Deficiencies per Year
28
21
14
7
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Follow-Up
Census: 105
Capacity: 123
Deficiencies: 5
Sep 10, 2025
Visit Reason
The visit was an unannounced partial inspection conducted as an interim review to verify the submitted plan of correction was fully implemented.
Findings
The inspection found multiple deficiencies related to annual medical evaluations, medication storage and labeling, medication administration documentation, and resident support plans for medical/dental care. The facility submitted and implemented plans of correction to address these issues, with ongoing audits and staff training planned to maintain compliance.
Deficiencies (5)
| Description |
|---|
| Resident had two medical evaluations completed with inconsistent dietary needs and body positioning/movement needs. |
| Expired Milk of Magnesia medication was stored in the home's first floor medication cart; an Ozempic pen was not labeled with the date opened. |
| Pharmacy label for a resident's medication did not include current instructions for administration, conflicting with physician's orders. |
| Medication Administration Record did not include initials of staff who administered medication at the correct time. |
| Resident support plans did not reflect risks, specific needs, or safe use of bedside mobility devices for multiple residents. |
Report Facts
License Capacity: 123
Residents Served: 105
Secured Dementia Care Unit Capacity: 13
Secured Dementia Care Unit Residents Served: 12
Hospice Current Residents: 5
Residents Age 60 or Older: 105
Residents with Intellectual Disability: 1
Residents with Mobility Need: 24
Residents with Physical Disability: 1
Total Daily Staff: 129
Waking Staff: 97
Inspection Report
Follow-Up
Census: 105
Capacity: 123
Deficiencies: 17
Jul 8, 2025
Visit Reason
The inspection was a provisional licensing inspection conducted to assess compliance with 55 Pa. Code Ch. 2600 relating to Personal Care Homes.
Findings
The facility was found to have multiple deficiencies including failure to post current license summary, unsecured poisonous materials accessible to residents, unsanitary conditions in resident rooms, elevator without current certificate of operation, uncovered food items, inconsistent medical evaluations, medication errors including discontinued medications kept, improper medication storage, incomplete medication records, and incomplete resident assessments and support plans. Plans of correction were accepted and implemented with ongoing monitoring.
Deficiencies (17)
| Description |
|---|
| Failure to post the current licensing summary in a conspicuous and public place accessible to residents and guests. |
| Poisonous materials were unlocked, unattended, and accessible to residents in laundry and cleaning areas. |
| Unsanitary conditions including soiled clothing basket in contact with clean towels and feces on toilet rim; strong odor and urine stain on recliner chair in resident rooms. |
| Elevator did not have a current certificate of operation from the Department of Labor and Industry or local authority. |
| Food items (ice cream) stored uncovered in a cabinet display freezer. |
| Resident had inconsistent medical evaluations with conflicting dietary and body positioning needs. |
| Discontinued medication (Sulfatrim) was found in medication cart. |
| Loose medication found in medication cart. |
| Medication administration errors including undocumented blood sugar checks and inconsistent glucometer readings. |
| Medication record did not include diagnosis or purpose for certain medications. |
| Medication administration record did not include initials of staff administering medication. |
| Refusal of medication was not documented in resident's record or medication record. |
| Failure to follow prescriber's orders with remaining doses not administered as documented. |
| Resident initial assessments were not completed within 15 days of admission. |
| Resident assessments did not reflect significant changes in condition, including mobility and dietary needs. |
| Resident support plans did not document medical, dental, vision, hearing, mental health or behavioral care services or device use accurately. |
| Resident record did not include resident's death certificate. |
Report Facts
License Capacity: 123
Residents Served: 105
Secured Dementia Care Unit Capacity: 13
Residents Served in Secure Dementia Care Unit: 12
Current Hospice Residents: 9
Staffing Hours: 129
Waking Staff: 97
Residents 60 Years or Older: 105
Residents with Mobility Need: 24
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Juliet Marsala | Deputy Secretary | Signed licensing letter and certificate of compliance. |
| Director of Facilities | Named in plan of correction for securing poisonous materials and elevator inspection. | |
| Housekeeping Supervisor | Named in plan of correction for cleaning resident rooms and securing chemicals. | |
| Memory Care Director | Named in plan of correction for medication errors and medical evaluation corrections. | |
| Director of Health and Wellness | Named in multiple plans of correction related to medical evaluations, medication audits, resident assessments, and support plans. | |
| Administrator | Named in plans of correction and responsible for ongoing compliance monitoring. |
Inspection Report
Follow-Up
Census: 107
Capacity: 123
Deficiencies: 6
Apr 22, 2025
Visit Reason
The inspection was a follow-up visit to verify the correction of previously identified deficiencies as part of a plan of correction submission.
Findings
The facility was found to have multiple deficiencies related to resident record confidentiality, unobstructed egress, smoking area guidelines, medication and syringe security, storage procedures, and following prescriber's orders. Immediate corrective actions were taken, and plans for ongoing training and monitoring were implemented to maintain compliance.
Deficiencies (6)
| Description |
|---|
| Resident records were left unlocked and unattended on the medication cart, accessible to unauthorized persons. |
| Egress route from the rehab room was blocked by a chair and two walkers. |
| Approximately 50 cigarette butts were observed outside the home's main entrance, indicating non-compliance with smoking area guidelines. |
| Unlocked, unattended pills were found accessible in the main hallway and kitchen. |
| Blood glucose readings were not properly documented and medication counts showed errors, indicating unsafe medication storage and handling procedures. |
| Incorrect insulin dosage was administered due to errors in recording blood glucose levels and medication administration. |
Report Facts
License Capacity: 123
Residents Served: 107
Secured Dementia Care Unit Capacity: 13
Secured Dementia Care Unit Residents Served: 10
Current Hospice Residents: 5
Med Tech Staff: 122
Waking Staff: 92
Mobility Need Residents: 15
Cigarette Butts Observed: 50
Tablets in Blister Pack: 66
Tablets Documented on Controlled Substance Report: 67
Inspection Report
Complaint Investigation
Census: 101
Capacity: 123
Deficiencies: 0
Mar 12, 2025
Visit Reason
The inspection was conducted as a complaint investigation with a partial, unannounced visit on 03/12/2025.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Complaint Details
The inspection was complaint-related as explicitly stated under Inspection Information with reason 'Complaint'.
Report Facts
License Capacity: 123
Residents Served: 101
Secured Dementia Care Unit Capacity: 13
Secured Dementia Care Unit Residents Served: 10
Current Hospice Residents: 7
Residents Age 60 or Older: 101
Residents Diagnosed with Intellectual Disability: 1
Residents with Mobility Need: 20
Inspection Report
Enforcement
Census: 109
Capacity: 123
Deficiencies: 25
Sep 10, 2024
Visit Reason
The inspection was conducted due to renewal, complaint, and incident reasons, including follow-up on previous violations and enforcement actions.
Findings
Multiple violations were found including failure to report incidents timely, missing or incorrect medication administration, unsafe storage of poisonous materials, inadequate staff training, and deficiencies in resident assessments and documentation. The facility was issued a first provisional license with fines pending if corrections are not made.
Complaint Details
The inspection included complaint investigations related to incident reporting delays, medication errors, and safety concerns. Specific incidents involved unwitnessed falls and respiratory distress that were not reported timely to the Department.
Deficiencies (25)
| Description |
|---|
| Failure to report incidents to the Department within required timeframes. |
| Missing carbon monoxide alarm near gas fireplace. |
| Resident-home contract not signed by resident. |
| Incomplete criminal background check for new hire. |
| Incomplete fire safety orientation for staff. |
| Unsafe bedside mobility device posing entrapment risk. |
| Poisonous materials not locked and accessible to residents in secured dementia care unit. |
| Unsanitary conditions in bathrooms including lack of paper towels and presence of soiled items. |
| Trash receptacles uncovered in kitchen and bathrooms. |
| No lids on dumpsters outside the home. |
| Emergency telephone numbers not posted by telephones in resident rooms. |
| First aid kits missing required items such as thermometer and eye coverings. |
| Soap dispenser empty in secured dementia care unit bathroom. |
| Lint accumulation in dryer lint traps. |
| Exterior door difficult to open, obstructing unobstructed egress. |
| Combustible materials stored near hot water heater. |
| Annual medical evaluations missing immunization history. |
| Discontinued medications present in medication carts. |
| Loose pills observed in medication carts. |
| Medication containers missing required pharmacy label information. |
| Discrepancies between blood sugar readings in glucometer and medication administration records; missing medications. |
| Failure to follow prescriber's orders including missed or incorrect medication administration. |
| Initial resident assessments missing required information such as supervision, mobility, and medications. |
| Missing cognitive preadmission screening for secured dementia care unit resident. |
| Directions for key-locking devices not posted near device. |
Report Facts
Fine amount: 327
Fine amount: 545
License capacity: 123
Residents served: 109
Residents served in secured dementia care unit: 12
Total daily staff: 131
Waking staff: 98
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Juliet Marsala | Deputy Secretary | Signed enforcement letter and licensing documents. |
| Unnamed LPN | Named in deficiencies related to medication errors and incident reporting failures. | |
| Unnamed Director of Health and Wellness | Director of Health and Wellness | Named in multiple findings related to medication management, staff training, and corrective actions. |
| Unnamed Administrator | Administrator | Named in relation to oversight, counseling staff, and monitoring compliance. |
| Unnamed Director of Facilities | Director of Facilities | Named in findings related to safety, maintenance, and environmental compliance. |
| Unnamed Memory Care Director | Memory Care Director | Named in findings related to secured dementia care unit compliance and safety. |
| Unnamed Business Office Manager | Named in findings related to contract signatures and background check compliance. |
Inspection Report
Complaint Investigation
Census: 103
Capacity: 123
Deficiencies: 26
Sep 10, 2024
Visit Reason
The inspection was conducted due to a combination of renewal, complaint, and incident reasons as part of a licensing inspection.
Findings
Multiple violations were found including failure to report incidents timely, missing or incorrect documentation, unsafe storage and handling of medications, unsafe environmental conditions, and failure to follow prescriber's orders. Several deficiencies were repeated from prior inspections.
Complaint Details
The inspection was complaint-related and included substantiated violations such as failure to timely report incidents, medication errors, and unsafe conditions.
Deficiencies (26)
| Description |
|---|
| Failure to report an unwitnessed fall resulting in a hip fracture within 24 hours to the Department. |
| No carbon monoxide detector near gas fireplace in lobby. |
| Resident-home contract not signed by resident. |
| Criminal background check not completed for staff member who lived in PA less than required time. |
| Direct care staff did not complete required fire safety and emergency preparedness orientation on first day. |
| Direct care staff did not complete required orientation on resident rights, emergency medical plan, and abuse reporting within 40 hours. |
| Bedside mobility device not securely fastened to bed, posing entrapment risk. |
| Poisonous materials unlocked and accessible to residents in secured dementia care unit. |
| Sanitary conditions not maintained: no paper towels, pungent odor, soiled items in bathrooms. |
| Trash receptacles uncovered in kitchen and bathrooms. |
| Trash dumpsters outside lacked lids. |
| Emergency telephone numbers not posted on or by telephones in resident rooms. |
| First aid kits missing thermometer and eye covering. |
| Soap dispenser empty in secured dementia care unit bathroom. |
| Lint accumulation in dryer lint traps. |
| Exterior door difficult to open, rusted hinges, obstructed egress. |
| Combustible cardboard box stored near gas-powered hot water heater. |
| Annual medical evaluations missing immunization history for residents. |
| Discontinued medications found in medication carts. |
| Loose pills found in medication carts. |
| Medication containers missing required pharmacy label information. |
| Discrepancies between blood sugar readings in glucometer and medication administration records; medications not available. |
| Failure to follow prescriber's orders including missed or incorrect medication administration. |
| Initial resident assessments missing required information such as supervision, mobility, and medications. |
| Written cognitive preadmission screening not completed for resident admitted to secured dementia care unit. |
| Directions for operating key-locking devices not conspicuously posted near secure dementia care unit entrance. |
Report Facts
License Capacity: 123
Residents Served: 103
Secured Dementia Care Unit Capacity: 13
Residents Served in Secured Dementia Care Unit: 11
Total Daily Staff: 118
Waking Staff: 89
Fines Proposed: 872
Inspection Report
Complaint Investigation
Census: 90
Capacity: 123
Deficiencies: 5
Nov 1, 2023
Visit Reason
The inspection was conducted as a complaint investigation with an unannounced partial inspection on 11/01/2023 and an off-site review on 11/03/2023.
Findings
The facility was found to have multiple deficiencies including failure to report incidents timely, medication administration errors, incomplete resident assessments, and inaccurate support plans. The submitted plan of correction was determined to be fully implemented as of the follow-up dates.
Complaint Details
The inspection was complaint-driven, with the reason explicitly stated as 'Complaint'. The plan of correction was submitted and fully implemented by 01/12/2024.
Deficiencies (5)
| Description |
|---|
| Failure to report a resident fall with fractured clavicle to the Department within 24 hours. |
| Medication order changed to 'as needed' without authorization from an authorized prescriber. |
| Resident did not receive prescribed medications on multiple dates due to unavailability. |
| Resident did not have updated assessments after experiencing falls to determine new needs or support. |
| Resident's support plan did not accurately reflect mobility status and other needs such as use of manual wheelchair and assistive devices. |
Report Facts
License Capacity: 123
Residents Served: 90
Secured Dementia Care Unit Capacity: 13
Residents Served in Dementia Unit: 11
Total Daily Staff: 112
Waking Staff: 84
Residents 60 Years or Older: 90
Residents with Mobility Need: 22
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tamara Martin | Administrator | Named as the facility administrator. |
Inspection Report
Complaint Investigation
Census: 90
Capacity: 123
Deficiencies: 3
Jul 25, 2023
Visit Reason
The inspection was conducted as a complaint and monitoring review of the facility on 07/25/2023 to evaluate compliance with regulatory requirements.
Findings
The inspection identified multiple medication-related deficiencies including unsecured medications stored in a resident's room, discrepancies between glucometer readings and electronic medication records, and unqualified staff performing blood glucose testing. Plans of correction were accepted and implemented by 08/17/2023.
Complaint Details
The visit was complaint-related and monitoring in nature, with no substantiation status explicitly stated.
Deficiencies (3)
| Description |
|---|
| Resident 4 self-administers medications stored unlocked and unattended in the resident's room. |
| Discrepancies between Residents 1, 2, and 3 glucometer readings and electronic medication administration records. |
| Staff person A performed blood glucose testing without completing required department-approved diabetes education within the last 12 months. |
Report Facts
License Capacity: 123
Residents Served: 90
Secured Dementia Care Unit Capacity: 13
Secured Dementia Care Unit Residents Served: 9
Hospice Current Residents: 5
Residents with Mobility Need: 24
Residents Age 60 or Older: 90
Residents Diagnosed with Intellectual Disability: 1
Residents with Physical Disability: 3
Inspection Report
Renewal
Census: 90
Capacity: 123
Deficiencies: 20
Jun 6, 2023
Visit Reason
The inspection was conducted as a full, unannounced review for renewal and complaint reasons on 06/06/2023 and 06/07/2023.
Findings
The inspection identified multiple deficiencies including failure to report resident abuse and medication errors, incomplete medical evaluations, inadequate staff training, obstructed egress, medication storage and administration issues, missing resident record content, and failure to post required signage. Plans of correction were accepted and many deficiencies were noted as repeated violations.
Complaint Details
The inspection included complaint-related reasons as indicated by the inspection information section listing 'Renewal, Complaint' as reasons for the visit.
Deficiencies (20)
| Description |
|---|
| Failure to report an altercation between residents to the local Area Agency on Aging. |
| Failure to report medication errors to the Department. |
| Last quality management review was completed on 03/31/2020, overdue for periodic review. |
| Only one staff person certified in first aid, obstructed airway techniques and CPR was present for 90 residents. |
| Staff did not receive required annual training in fire safety, Older Adult Protective Services Act, falls and accident prevention. |
| Metal exterior door in secured care unit had rust and debris causing blocked egress. |
| Medical evaluation for Resident 8 was not completed within 60 days prior to admission. |
| Resident 1 and Resident 4 had overdue annual medical evaluations. |
| First aid kit in transport vehicle missing tweezers, thermometer, breathing shield, and eye coverings. |
| Resident 10 had unlocked, unattended medications and prescription bottle missing required labeling information. |
| Resident 5's glucometer was not calibrated with the correct date; discrepancies found between Resident 8's glucometer and medication records. |
| Medications were not administered to Residents 1, 2, 5, and 6 as prescribed due to unavailability or missed checks. |
| Staff person administered medications without completing Department-approved medication administration course. |
| Residents 4 and 6 were not educated on their right to refuse medication if they believed there was an error. |
| Resident 6's initial assessment was not completed within 15 days of admission. |
| Resident 7's previous annual assessment was overdue. |
| Resident 2's cognitive preadmission screening for Secure Dementia Care Unit was completed late. |
| No documentation that Residents 1 and 2 or their designated persons objected to admission to Secure Dementia Care Unit. |
| Directions for operating door locking mechanism at main entrance gate in Secure Dementia Care Unit were not conspicuously posted. |
| Resident records for Residents 2, 5, and 8 lacked color of hair, color of eyes, and identifying marks. |
Report Facts
License Capacity: 123
Residents Served: 90
Secured Dementia Care Unit Capacity: 13
Secured Dementia Care Unit Residents Served: 9
Current Hospice Residents: 8
Residents Age 60 or Older: 90
Residents with Mobility Need: 24
Residents with Physical Disability: 3
Total Daily Staff: 114
Waking Staff: 86
Inspection Report
Complaint Investigation
Census: 90
Capacity: 123
Deficiencies: 3
May 9, 2023
Visit Reason
The inspection was conducted as a complaint investigation with a partial, unannounced review on 05/09/2023, 05/11/2023, and 05/12/2023 to assess compliance following allegations of abuse and other regulatory concerns.
Findings
The inspection found multiple deficiencies including failure to report an abuse incident within 24 hours, physical abuse of a resident resulting in injury, and medication administration by a staff member without proper certification. Plans of correction were accepted and implemented with training and procedural updates.
Complaint Details
The complaint investigation was substantiated with findings of abuse and neglect. Staff member A was suspended and subsequently terminated. Training on abuse, resident rights, and reporting requirements was mandated for all direct care staff.
Deficiencies (3)
| Description |
|---|
| Failure to report an allegation of abuse involving a resident to the Department within 24 hours as required. |
| Resident was physically abused by a staff member, resulting in injury including cuts and a broken finger. |
| Staff member administered medications without successfully completing the Department-approved medication administration course within the past 2 years. |
Report Facts
License Capacity: 123
Residents Served: 90
Secured Dementia Care Unit Capacity: 13
Residents Served in Dementia Unit: 12
Current Hospice Residents: 5
Residents Age 60 or Older: 93
Residents with Mobility Need: 30
Total Daily Staff: 120
Waking Staff: 90
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff Member A | Named in abuse incident involving physical harm to a resident; suspended and terminated. | |
| Staff Member B | Witnessed abuse incident involving Staff Member A and Resident 1. | |
| Staff Member C | Administered medications without required certification; removed from medication administration duties. |
Inspection Report
Renewal
Census: 75
Capacity: 123
Deficiencies: 19
Sep 28, 2022
Visit Reason
The inspection was conducted as a renewal review of the facility's compliance with licensing requirements.
Findings
The inspection identified multiple deficiencies including unlabeled carbon monoxide detector batteries, unsigned resident contracts, open dumpster lids, improper food labeling and storage, outdated or dented food cans, obstructed egress due to rusted door, incomplete or untimely medical evaluations, unlocked medications in resident rooms, discontinued medications not removed, medication labeling errors, glucometer calibration and documentation errors, failure to follow prescriber's orders, missing resident education on medication refusal rights, unsigned support plans, and missing signage for key locking devices. Plans of correction were accepted or directed with completion dates mostly in November 2022.
Deficiencies (19)
| Description |
|---|
| Carbon monoxide detector batteries were not labeled with the date changed and no log was maintained. |
| Resident-home contracts for Residents #2 and #4 were not signed by the residents. |
| Dumpster lids were open, allowing potential insect and rodent infestation. |
| Unlabeled and undated leftover food containers found in secured care unit refrigerator. |
| Food stored in unsealed containers in secured care unit refrigerator. |
| Dented cans of food were stored and used for meal preparation. |
| Dryer ductwork cleaning was not performed according to manufacturer's instructions. |
| Exterior door to secured care unit was rusted and difficult to open, blocking egress. |
| Resident #5's medical evaluation was not completed within required timeframe. |
| Resident #6's medical evaluation was incomplete, missing health status, cognitive function, and provider license number. |
| Medications were found unlocked and accessible in Resident #6's room. |
| Discontinued medications for Residents #4 and #6 were not removed from medication carts. |
| Medication label for Resident #2 did not reflect current prescribed dosage. |
| Glucometer for Resident #6 was not calibrated to correct date and time; multiple documentation errors in blood glucose readings. |
| Medication administration times were inaccurately documented for Resident #6. |
| Blood glucose checks were not performed or documented for Residents #2 and #3 as prescribed. |
| Residents #2 and #4 were not educated on their right to refuse medication. |
| Resident #5 did not sign the support plan as required. |
| Directions for operating key locking devices were not posted near the Secure Dementia Care Unit exit door. |
Report Facts
License Capacity: 123
Residents Served: 75
Secured Dementia Care Unit Capacity: 13
Secured Dementia Care Unit Residents Served: 8
Hospice Current Residents: 3
Residents with Mobility Need: 13
Residents with Physical Disability: 1
Total Daily Staff: 88
Waking Staff: 66
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Facilities Maintenance | Named in relation to carbon monoxide detector battery replacement and maintenance. | |
| Interim Executive Director | Provided re-education and oversight for multiple deficiencies and plans of correction. | |
| Business Office Manager | Responsible for monitoring resident contracts and ensuring signatures. | |
| Director of Culinary | Responsible for monitoring dumpster lids and food safety. | |
| Director of Memory Care | Responsible for monitoring food labeling, signage, and exit door compliance. | |
| Sales Counselor | Re-educated on resident contracts and medical evaluation timeframes. | |
| Sales Lifestyle Coordinator | Re-educated on resident contracts and rights. | |
| Director of Health and Wellness | Involved in medical evaluation audits, medication administration, and staff re-education. | |
| Charge Nurse | Involved in auditing medical evaluations, medication carts, and support plans. | |
| Certified Diabetic Educator | Provided training on glucometer calibration and documentation. |
Inspection Report
Routine
Deficiencies: 0
Mar 23, 2022
Visit Reason
The inspection was conducted as a licensing inspection by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing.
Findings
No regulatory citations were identified as a result of this inspection.
Notice
Capacity: 123
Deficiencies: 0
Jan 25, 2021
Visit Reason
The document serves as a renewal notification and license issuance for The Haven at Springwood Personal Care Home, confirming receipt of the renewal application and advising of the requirement for an annual onsite inspection within the next twelve months.
Findings
No inspection findings are reported in this document; it is a license renewal notice and certificate of compliance.
Report Facts
Maximum capacity: 123
Secure Dementia Care Unit capacity: 13
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary, Office of Long-term Living | Signed the renewal notification letter |
Loading inspection reports...
