of documentation for resident rights education, and incomplete resident support plans. All deficiencies had plans of correction submitted and were implemented by 08/02/2023.
Deficiencies (6)
| Description |
|---|
| The public bathroom on the 3rd floor had a garbage can with no lid. |
| Two cans of chicken noodle soup were observed on the floor in the pantry area of the kitchen. |
| No thermometer was found in the refrigerator or freezer in the activity room. |
| The fire extinguisher located in the home’s transportation van was last inspected in 3/2022. |
| No documentation that Resident 1 was orientated regarding their right to question or refuse medications. |
| The most recent Resident Assessment Support Plan (RASP) for Resident 2 did not indicate that the resident utilizes a bed cane on their bed. |
Report Facts
License Capacity: 104
Residents Served: 84
Current Hospice Residents: 5
Residents 60 Years or Older: 84
Residents Diagnosed with Intellectual Disability: 1
Residents with Mobility Need: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Housekeeping | Named in relation to replacing garbage can lid and educating housekeeping staff | |
| Director of Culinary | Named in relation to educating dining staff on food storage and monitoring pantry | |
| Director of Activities | Named in relation to re-education on refrigerator/freezer thermometer monitoring and logging | |
| Executive Director | Named in multiple contexts including monitoring compliance, contacting fire protection company, and reviewing resident paperwork | |
| Director of Maintenance | Named in relation to fire extinguisher inspection and monitoring | |
| Business Office Manager | Named in relation to auditing Resident Agreements | |
| Director of Health and Wellness | Named in relation to updating Resident 2's support plan and re-education | |
| Nursing Supervisor | Named in relation to re-education on updating resident support plans |
Inspection Report
Complaint Investigation
Census: 86
Capacity: 104
Deficiencies: 1
Mar 27, 2023
Visit Reason
The inspection was conducted as a complaint and incident investigation at the facility.
Findings
The facility failed to submit an incident report to the Department's personal care home regional office within 24 hours as required after a Protective Services Case Manager visited to interview a resident regarding possible abuse. The Executive Director was unaware of these visits and corrective actions were implemented to educate staff on timely reporting.
Complaint Details
A Protective Services Case Manager from Berks County Area Agency on Aging visited the facility on 3/22/23 and 3/29/23 to interview resident #1 regarding possible resident abuse. Facility staff were also interviewed. The home failed to report the incident within 24 hours as required.
Deficiencies (1)
| Description |
|---|
| Failure to submit an incident report to the Department's personal care home regional office within 24 hours as required. |
Report Facts
License Capacity: 104
Residents Served: 86
Current Residents in Hospice: 5
Residents Age 60 or Older: 85
Residents Diagnosed with Intellectual Disability: 1
Residents with Mobility Need: 3
Inspection Report
Follow-Up
Census: 80
Capacity: 104
Deficiencies: 1
Jun 15, 2022
Visit Reason
The inspection was a partial, unannounced review conducted due to an incident, with follow-up visits to verify the submitted plan of correction.
Findings
The submitted plan of correction related to Resident #1's support plan addressing frequent confusion and orientation issues was found to be fully implemented. Continued compliance must be maintained.
Deficiencies (1)
| Description |
|---|
| Resident #1's assessment and support plan did not include behaviors related to frequent confusion and disorientation or plans to meet these needs. |
Report Facts
License Capacity: 104
Residents Served: 80
Current Residents in Hospice: 7
Resident Mobility Need: 4
Total Daily Staff: 84
Waking Staff: 63
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Anne Graziano | Signed the letter confirming plan of correction implementation | |
| Director of Health and Wellness | Named in plan of correction for updating Resident #1's assessment and support plan and monitoring compliance | |
| Executive Director | Responsible for monitoring compliance with the plan of correction |
Inspection Report
Renewal
Census: 86
Capacity: 104
Deficiencies: 7
Mar 29, 2022
Visit Reason
The inspection was conducted as a renewal inspection combined with a complaint investigation, with an exit conference held on 03/31/2022.
Findings
The inspection identified multiple deficiencies including expired CO2 detector batteries, uncovered enabler bars in resident apartments, hot water temperatures exceeding 120°F in some rooms, lack of a barrier near a steep drop off at an exit door, insufficient emergency water supply, obstructed emergency exit egress, and expired medication. Plans of correction were accepted and implemented for all deficiencies.
Complaint Details
The inspection included a complaint investigation as part of the renewal inspection. Specific substantiation status was not stated.
Deficiencies (7)
| Description |
|---|
| CO2 detector on the 2nd floor west wing had expired batteries dated 3/1/21, requiring yearly replacement. |
| Enabler bars in apartments 110 and 217 had no covers with openings 5 inches or greater, posing a hazard. |
| Hot water temperatures in rooms 217 and 317 were 128°F and 124°F respectively, exceeding the 120°F limit. |
| Exit door near laundry room had a ravine with no barrier approximately 5 feet from the door and a 15-foot drop off. |
| The home did not have a 3-day supply of emergency water available, and the water supplier letter did not guarantee immediate emergency water supply. |
| Emergency exit adjacent to the main kitchen and resident activity room was blocked by trash cans, rock salt bag, and spreader machine. |
| Resident medication had expired as of 12/2021 and was discarded at the time of inspection. |
Report Facts
License Capacity: 104
Residents Served: 86
Hot Water Temperature: 128
Hot Water Temperature: 124
Steep Drop Off Height: 15
Barrier Distance from Exit Door: 5
Emergency Water Supply Duration: 3
Obstruction Weight: 50
Plan of Correction Completion Dates: Multiple completion dates ranging from 03/29/2022 to 05/21/2022 for various deficiencies.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Facility Maintenance | Responsible for monitoring CO2 detector batteries, property hazards, water temperatures, and emergency exits. | |
| Executive Director | Monitors compliance for all corrective actions and provided education on emergency exit obstruction. | |
| Director of Health and Wellness | Provided education to residents and staff regarding enabler bars and medication expiration; contacted hospice for medication refill. | |
| Director of Housekeeping | Monitors resident apartments for enabler bar coverings during weekly cleaning. | |
| Director of Culinary | Monitors emergency water supply. |
Inspection Report
Renewal
Deficiencies: 0
Mar 22, 2022
Visit Reason
The inspection was conducted as a licensing inspection by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing on 03/22/2022.
Findings
No regulatory citations were identified as a result of this inspection.
Inspection Report
Follow-Up
Census: 78
Capacity: 104
Deficiencies: 1
Feb 23, 2022
Visit Reason
The inspection was conducted as a follow-up to verify the implementation of a previously submitted plan of correction related to medication administration documentation.
Findings
The facility was found to have fully implemented the plan of correction regarding medication administration records, including staff education and ongoing audits to ensure compliance.
Deficiencies (1)
| Description |
|---|
| Medications were not initialed as administered on the medication administration record for resident #1 on multiple dates in February 2022. |
Report Facts
Residents served: 78
License capacity: 104
Total daily staff: 79
Waking staff: 59
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Health and Wellness | Named in medication administration documentation deficiency and plan of correction |
Inspection Report
Renewal
Census: 76
Capacity: 104
Deficiencies: 12
Jul 13, 2021
Visit Reason
The inspection was conducted as a full, unannounced visit for renewal and complaint reasons from 07/13/2021 to 07/15/2021.
Findings
The inspection identified multiple deficiencies including safety hazards with resident equipment, uncovered trash receptacles, missing emergency telephone numbers, lack of operable bedside lamps, outdated food without dates, missing or late annual medical evaluations, medication storage and administration errors, and incomplete preadmission and resident assessments. Plans of correction were accepted and documented as implemented.
Complaint Details
The inspection included complaint investigation as part of the renewal inspection. Specific substantiation status is not stated.
Deficiencies (12)
| Description |
|---|
| An enable bar without a cover was attached to Resident #7's bed creating a possible entrapment risk. |
| Uncovered trash can in the kitchen not being actively used. |
| Telephone numbers required by regulation were not posted by the phone in room #229. |
| No operable lamp or other source of lighting at bedside in resident rooms 107, 229, 234, and 327. |
| Freezer in kitchen had packages of sausage and sweet potato fries that were not dated. |
| Resident #3, #4, #5, and #6 did not have annual medical evaluations completed within the required timeframe. |
| Resident #1's prescription medications were combined improperly into one bottle, violating medication storage rules. |
| Narcotic count discrepancies and failure to follow policy for controlled substance accountability. |
| Resident #2 was administered medication doses less than six hours apart, not following prescriber's orders. |
| Preadmission screening for Resident #7 did not indicate if the resident's needs could be met by the home. |
| Resident #3's initial assessment was completed more than 15 days after admission. |
| Resident #3's additional assessment was completed beyond the annual timeframe. |
Report Facts
License Capacity: 104
Residents Served: 76
Current Residents on Hospice: 8
Residents 60 Years or Older: 76
Residents with Intellectual Disability: 1
Residents with Mobility Need: 4
Total Daily Staff: 80
Waking Staff: 60
Notice
Capacity: 104
Deficiencies: 0
Jun 11, 2021
Visit Reason
The document serves as a renewal notification and issuance of a regular license for the Personal Care Home facility pursuant to Title 55, PA Code, Chapter 2600. It also advises that an annual onsite inspection will be conducted within the next twelve months.
Findings
No inspection findings are reported in this document; it confirms the issuance of a regular license and states that enforcement action will be taken if noncompliance is found during future inspections.
Report Facts
Total licensed capacity: 104
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary, Office of Long-term Living | Signed the renewal notification letter |
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