Inspection Reports for Roxborough Home for Women
601 Leverington Avenue Philadelphia, PA 19128, PA, 19128
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Inspection Report
Follow-Up
Census: 16
Capacity: 30
Deficiencies: 8
Aug 14, 2025
Visit Reason
The inspection was conducted as a partial, unannounced incident review related to a complaint or incident at the facility on 08/14/2025.
Findings
The inspection found multiple violations including failure to report suspected resident abuse, improper treatment of residents, incomplete criminal background checks for staff, improper food storage practices, untimely medical evaluations, incomplete resident contracts, denial of additional meal portions, and incomplete preadmission screening forms. Corrective actions and plans of correction were accepted with completion dates mostly by September 2025.
Complaint Details
The visit was triggered by an incident involving a resident requesting an additional sandwich and being yelled at by staff, which led to a complaint investigation. The incident was not initially reported as required, and the resident was upset and embarrassed by the staff's behavior.
Deficiencies (8)
| Description |
|---|
| Failure to immediately report suspected abuse of a resident and failure to comply with reporting requirements under the Older Adult Protective Services Act. |
| Resident was not treated with dignity and respect; staff yelled at resident and denied requested additional food. |
| Staff member began work without a completed criminal background check. |
| Unsealed and undated container of ice cream found in basement freezer, violating food safety requirements. |
| Medical evaluation for a resident was not completed within 60 days prior to admission or within 30 days after admission. |
| Resident-home contract did not indicate whether the home collects a portion of the resident's rent rebate benefit. |
| Resident was denied additional portions of meals and beverages at mealtimes, violating resident rights. |
| Preadmission screening form did not include a determination that the needs of the resident can be met by the services provided by the home. |
Report Facts
License Capacity: 30
Residents Served: 16
Staffing: 17
Waking Staff: 13
Resident Supplemental Security Income: 1
Residents Age 60 or Older: 16
Residents Diagnosed with Mental Illness: 11
Residents Diagnosed with Intellectual Disability: 1
Residents with Mobility Need: 1
Residents with Physical Disability: 0
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff Member A | Named in findings related to resident abuse, treatment with dignity, and denial of additional meal portions; was removed from direct care, suspended, and terminated. | |
| Staff Member B | Named in finding related to lack of completed criminal background check prior to employment; background check completed retroactively. | |
| Administrator | Involved in issuing apologies to residents, overseeing corrective actions, conducting audits, and responsible for compliance and training plans. | |
| PCA Supervisor | Responsible for conducting training sessions and monitoring staff-resident interactions. | |
| Kitchen Supervisor | Responsible for retraining kitchen staff, conducting daily food storage inspections, and overseeing food safety compliance. |
Inspection Report
Renewal
Census: 15
Capacity: 30
Deficiencies: 14
Nov 13, 2024
Visit Reason
The inspection was an unannounced full renewal inspection conducted on November 13, 2024, to review compliance with licensing requirements and verify the implementation of the submitted plan of correction.
Findings
The inspection identified multiple deficiencies including failure to post the current license and influenza information, incomplete resident contracts, missing criminal background checks, sanitary issues, missing bedside furniture and lighting, improper food storage, repeated use of the same fire drill exit, inadequate smoking area signage, staff driving without valid licenses, and incomplete first aid kits. All deficiencies had plans of correction accepted and were implemented by June 10, 2025.
Deficiencies (14)
| Description |
|---|
| The home's inspection summary report dated April 18, 2024, was not posted in a conspicuous and public place. |
| The home did not have the required influenza poster in a public place as required by the Influenza Awareness Act. |
| Resident #1's contract was not signed and reviewed by the resident until after admission. |
| Resident-home contracts for Residents #1 through #4 did not indicate whether the home collects a portion of the resident’s rent rebate benefit. |
| Staff person A did not have a completed criminal background check including an FBI check. |
| Trash can in staff restroom was uncovered and filled. |
| Resident #2 did not have a bedside table or shelf beside the resident. |
| Resident #2 did not have access to a source of light that can be turned on/off at bedside. |
| Opened and unsealed bag of frozen fish patties found in basement freezer. |
| Unlabeled, undated bag of frozen carrots and frozen fish patties found in basement freezer. |
| The enclosed porch exit route was the same exit used during multiple fire drills, not alternating exits as required. |
| No signage indicating the designated smoking area; cushions on benches in smoking area. |
| Staff person B transports residents but does not have a current driver's license. |
| First aid kit in the van used to transport residents did not include a breathing shield. |
Report Facts
License Capacity: 30
Residents Served: 15
Total Daily Staff: 15
Waking Staff: 11
Residents Diagnosed with Mental Illness: 13
Residents Diagnosed with Intellectual Disability: 3
Residents 60 Years or Older: 15
Residents Receiving Supplemental Security Income: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff person A | DOH | Named in criminal background check deficiency |
| Staff person B | Named in driver's license deficiency for transporting residents |
Inspection Report
Census: 15
Capacity: 30
Deficiencies: 0
Apr 18, 2024
Visit Reason
The inspection was a partial, unannounced visit conducted due to an incident at the facility on 04/18/2024.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Total Daily Staff: 15
Waking Staff: 11
Residents Served: 15
License Capacity: 30
Residents 60 Years or Older: 14
Residents Diagnosed with Mental Illness: 4
Residents Diagnosed with Intellectual Disability: 1
Inspection Report
Complaint Investigation
Census: 17
Capacity: 30
Deficiencies: 14
Nov 21, 2023
Visit Reason
The inspection was conducted as a complaint investigation with a partial, unannounced visit on 11/21/2023 and an exit conference on 11/29/2023.
Findings
The facility was found to have multiple deficiencies including failure to report incidents, inadequate supervision and disciplinary actions for staff misconduct, privacy violations due to camera recordings, sanitary and infestation issues, obstructed egress, incomplete medical evaluations, and medication administration concerns. Plans of correction were accepted and implemented by 01/12/2024.
Complaint Details
The inspection was complaint-driven as indicated by the reason 'Complaint' and the partial unannounced inspection on 11/21/2023.
Deficiencies (14)
| Description |
|---|
| Failure to develop and implement a plan of supervision for a staff member involved in an alleged abuse incident. |
| Failure to report multiple incidents including medication flushing, bullying, choking, and staff misconduct to the Department. |
| Failure to notify designated persons following a resident fall incident. |
| Violation of HIPAA due to video recording of a resident in a state of undress and improper handling of the video. |
| Staff member yelling, screaming, banging on table, and using foul language towards residents. |
| Privacy violation due to security cameras recording residents' bedroom doors. |
| Criminal background check for a staff member was completed after the start date of employment. |
| Unsanitary conditions including uncovered trash and recycling bins with presence of flies, and unclean resident room. |
| Evidence of infestation with flies in the second floor halls and resident room. |
| Obstructed egress in a resident room due to clutter and objects blocking the door and walkway. |
| Fire drill record did not accurately report resident non-compliance during evacuation. |
| Medical evaluations missing pertinent information including emergency diagnosis and immunization history. |
| Resident allowed to take loose medications out of the home without documentation of administration; lack of physician assessment for self-administration ability. |
| Preadmission screening form was completed after the resident's admission date. |
Report Facts
License Capacity: 30
Residents Served: 17
Total Daily Staff: 17
Waking Staff: 13
Residents 60 Years or Older: 16
Residents in Hospice: 0
Residents Receiving Supplemental Security Income: 0
Residents Diagnosed with Mental Illness: 0
Residents Diagnosed with Intellectual Disability: 0
Residents with Mobility Need: 0
Residents with Physical Disability: 0
Fire Drill Residents Present: 15
Fire Drill Evacuation Time (seconds): 232
Inspection Report
Renewal
Census: 18
Capacity: 30
Deficiencies: 18
Sep 6, 2023
Visit Reason
The inspection was conducted as a renewal inspection of the Roxborough Home for Women facility to assess compliance with licensing requirements.
Findings
The inspection identified multiple deficiencies including failure to post influenza information, privacy policy issues, late criminal background checks for staff, staff qualification deficiencies, safety hazards on the exterior grounds, inadequate lighting in resident rooms, improper food storage and labeling, incomplete medical evaluations, smoking area safety issues, incomplete menu postings, medication administration by untrained staff, incomplete training records, and incomplete resident records. All deficiencies had plans of correction accepted and were implemented by November 27, 2023.
Deficiencies (18)
| Description |
|---|
| Failure to post required influenza information in a public place year-round. |
| Admissions policy allowed room inspections at any time, violating resident privacy rights. |
| Criminal background checks for two staff members were completed late. |
| Direct care staff person A lacked a high school diploma, GED, or active nurse aide registry status. |
| Metal bench on exterior grounds was uneven and had a cushion blown off. |
| Resident #1 did not have access to a bedside lamp that can be turned on/off. |
| Kitchen refrigerator temperature was above 40°F at time of inspection. |
| Several unlabeled and undated food items found in refrigerator and walk-in freezer. |
| Resident #2's medical evaluation was incomplete and used outdated dates. |
| Resident #3's medical evaluation did not include medication regimen and related information. |
| Resident #4's medical evaluation did not reflect a significant change in medication self-administration ability. |
| Designated smoking areas lacked fire resistant furniture. |
| Menus were not posted for more than one week in advance. |
| Staff persons C and D administered medications without completing required medication administration training. |
| Medication administration training records for staff persons C and D lacked documentation of successful completion. |
| Resident #2’s preadmission screening form lacked determination that resident needs can be met by the home. |
| Resident #4's support plan was missing a page and did not identify need for medication assistance. |
| Resident #2's record lacked race, height, weight, hair and eye color, religious affiliation, identifying marks, recent photo, communication means, and medical insurance information. |
Report Facts
License Capacity: 30
Residents Served: 18
Staffing Hours: 18
Waking Staff: 14
Residents 60 Years or Older: 17
Residents Diagnosed with Mental Illness: 3
Residents Diagnosed with Intellectual Disability: 1
Inspection Report
Renewal
Census: 19
Capacity: 30
Deficiencies: 13
Aug 15, 2022
Visit Reason
The inspection was conducted as a renewal review of the Roxborough Home for Women facility on 08/15/2022 and 08/16/2022 to verify compliance with licensing requirements and the implementation of the submitted plan of correction.
Findings
The inspection identified multiple deficiencies including failure to post the current license, lack of carbon monoxide detectors, incomplete criminal background check for the administrator, rodent infestation evidence, insufficient hot water temperature, incomplete first aid kit supplies, unlabeled and undated leftover food items, missing posted menus, incomplete past menu records, medication documentation errors, incomplete preadmission screening, and unsigned support plans. All deficiencies had plans of correction submitted and were implemented by 01/11/2023.
Deficiencies (13)
| Description |
|---|
| The personal care home did not post the current license in a conspicuous and public place. |
| No carbon monoxide detectors were installed near fossil-fuel burning appliances. |
| The administrator did not have a completed criminal background check. |
| Rodent droppings were found on and around food storage cans indicating infestation. |
| An uncovered, unattended trash can was observed in the main kitchen. |
| Insufficient hot water temperature at bathroom sinks in residents' rooms. |
| The first aid kit in the medication room did not include bandages in a regular standard package. |
| Unlabeled and undated leftover food items were found in multiple refrigerators and freezers. |
| The weekly menu for one week in advance was not posted in a conspicuous and public place. |
| Past menus of meals served, including changes, were not kept from the previous month. |
| Glucometer readings for resident 3 were not documented in the MAR logs. |
| Resident 4’s preadmission screening form did not include a determination that the resident's needs can be met. |
| Resident 3 participated in the development of the support plan but did not sign it. |
Report Facts
Inspection Dates: Inspection conducted on 08/15/2022 and 08/16/2022
Residents Served: 19
License Capacity: 30
Staffing: 19
Waking Staff: 14
Notice
Capacity: 30
Deficiencies: 0
Sep 16, 2021
Visit Reason
The document serves as a renewal notification and license issuance for Roxborough Home for Women, a Personal Care Home, and 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 following the renewal application.
Report Facts
Maximum capacity: 30
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary, Office of Long-term Living | Signed the renewal notification letter. |
Inspection Report
Renewal
Census: 18
Capacity: 30
Deficiencies: 8
Jul 12, 2021
Visit Reason
The inspection was a full, unannounced renewal inspection conducted on 07/12/2021 to review compliance with licensing requirements for Roxborough Home for Women.
Findings
The inspection identified multiple deficiencies including privacy violations related to video camera signage, disrepair of bathroom ceilings, insufficient emergency food and water supplies, incomplete medical evaluations, outdated or discontinued medications, delayed resident assessments, and missing recent photographs in resident records. Plans of correction were accepted and documented for all deficiencies.
Deficiencies (8)
| Description |
|---|
| Video cameras recording near exit doors without posted signs indicating recording. |
| Bathroom ceiling across from dining room in disrepair with holes and missing tiles exposing pipes. |
| Insufficient emergency drinking water supply (6 gallons onsite vs 54 gallons required) and no 3-day supply of nonperishable emergency food onsite. |
| Resident #1's medical evaluation incomplete; medication addendum missing. |
| Discontinued medication still present in resident #3's medication bin. |
| Resident #1's initial assessment not completed within 15 days of admission. |
| Resident #2's initial assessment not completed within required timeframe. |
| Resident #1 and #2's records missing photographs no more than 2 years old. |
Report Facts
License Capacity: 30
Residents Served: 18
Emergency Drinking Water Required: 54
Emergency Drinking Water Onsite: 6
Total Daily Staff: 18
Waking Staff: 14
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