Deficiencies (last 5 years)
Deficiencies (over 5 years)
42 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
794% worse than Pennsylvania average
Pennsylvania average: 4.7 deficiencies/yearDeficiencies per year
24
18
12
6
0
Census
Latest occupancy rate
61% occupied
Based on a September 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 23
Capacity: 38
Deficiencies: 0
Date: Sep 2, 2025
Visit Reason
The inspection was conducted as a complaint investigation at the facility on 09/02/2025.
Complaint Details
The inspection was triggered by a complaint; the inspection type is listed as Partial and Unannounced. No deficiencies were found.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
License Capacity: 38
Residents Served: 23
Current Hospice Residents: 4
Resident Support Staff Daily Total: 25
Waking Staff: 19
Residents Age 60 or Older: 21
Residents Diagnosed with Mental Illness: 4
Residents with Mobility Need: 2
Inspection Report
Census: 23
Capacity: 38
Deficiencies: 0
Date: Jun 30, 2025
Visit Reason
The inspection was a partial, unannounced visit conducted due to an incident at the facility.
Findings
No regulatory citations or deficiencies were identified during this inspection.
Report Facts
License Capacity: 38
Residents Served: 23
Current Hospice Residents: 5
Resident Support Staff Hours: 0
Total Daily Staff Hours: 31
Waking Staff Hours: 23
Inspection Report
Complaint Investigation
Census: 23
Capacity: 38
Deficiencies: 7
Date: May 15, 2025
Visit Reason
The inspection was conducted as a complaint investigation following allegations of verbal and physical abuse by a staff member, as well as other regulatory concerns.
Complaint Details
The complaint investigation was triggered by allegations of verbal and physical abuse by direct care staff person A against residents. The allegations were reported late to the Department, and the staff member returned to work under an unapproved supervision plan before suspension. The investigation confirmed the abuse and other regulatory violations.
Findings
The investigation found multiple violations including failure to immediately report suspected abuse, improper supervision of a staff member involved in abuse allegations, delayed reporting to the Department, resident mistreatment with lack of dignity and respect, infestation of insects in resident areas, and failure to update resident assessments reflecting behavioral concerns. Corrective actions and staff training were implemented.
Deficiencies (7)
Failure to immediately report suspected abuse of a resident in accordance with the Older Adult Protective Services Act and related regulations.
Failure to immediately develop and implement a plan of supervision or suspend the staff person involved in the alleged abuse incident.
Failure to submit a plan of supervision or notice of suspension to the Department’s regional office and continued work of staff under unapproved supervision plan.
Failure to report the incident or condition to the Department’s personal care home regional office or complaint hotline within 24 hours as required.
Resident was verbally scolded by a staff member off duty, causing disrespect and discomfort to residents.
Infestation of approximately sixty fruit flies or gnats in the shared resident bathroom of a resident room.
Resident assessment was not updated to reflect behavioral concerns despite incidents and staff interviews indicating inappropriate behavior.
Report Facts
License Capacity: 38
Residents Served: 23
Current Hospice Residents: 4
Staffing Hours - Total Daily Staff: 28
Staffing Hours - Waking Staff: 21
Infestation Count: 60
Inspection Report
Complaint Investigation
Census: 24
Capacity: 38
Deficiencies: 9
Date: Feb 24, 2025
Visit Reason
The inspection was conducted as a complaint and interim review, unannounced, to investigate specific concerns at the facility.
Complaint Details
The inspection was complaint-related and interim in nature, conducted unannounced on 02/24/2025. The plan of correction was accepted and fully implemented as of the follow-up dates.
Findings
Multiple deficiencies were found including privacy issues with a resident room door, excessively high hot water temperatures, snow and ice obstructions outside, incomplete resident medical evaluations, improper medication storage and labeling, lack of resident education on medication refusal rights, and incomplete resident assessments.
Deficiencies (9)
Door to resident room #6 did not latch and remained open 2.5"-3", precluding privacy.
Hot water temperature at sinks in resident bathrooms measured between 139.8°F and 150.2°F, exceeding the 120°F limit.
Approximately 1/4" coating of ice and snow on emergency egress sidewalks and exit door area.
Resident medical evaluation did not include whether immunizations were up to date.
Prescription medication was not dated when opened.
Prescription medications lacked pharmacy labels, including insulin pens.
Uncapped insulin pen with exposed membrane found in resident's diabetic supplies.
No documentation that resident was educated on the right to question or refuse medication if a medication error is suspected.
Resident's initial assessment did not address diagnoses noted in medical evaluation.
Report Facts
License Capacity: 38
Residents Served: 24
Current Hospice Residents: 4
Hot Water Temperature: 150.2
Hot Water Temperature: 139.8
Hot Water Temperature: 145.7
Ice Coating Thickness: 0.25
Snow Coating Thickness: 0.25
Inspection Report
Complaint Investigation
Census: 27
Capacity: 38
Deficiencies: 17
Date: Nov 21, 2024
Visit Reason
The inspection was conducted as a complaint investigation with provisional and incident reasons, including follow-up on a previously submitted plan of correction.
Complaint Details
The inspection was complaint-related with provisional and incident reasons. The submitted plan of correction was found to be fully implemented after follow-up inspections.
Findings
The facility was found to be in compliance with 55 Pa. Code Chapter 2600 after multiple inspections and corrections. Several deficiencies were identified related to resident contracts, infestation, hot water temperature, windows, furniture, snow removal, medical evaluations, medication storage, resident rights, and record content, all of which had plans of correction implemented.
Deficiencies (17)
Resident #1's contract was missing under the old entity and was completed on 9/1/24.
Infestation of more than 30 gnat-like insects in the shower curtain and dining room sink and juice machine.
Hot water temperature at the dining room sink measured 140.6 degrees Fahrenheit, exceeding the 120°F limit.
Window screen in room Annex B was not secured, leaving an 8-inch gap.
Lint screen in laundry room dryer was rusted and torn, preventing efficient lint catching.
Snow and ice obstructed emergency egress sidewalks and walkways.
Mattress in resident room Annex B was sunken and did not adequately support the resident.
No chair was present in resident room Annex B.
Use of a common towel was observed in a shared resident bathroom.
Four bottles of mustard and one ketchup bottle were left unrefrigerated on dining room tables.
Resident #2's Novolog Flexpen medication was not dated when opened.
Resident #2's Lantus Solostar pen medication lacked a pharmacy label.
Resident #1's medical evaluation did not include up-to-date immunization status.
Resident #4's record lacked documentation for reason, date, and destination of discharge.
Resident #1, #2, #3, #4, and #5 were not educated or documented on their right to question or refuse medication.
Menus posted only indicated 'Week 1' and 'Week 4' without effective dates.
Door to resident room #6 did not latch properly, compromising privacy.
Report Facts
License Capacity: 38
Residents Served: 27
Current Residents: 6
Total Daily Staff: 36
Waking Staff: 27
Hot Water Temperature: 140.6
Hot Water Temperature: 150.2
Hot Water Temperature: 139.8
Hot Water Temperature: 145.7
Inspection Report
Re-Inspection
Census: 36
Capacity: 38
Deficiencies: 15
Date: Jun 21, 2024
Visit Reason
The inspection was conducted due to a change in legal entity and as a re-inspection within 3 months of the effective date of the provisional license to verify compliance with 55 Pa.Code Ch. 2600 regulations.
Findings
The facility was found to be in substantial compliance but not complete compliance with applicable regulations. Multiple citations were identified related to health and safety laws, sanitary conditions, emergency telephone numbers, windows, furniture and equipment, soap dispensers, towels, food/water supply, emergency management, furnace inspection, fire drills, and medication storage. Plans of correction were submitted with proposed completion dates.
Deficiencies (15)
Smoking sign was not properly posted and was obscured.
Strong smell of urine and accumulation of dirt and debris in resident rooms; lack of paper towels in common bathroom.
Emergency telephone numbers missing from resident rooms.
Exit door propped open with a rock and no screen present.
Toilet paper holder in resident room #20 was broken and non-operational.
Unlabeled soap bar in shared bathroom of resident room #8.
Use of a common towel prohibited; towels not properly identified to residents.
Home did not maintain at least a 3-day supply of nonperishable food and drinking water.
Emergency management plan not reviewed and submitted annually to local agency.
Furnace inspection not completed within the past year; only partial documentation provided.
Unannounced fire drill not conducted in March 2024.
Fire drill record for 6/14/24 did not indicate time of drill or evacuation details.
Fire safety inspection and fire drill conducted by fire safety expert not completed annually.
Residents were not able to evacuate the building within the required safe evacuation time.
Prescription medications and syringes were not kept locked; hospice aide left medication unsecured.
Report Facts
License Capacity: 38
Residents Served: 36
Current Residents in Hospice: 7
Residents with Supplemental Security Income: 4
Residents Age 60 or Older: 34
Residents Diagnosed with Mental Illness: 7
Residents with Mobility Need: 7
Residents with Physical Disability: 3
Total Daily Staff: 43
Waking Staff: 32
Inspection Report
Complaint Investigation
Census: 32
Capacity: 38
Deficiencies: 13
Date: Feb 29, 2024
Visit Reason
The inspection was a complaint investigation and provisional visit conducted on 02/29/2024, following prior complaint and fine issues.
Complaint Details
The inspection was triggered by complaints and fines related to multiple regulatory violations. The license was revoked due to failure to comply with regulations and failure to submit or comply with acceptable plans of correction.
Findings
The facility was found to have multiple violations including criminal background check deficiencies, incomplete training records, medical evaluation issues, medication administration errors, sanitary condition problems, privacy violations, staffing inadequacies, and failure to maintain proper documentation. The license was revoked due to failure to comply with regulations and plans of correction.
Deficiencies (13)
Criminal background checks not completed for several direct care staff.
Training records incomplete for direct care staff.
Medical evaluations for residents incomplete or missing required documentation.
Medication administration records missing prescribed medication details and administration documentation.
Failure to follow prescriber's orders for medications.
Initial assessments and support plans for residents incomplete or missing.
Sanitary conditions poor with unclean surfaces, matted dust, dried fecal matter, and cigarette butts outside.
Infestation of gnats in resident bathroom.
Hot water temperatures exceeded 120°F in multiple resident bathrooms.
Fire drill records incomplete, missing year of drills and alternate exit routes not used.
Privacy violations due to video monitoring capturing interior spaces of bathrooms.
Staffing inadequate to meet resident needs during certain shifts.
Direct care staff did not receive required annual training.
Report Facts
Census at Inspection: 32
Total Capacity: 38
Fine Amounts: 160
Fine Amounts: 96
Number of Violations: 14
Resident Counts: 32
Staffing: 45
Waking Staff: 34
Inspection Report
Complaint Investigation
Census: 32
Capacity: 38
Deficiencies: 18
Date: Feb 29, 2024
Visit Reason
The inspection was a complaint investigation and provisional review conducted at Victoria Manor Personal Care Home on February 29, 2024, following prior inspections and plan of correction submissions.
Complaint Details
The inspection was triggered by a complaint and included a provisional review. The report notes multiple repeat violations and deficiencies related to resident care, staff training, medication administration, and facility conditions.
Findings
The inspection found multiple violations including criminal background check deficiencies, incomplete training records, medical evaluation issues, medication administration errors, sanitary condition problems, privacy breaches, staffing inadequacies, and fire drill record deficiencies. Several violations were repeat issues from prior inspections. The facility's license was revoked due to failure to comply with regulations and plans of correction.
Deficiencies (18)
Criminal background checks not completed for certain staff by 1/9/24.
Training records incomplete for direct care staff.
Medical evaluations for residents incomplete or missing required documentation.
Medication administration records missing prescribed medication documentation.
Failure to follow prescriber's orders for medications.
Resident assessments and support plans incomplete or missing.
Incident reports for resident deaths not timely reported.
Confidential resident records left unsecured and accessible.
Sanitary conditions poor with unclean surfaces, dust, debris, and insect infestation.
Trash outside home not properly contained; cigarette butts found in smoking area.
Hot water temperatures exceeded 120°F in resident bathrooms.
Fire drill records incomplete; missing dates and details.
Alternate exit routes not used during fire drills.
Annual medical evaluations not completed for some residents.
Prescription medications not stored properly or expired medications present.
Medication administration errors including missed doses and incomplete documentation.
Staffing levels inadequate to meet resident needs during certain shifts.
Direct care staff did not receive required annual training.
Report Facts
Census at Inspection: 32
Total Capacity: 38
Deficiencies cited: 18
Fine per day: 160
Fine per day: 96
Inspection Report
Complaint Investigation
Census: 30
Capacity: 38
Deficiencies: 22
Date: Jul 6, 2023
Visit Reason
The inspection was conducted as a complaint investigation and provisional licensing review of Victoria Manor Personal Care Home.
Complaint Details
The inspection was complaint-related and provisional licensing related. Multiple repeat violations were noted, including issues with staff qualifications, training, medical evaluations, medication management, and resident care documentation.
Findings
Multiple violations were found including issues with record confidentiality, rent rebate contract inconsistencies, incomplete criminal background checks, insufficient staff qualifications and training, sanitary condition problems, missing or incomplete medical evaluations, medication storage and administration errors, and incomplete resident assessments and support plans.
Deficiencies (22)
Laptops on medication carts were unlocked and accessible, allowing access to resident medication records.
Resident #2's resident-home contract had conflicting information regarding rent rebate percentages.
Staff person A did not have a completed Pennsylvania criminal background check at the time of hire.
Direct care staff person B lacked a high school diploma, GED, or active registry status on the Pennsylvania nurse aide registry.
Direct care staff person B did not receive required fire safety and emergency preparedness orientation on the first day.
Direct care staff person C did not complete and pass the Department-approved direct care training course and competency test.
Direct care staff person D only received 3 hours of annual training during the 2022 training year instead of the required 12 hours.
Direct care staff person D did not receive training on required annual topics including fire safety and falls prevention during the 2022 training year.
Strong odor of urine and feces present in resident #2's shared bedroom and bathroom.
No screen was present in resident #3's bedroom window which was open during inspection.
No linens were present on resident #2's bed during inspection.
No thermometer was present in the storage room silver refrigerator.
Open and unsealed bags of potato chips and stuffing mix were found in kitchen cabinets.
A fire drill during sleeping hours was not conducted within the past 6 months.
No medical evaluation was completed for resident #5 within required timeframe; resident #2's medical evaluation was incomplete.
Resident #4's most recent medical evaluation was incomplete, missing temperature and body positioning/movement needs.
Resident #3's Toujeo insulin pen was open, undated, and lacked a pharmacy label.
Resident #4's controlled drug report indicated 2 syringes of Morphine Sulfate, but only 1 was present.
Resident #1's and #3's medication administration records did not include initials of staff administering medications on specified dates.
Resident #6's initial assessment was not completed within 15 days of admission and was missing supervision and medication administration needs.
Resident #1's support plan did not reflect assessment findings regarding memory problems.
Correction fluid was used on resident #2's legally-appointed guardian and payment sections of resident-home contract.
Report Facts
License Capacity: 38
Census: 30
Staffing Hours: 35
Waking Staff: 26
Number of Residents with Mobility Need: 5
Number of Residents 60 Years or Older: 30
Number of Residents Diagnosed with Mental Illness: 1
Number of Residents Diagnosed with Intellectual Disability: 1
Number of Residents Receiving Supplemental Security Income: 2
Number of Deficiencies Cited: 26
Inspection Report
Complaint Investigation
Census: 30
Capacity: 38
Deficiencies: 22
Date: Jul 6, 2023
Visit Reason
The inspection was conducted as a complaint investigation and provisional licensing inspection of Victoria Manor Personal Care Home.
Complaint Details
The inspection was complaint-related and provisional licensing. Multiple repeat violations were noted from prior inspections.
Findings
Multiple violations were found including issues with resident record confidentiality, incomplete resident contracts, staff qualifications and training deficiencies, sanitary conditions, medication storage and administration errors, and incomplete resident medical evaluations and assessments.
Deficiencies (22)
Laptops on medication carts were unlocked and accessible, allowing access to resident medication records.
Resident #2's resident-home contract had conflicting information regarding rent rebate percentages.
Staff person A did not have a completed Pennsylvania criminal background check at time of hire.
Direct care staff person B lacked required qualifications including high school diploma or GED.
Direct care staff person B did not receive required fire safety and emergency preparedness orientation on first day.
Direct care staff person C did not complete required direct care training and competency test.
Direct care staff person D did not receive required 12 hours of annual training related to job duties.
Direct care staff person D did not receive training on required annual topics including medication self-administration, dementia care, infection control, and safe management techniques.
Direct care staff person D did not receive training on fire safety and falls/accident prevention during 2022 training year.
Strong odor of urine and feces present in resident #2's shared bedroom and bathroom.
Resident #3's bedroom window was open and missing a screen.
No linens were present on resident #2's bed during inspection.
No thermometer was present in the storage room silver refrigerator.
Open and unsealed bags of potato chips and stuffing mix found in kitchen cabinets.
Resident #5 had no medical evaluation completed within required timeframe; resident #2's medical evaluation was incomplete.
Resident #4's most recent medical evaluation was incomplete, missing temperature and body positioning/movement needs.
Resident #3's Toujeo insulin pen was open, undated, and lacked pharmacy label.
Resident #4's controlled drug count was off by one syringe; staff not routinely counting narcotics in refrigerator.
Resident #1 and #3's medication administration records lacked staff initials for administered medications.
Resident #6's initial assessment was not completed within 15 days of admission and was missing supervision and medication administration needs.
Resident #1's support plan did not reflect assessment findings regarding memory problems.
Correction fluid was used on resident #2's legally-appointed guardian and payment sections of resident-home contract.
Report Facts
License Capacity: 38
Census at Inspection: 30
Staffing Hours: 35
Waking Staff: 26
Number of Violations: 21
Residents Served: 28
Total Daily Staff: 31
Waking Staff: 23
Inspection Report
Complaint Investigation
Census: 27
Capacity: 38
Deficiencies: 12
Date: May 9, 2023
Visit Reason
The inspection was conducted as a complaint investigation and included a fine, with an unannounced partial inspection on 05/09/2023.
Complaint Details
The inspection was complaint-related and included a fine. The complaint triggered an unannounced partial inspection on 05/09/2023.
Findings
Multiple violations were found including lack of criminal background checks and qualifications for direct care staff, unsafe placement of medication carts, unsanitary conditions, incomplete resident assessments and support plans, and deficiencies in fire drill procedures and documentation.
Deficiencies (12)
No Pennsylvania criminal background check was completed for direct care staff person A.
No high school diploma, GED, or active registry status on the Pennsylvania nurse aide registry was present for direct care staff person A.
The home routinely leaves medication carts in the hallway near resident #1's bedroom, blocking safe movement.
Strong odor of urine was present in the hallway outside bedrooms and inside a bedroom.
Numerous dark and sticky stains were present on the carpeting near resident #1's bed.
No pillow case was present on resident #1's pillow and the pillow was stained with dark red/brown stains.
Administrator routinely notifies staff in advance of monthly fire drills, violating unannounced drill requirements.
Fire drill records do not indicate if the drill conducted on 4/20/23 at 10:30 was am or pm.
The home lacks documentation from a fire safety expert within the past year indicating maximum evacuation times; evacuation times exceeded 2 minutes 30 seconds in multiple drills.
Fire alarm or smoke detector was not set off during monthly fire drills.
Initial assessments were not completed within 15 days of admission for four residents.
Support plans were not completed within 30 days of admission for four residents.
Report Facts
Total Daily Staff: 33
Waking Staff: 25
License Capacity: 38
Residents Served: 27
Current Hospice Residents: 4
Residents with Mobility Need: 6
Residents 60 Years or Older: 27
Fire Drill Evacuation Time: 170
Fire Drill Evacuation Time: 290
Fire Drill Evacuation Time: 330
Inspection Report
Renewal
Census: 27
Capacity: 38
Deficiencies: 19
Date: Jan 11, 2023
Visit Reason
The inspection was conducted for renewal, complaint, and monitoring purposes with unannounced full inspections on January 11, 18, 19, and an off-site exit conference on January 23, 2023.
Findings
Multiple violations were found including issues with access to records, personal needs allowance contracts, staff qualifications, privacy, storage of poisonous materials, sanitary conditions, fire safety drills and documentation, medication storage, and resident record completeness. Several plans of correction were submitted with some not yet implemented as of the last follow-up.
Deficiencies (19)
Administrator did not provide requested financial records for residents #1 and #2.
Resident #1 and #2 contracts did not specify personal needs allowance amounts.
Resident #2's contract charged rent exceeding SSI allowable amount.
Lock on bedroom 18 door was broken, compromising resident privacy.
Direct care staff person C lacked required high school diploma or equivalent.
Staff person D lacked required first day orientation in fire safety and emergency preparedness.
Poisonous materials stored without original labels and not locked, accessible to residents.
Trash outside home was found in uncovered receptacle on the ground.
Residents' bedrooms lacked operable lamps at bedside.
Carpet stain found in bedroom 10.
Outdated or undated food found in freezer.
Unobstructed egress compromised by dog leash and toys posing tripping hazards.
No fire drill conducted in September 2022; fire drill records incomplete and evacuation times exceeded limits.
Fire drills held on same day each month, not varying days/times.
Menus for upcoming week not posted.
Medications and syringes found unlocked and accessible in resident's room.
Medication administration record missing diagnosis or purpose for medication.
Resident initial assessment not completed within 15 days of admission.
Resident death certificate not on file at time of inspection.
Report Facts
Census at inspection: 27
Total licensed capacity: 38
Number of staff: 33
Waking staff: 25
Number of residents receiving hospice: 4
Number of residents aged 60 or older: 25
Number of residents diagnosed with mental illness: 3
Number of residents with mobility needs: 6
Number of residents receiving Supplemental Security Income: 2
Number of deficiencies cited: 24
Fire drill evacuation times (seconds): 15
Inspection Report
Enforcement
Census: 25
Capacity: 38
Deficiencies: 9
Date: Oct 24, 2022
Visit Reason
The inspection was a complaint investigation with a fine exit conference conducted on 10/24/2022, triggered by complaints and fines related to regulatory violations at Victoria Manor Personal Care Home.
Complaint Details
The inspection was complaint-related with fines assessed for multiple violations unless corrected by mandated dates. The complaint involved medication errors, failure to report incidents, improper discharge procedures, and other regulatory noncompliance.
Findings
The inspection found multiple violations including failure to provide immediate access to records, medication errors and failures to report incidents timely, improper medication administration and documentation, unlocked medication carts, improper food storage, missing resident assessments and support plans, and improper discharge procedures. Several violations were repeat findings from prior inspections.
Deficiencies (9)
Records for residents #1, #3, #4, #5 were locked and not accessible to staff or agents upon request.
Medication errors including failure to administer prescribed medications and improper tablet splitting without scored tablets.
Failure to report medication errors and incidents to the Department within 24 hours.
Resident #12 was issued a 30-day discharge notice for nonpayment but was refused re-admission after hospital transfer without proper grounds or documented attempts to obtain payment.
Multiple food items were found open and unsealed in the kitchen.
Medication cart was found unlocked, unattended, and accessible to residents.
Medication administration records lacked initials of staff administering medications for multiple residents on multiple dates.
Failure to complete initial assessments within 15 days of admission for several residents.
Failure to complete written support plans within 30 days of admission for several residents.
Report Facts
Census at Inspection: 25
Total Capacity: 38
Fine per resident per day: 5
Calculated Fine per day: 135
Number of violations cited: 9
Inspection Report
Complaint Investigation
Census: 23
Capacity: 38
Deficiencies: 8
Date: Mar 30, 2022
Visit Reason
The inspection was a partial, unannounced visit conducted on 03/30/2022 due to an incident involving medication administration errors at Victoria Manor Personal Care Home.
Complaint Details
The visit was complaint-related due to an incident involving medication errors for Resident #1, including missed insulin doses and inaccurate medication records. The home failed to report these medication errors to the Department as required.
Findings
The inspection found multiple deficiencies related to medication management, including missing medical evaluations, improper medication storage, inaccurate medication administration records, failure to follow prescriber's orders, and failure to report medication errors to the Department. Plans of correction were accepted with training and auditing measures implemented.
Deficiencies (8)
Resident #1’s medical evaluation was incomplete with missing medication addendum.
Resident #1's bottles of Novolog and Lantus insulin were open and undated, violating storage requirements.
Blood sugar documentation errors for Resident #1 with incorrect recording on medication administration record (MAR).
Resident #1’s medication administration record (MAR) lacked documentation of certain prescribed medications and incorrect insulin dosages were recorded.
Failure to report medication errors involving Resident #1 to the Department within required timeframe.
Medication administration records lacked initials of staff administering medications on multiple occasions for Resident #1.
Resident #1 was administered insulin doses inconsistent with blood sugar readings and sliding scale orders.
Resident #1 did not receive prescribed insulin doses due to unavailability of insulin syringes.
Report Facts
License Capacity: 38
Census: 23
Staffing: 25
Waking Staff: 19
Medication Errors: 4
Completion Dates: May 20, 2022
Inspection Report
Complaint Investigation
Census: 22
Capacity: 38
Deficiencies: 4
Date: Jan 25, 2022
Visit Reason
The inspection was conducted as a complaint and monitoring visit to assess compliance with licensing regulations at Victoria Manor Personal Care Home.
Complaint Details
The visit was complaint-related and monitoring in nature. Specific complaints involved access to financial records, contract signatures, refund processing, and resident record access.
Findings
The inspection identified several deficiencies including failure to provide immediate access to financial records, unsigned resident-home contract, delayed refund to a resident's estate, and failure to provide timely access to resident records. Plans of correction were accepted with completion dates set.
Deficiencies (4)
Financial records for resident #1 were not available in the home and not provided on the day of inspection.
The resident-home contract for resident #3 was not signed by the resident.
Refund of $2,400 for resident #1's previously-paid charges was not sent to the estate until the end of November 2021.
Resident #4's designated person requested access to records on 10/11/21 but had not received access as of 1/25/22.
Report Facts
License Capacity: 38
Residents Served: 22
Refund Amount: 2400
Staffing: 26
Waking Staff: 20
Inspection Report
Complaint Investigation
Census: 22
Capacity: 38
Deficiencies: 7
Date: Oct 5, 2021
Visit Reason
The inspection was conducted as a complaint investigation following allegations related to resident privacy and other regulatory concerns at Victoria Manor Personal Care Home.
Complaint Details
The inspection was complaint-driven, focusing on privacy violations and other regulatory compliance issues. The complaint was substantiated with findings including unauthorized access to resident's personal property and improper discharge procedures.
Findings
The inspection identified multiple deficiencies including a repeat privacy violation involving unauthorized viewing and deletion of resident's cell phone photos, menu posting and meal substitution issues, incomplete preadmission screening and assessments, and improper discharge procedures for a resident without proper 30-day notice or grounds.
Deficiencies (7)
Unauthorized viewing and deletion of photographs on resident #1's cell phone without consent, a repeat violation.
Only one menu posted dated 10/8/21 through 10/11/21, not meeting the requirement for weekly menus posted one week in advance.
Meal substitution served (spaghetti and bread instead of soup and salad) without advance notice to residents.
Resident #1's preadmission screening form missing determinations of supervision level, medication self-administration ability, and safety with poisonous materials.
Resident #1's initial assessment missing supervision and medication needs documentation.
Resident #1 discharged without proper 30-day advance written notice citing reasons for discharge as required.
Resident #1 discharged without grounds for discharge as specified in regulations, despite notification from Department staff.
Report Facts
License Capacity: 38
Residents Served: 22
Total Daily Staff: 27
Waking Staff: 20
Current Residents on Hospice: 4
Residents Age 60 or Older: 22
Residents with Mobility Need: 5
Residents with Physical Disability: 1
Inspection Report
Complaint Investigation
Census: 28
Capacity: 38
Deficiencies: 1
Date: Sep 9, 2021
Visit Reason
The inspection was conducted as a complaint investigation following a report of an incident involving a family member shouting at staff, scaring residents, and refusing to leave the property.
Complaint Details
The complaint was substantiated as the facility did not report an incident involving a family member shouting at staff and scaring residents until over a month later. The incident occurred on 08/04/2021 and was reported on 09/09/2021.
Findings
The facility failed to report the incident to the Department within the required 24-hour timeframe, reporting it only on 09/09/2021 despite the incident occurring on 08/04/2021. The submitted plan of correction was fully implemented, including staff training on incident reporting protocols.
Deficiencies (1)
Failure to report an incident to the Department within 24 hours as required.
Report Facts
License Capacity: 38
Residents Served: 28
Current Residents on Hospice: 4
Residents 60 Years or Older: 27
Residents with Mobility Need: 7
Total Daily Staff: 35
Waking Staff: 26
Resident Support Staff: 0
Incident Report Completion Date: Oct 12, 2021
Training Completion Date: Oct 15, 2021
Number of Staff Trained: 5
Inspection Report
Monitoring
Census: 27
Capacity: 38
Deficiencies: 6
Date: Apr 16, 2021
Visit Reason
The inspection was an unannounced monitoring visit conducted on 04/16/2021 to assess compliance with licensing regulations at Victoria Manor Personal Care Home.
Findings
The inspection identified multiple deficiencies including breaches of resident record confidentiality, failure to comply with face covering requirements, lack of resident privacy during medical procedures, unsanitary conditions, unlocked medication cart with medications accessible, and incomplete medication administration records. Plans of correction were accepted with training and monitoring measures implemented.
Deficiencies (6)
Laptop on medication cart was unlocked and unattended, exposing resident prescription information.
Staff person was not wearing a face covering while serving breakfast to residents.
Staff tested resident's blood sugar in dining room in presence of other residents, violating privacy.
Resident's catheter bag containing urine was hanging from shower head; feces present on resident's toilet.
Medication cart was unlocked and unattended with medications accessible; resident asked to watch cart.
Resident medication administration record lacked initials of staff administering medications and missing exceptions for held insulin doses.
Report Facts
License Capacity: 38
Residents Served: 27
Staffing: 34
Waking Staff: 26
Current Hospice Residents: 1
Residents with Mobility Need: 7
Inspection Report
Renewal
Census: 26
Capacity: 38
Deficiencies: 21
Date: Jan 25, 2021
Visit Reason
The inspection was conducted as a renewal and complaint investigation to assess compliance with 55 Pa. Code Ch. 2600 relating to Personal Care Homes.
Complaint Details
The inspection included complaint investigation as part of the renewal process. Specific complaints are not detailed, but deficiencies related to medication administration, privacy, and safety were identified and addressed.
Findings
The facility was found to have multiple deficiencies including issues with carbon monoxide detector battery labeling, cracked grab bars, unsecured poisonous materials, unlabeled glucometers, lack of emergency communication system, broken freezer seal, unlabeled soap bars, improper food storage, medication labeling errors, medication storage and administration issues, and privacy violations. Plans of correction were accepted for all deficiencies with follow-up inspections scheduled.
Deficiencies (21)
Carbon monoxide detectors' batteries were not labeled with installation dates as required.
Approximate 2" crack in the grab bar next to the toilet in resident #1's bathroom.
Four 5 gallon buckets of poisonous laundry detergent were not properly secured.
Six unlabeled glucometers were found; one was used on resident #3.
No system or method of communication enabling staff to immediately contact others in an emergency.
Pantry deep freezer was in disrepair with exposed insulation and broken rubber seal.
Unlabeled, used bar of soap found in shared bathroom of residents #4 and #5.
Frigidaire freezer temperature was 2°F, above required 0°F.
Uncovered pan of stuffed green peppers found in pantry deep freezer.
Medication label error: Levothyroxine label incorrectly stated 175 MG instead of 175 MCG.
Blood sugar readings on resident #3's log were not present on the glucometer.
Controlled drug records for resident #1 did not include number of doses delivered to the home.
Resident #1 was not administered correct insulin doses on multiple dates.
Resident #3 missed blood sugar checks and medication doses on multiple dates.
Laptop on medication cart was unlocked and unattended, exposing resident information.
Staff person was not wearing face covering while serving breakfast to residents.
Resident #5's blood sugar was tested in dining room in presence of other residents, violating privacy.
Resident #1's catheter bag was hanging from shower head with urine in bag; feces present in toilet.
Medication cart was unlocked and unattended; resident asked to watch cart.
Medication administration record did not include initials of staff administering medications on 4/14/21.
Insulin was administered despite blood sugar readings below threshold without documented exception.
Report Facts
License Capacity: 38
Residents Served: 26
Staffing Hours: 34
Waking Staff: 26
Number of Deficiencies: 21
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tracy Romigh | Administrator | Named as facility administrator and involved in corrective actions. |
| Ashley Roser | Lead Inspector | Lead inspector for the January 25, 2021 and April 16, 2021 inspections. |
| Jamie L. Buchenauer | Deputy Secretary | Signed licensing correspondence. |
| Laurie Garrigan | Department Representative | Participated in January 25, 2021 inspection. |
| Larry Mazza | Lead Reviewer | Reviewed follow-up submissions. |
| Joe Eveges | Department Representative | Participated in April 16, 2021 inspection. |
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