Inspection Report
Renewal
Census: 94
Capacity: 149
Deficiencies: 11
Dec 3, 2024
Visit Reason
The inspection was an unannounced full renewal inspection conducted on 12/03/2024 and 12/04/2024 to review compliance with licensing requirements.
Findings
The facility was found to have multiple deficiencies including failure to post current license documents, unsigned resident-home contracts, delayed refunds after resident deaths, missing signed resident rights statements, incomplete staff training, unlocked poisonous materials accessible to residents, inoperable bedside lamps, incomplete medication records, lack of resident education on medication refusal rights, incomplete resident-home contract disclosures, and insufficient dementia care training hours for staff.
Deficiencies (11)
| Description |
|---|
| The home's current violation report was not posted in a conspicuous and public place. |
| Resident-home contracts for residents #1, #2, and #3 were not signed by the residents. |
| Refunds to estates for deceased residents #4 and #5 were not processed within required timeframes. |
| Residents #1, #2, and #3's records lacked signed statements acknowledging receipt of resident rights and complaint procedures. |
| Direct care staff persons A, C, and D did not receive required training in meeting resident needs, medication self-administration, emergency preparedness, and dementia care during 2023. |
| Poisonous materials were unlocked and accessible to residents in the memory care unit. |
| Bedside lamps in rooms 109 and 209 were missing or not working, leaving residents without operable lighting at bedside. |
| Resident #6 and #7 medication records did not include all current medications present in their rooms. |
| Residents #1, #2, and #3 were not educated on their right to refuse medication if they believed there was a medication error. |
| Resident-home contracts for residents #2 and #3 lacked disclosure of services offered in the secured dementia care unit. |
| Direct care staff persons A and D working in the secured dementia care unit had less than the required 6 hours of dementia care training during 2023. |
Report Facts
License Capacity: 149
Residents Served: 94
Secured Dementia Care Unit Capacity: 26
Residents in Secured Dementia Care Unit: 21
Current Hospice Residents: 2
Direct Care Staff Training Hours Deficiency: 5
Total Daily Staff: 162
Waking Staff: 122
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Resident #1 | Resident | Named in findings related to unsigned contracts, missing signed resident rights statements, and lack of medication refusal education. |
| Resident #2 | Resident | Named in findings related to unsigned contracts, missing signed resident rights statements, lack of medication refusal education, and incomplete resident-home contract disclosures. |
| Resident #3 | Resident | Named in findings related to unsigned contracts, missing signed resident rights statements, lack of medication refusal education, and incomplete resident-home contract disclosures. |
| Resident #4 | Resident | Named in findings related to delayed refund processing after death. |
| Resident #5 | Resident | Named in findings related to delayed refund processing after death. |
| Resident #6 | Resident | Named in findings related to incomplete medication records. |
| Resident #7 | Resident | Named in findings related to incomplete medication records. |
| Direct Care Staff Person A | Direct Care Staff | Named in findings related to incomplete training in resident needs and dementia care. |
| Direct Care Staff Person C | Direct Care Staff | Named in findings related to incomplete training in medication self-administration and emergency preparedness. |
| Direct Care Staff Person D | Direct Care Staff | Named in findings related to incomplete training in resident needs, emergency preparedness, and dementia care. |
Inspection Report
Follow-Up
Census: 91
Capacity: 149
Deficiencies: 2
Jun 21, 2023
Visit Reason
The inspection visit on 06/21/2023 was a partial, unannounced review conducted due to an incident, with a follow-up type of Plan of Correction (POC) submission.
Findings
The inspection found deficiencies in resident record content, specifically missing race, color of hair, color of eyes, and incident reports for individual residents. The submitted plan of correction was determined to be fully implemented as of the review date.
Deficiencies (2)
| Description |
|---|
| Resident 1's record does not include race, color of hair, color of eyes and a record of incident reports for the individual resident. |
| Resident 2's record does not include race and a record of incident reports for the individual resident. |
Report Facts
Residents Served: 91
License Capacity: 149
Secured Dementia Care Unit Capacity: 26
Secured Dementia Care Unit Residents Served: 23
Hospice Current Residents: 3
Residents Age 60 or Older: 90
Residents Diagnosed with Mental Illness: 2
Residents with Mobility Need: 64
Residents with Physical Disability: 1
Inspection Report
Renewal
Census: 81
Capacity: 149
Deficiencies: 15
Jul 20, 2022
Visit Reason
The inspection was an unannounced full renewal inspection conducted on 07/20/2022 and 07/21/2022 to review compliance with licensing requirements.
Findings
The inspection identified multiple deficiencies including lack of carbon monoxide detectors near gas appliances, unlocked poisonous materials accessible to residents, improper refrigerator/freezer temperatures, uncovered food items, outdated or unlabeled food, missing emergency procedure submissions, missed fire drills, medication labeling errors, inaccurate glucometer readings, incomplete preadmission screening and support plans, and incomplete resident record content. All deficiencies had plans of correction submitted and were implemented by 01/13/2023.
Deficiencies (15)
| Description |
|---|
| No carbon monoxide detectors located in the area of the kitchen near gas operated stove. |
| Toothpaste and disinfectant wipes with poison label were unlocked and accessible in resident room of secure dementia care unit. |
| Temperature in ice cream freezer was above required temperature (10°F and 8°F). |
| Uncovered ice cream tub in ice cream freezer. |
| Unlabeled and undated food item (20oz Wawa cup) in pathways fridge. |
| Written emergency procedures not submitted to local emergency management agency in 2021 and 2022. |
| Unannounced fire drills not held during months of January 2022 and May 2022. |
| Medication labels did not match prescribed orders for Resident #1. |
| Glucometer reading for Resident #1 was inaccurate (139 documented as 135). |
| Resident #2 admitted without completed preadmission screening form. |
| Resident #3 support plan was not signed by resident and assessor. |
| Resident #2 admitted to secured dementia care unit without completed cognitive preadmission screening. |
| Resident #2 and designated person did not have documentation of no objection to admission to secured dementia care unit. |
| Resident #2's initial support plan was not completed within required timeframe. |
| Resident records missing eye color and hair color information. |
Report Facts
License Capacity: 149
Residents Served: 81
Secured Dementia Care Unit Capacity: 26
Secured Dementia Care Unit Residents Served: 18
Hospice Residents: 7
Total Daily Staff: 134
Waking Staff: 101
Mobility Need Residents: 53
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Maintenance | Named in corrective action for carbon monoxide alarms. | |
| Dining Director | Responsible for refrigerator/freezer temperature compliance and food storage. | |
| Program Directors (Memory Care) | Responsible for securing poisonous materials and resident room inspections. | |
| LPN | Responsible for verifying prescription orders with pharmacy. | |
| DON | Director of Nursing | Responsible for auditing glucometers and reviewing preadmission screenings. |
| Program Coordinator | Responsible for medication compliance, support plans, and resident record content. | |
| Executive Director | Responsible for emergency procedure submission and review of support plans. | |
| Maintenance Coordinator | Responsible for scheduling monthly fire drills. |
Inspection Report
Follow-Up
Census: 69
Capacity: 149
Deficiencies: 5
Feb 18, 2022
Visit Reason
The inspection was an unannounced partial review conducted due to an incident at the facility.
Findings
The inspection found multiple violations related to supervision, abuse, restraints, and positive interventions involving a staff person forcibly moving a resident and pulling their hair. The facility submitted plans of correction and investigations found no violations, with the staff member returning to work. Training and resident interviews were directed to ensure compliance.
Deficiencies (5)
| Description |
|---|
| Staff person A restrained and pulled resident 1's hair while attempting to force them to get up off the sofa to go to sleep. |
| Resident 1 was physically and verbally abused by staff person A who forced the resident to move and pulled their hair causing pain. |
| Resident 1 was held in a hugging position restraining their arms and forcibly moved off the sofa by staff person A. |
| Failure to implement positive interventions to modify or eliminate resident 1's behavior; staff person A used force instead. |
| Use of prohibited restraints including manual restraint and mechanical restraint techniques by staff person A on resident 1. |
Report Facts
License Capacity: 149
Residents Served: 69
Secured Dementia Care Unit Capacity: 26
Secured Dementia Care Unit Residents Served: 17
Current Hospice Residents: 7
Residents Age 60 or Older: 69
Residents with Mental Illness: 3
Residents with Physical Disability: 1
Residents with Mobility Need: 47
Notice
Capacity: 149
Deficiencies: 0
Sep 14, 2021
Visit Reason
This document serves as a renewal notification and license issuance for the Personal Care Home 'Rose Tree Place' following receipt of the renewal application on September 9, 2021.
Findings
The Department issued a regular license in response to the renewal application and advised that an annual onsite inspection will be conducted within the next twelve months to ensure compliance with applicable regulations.
Report Facts
Maximum capacity: 149
Secure Dementia Care Unit capacity: 26
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary, Office of Long-term Living | Signed the renewal notification letter. |
Inspection Report
Renewal
Census: 72
Capacity: 149
Deficiencies: 4
Apr 5, 2021
Visit Reason
The inspection was conducted as a renewal review of the facility's compliance with licensing requirements on 04/05/2021 and 04/06/2021.
Findings
The inspection identified several deficiencies including failure of direct care staff to complete required training, exit door egress issues, improper calibration of glucometers, and a medical evaluation timing discrepancy for a resident in the secured dementia care unit. Plans of correction were accepted and implemented to address these issues.
Deficiencies (4)
| Description |
|---|
| Direct care staff persons A and B provided unsupervised ADL services without completing the Department-approved direct care training course and competency test after CNA registration expired or since hire. |
| The exit door at the Southeast Stairwell #1 had a magnetic lock with keypad code not posted in a conspicuous location for easy egress. |
| Glucometers for residents #1 and #2 were not calibrated to the correct date and time due to daylight saving time adjustment not made. |
| Resident #3 was admitted to the Secure Dementia Care Unit one day before the medical evaluation was completed, which was outside the required 60 days prior to admission. |
Report Facts
License Capacity: 149
Residents Served: 72
Secured Dementia Care Unit Capacity: 26
Current Hospice Residents: 16
Residents Age 60 or Older: 66
Residents with Mobility Need: 54
Residents Diagnosed with Mental Illness: 3
Residents with Physical Disability: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Shawn Parker | Signed the letter confirming plan of correction implementation |
Inspection Report
Complaint Investigation
Census: 68
Capacity: 149
Deficiencies: 3
Feb 4, 2021
Visit Reason
The inspection was conducted as a complaint investigation triggered by a complaint received from the family of Resident #1.
Findings
The inspection found deficiencies related to incomplete preadmission screening documentation and inadequate additional assessments for Resident #1, who had a history of falls. The facility submitted a plan of correction including new assessments and support plans, which were implemented and accepted. The violation related to the support plan was later withdrawn.
Complaint Details
The complaint investigation was initiated based on a family complaint regarding Resident #1. The Department interviewed Resident #1 and requested a new assessment. The investigation found issues with documentation and assessments related to Resident #1's falls and ambulation.
Deficiencies (3)
| Description |
|---|
| Resident #1's preadmission screening form was not dated. |
| Resident #1's additional assessment was outdated and did not reflect the resident's frequent falls and use of a walker. |
| Resident #1's support plan did not address the use of a walker under the ambulating section. |
Report Facts
License Capacity: 149
Residents Served: 68
Residents in Secured Dementia Care Unit: 14
Secured Dementia Care Unit Capacity: 26
Current Hospice Residents: 15
Residents Age 60 or Older: 67
Residents Diagnosed with Mental Illness: 3
Residents with Mobility Need: 43
Residents with Physical Disability: 1
Falls by Resident #1: 5
Mini-Mental State Exam Score: 29
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