Inspection Report
Plan of Correction
Census: 55
Capacity: 122
Deficiencies: 2
Aug 26, 2025
Visit Reason
The inspection was conducted as a partial, unannounced review due to an incident at the facility.
Findings
Two deficiencies were identified: one involving resident abuse where an employee struck a resident during care, and another involving a blocked egress route by a utility cart. Both issues were addressed with corrective actions including employee termination and removal of the obstruction.
Deficiencies (2)
| Description |
|---|
| Employee handled resident roughly and struck in the back with a closed fist while washing during a shower. |
| A grey wheeled utility cart blocked egress from the home’s dining room exit door to the outside parking lot. |
Report Facts
License Capacity: 122
Residents Served: 55
Secured Dementia Care Unit Capacity: 28
Secured Dementia Care Unit Residents Served: 18
Hospice Current Residents: 2
Resident Support Staff: 21
Total Daily Staff: 97
Waking Staff: 73
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee A | Named in resident abuse finding for striking resident during care |
Inspection Report
Follow-Up
Census: 58
Capacity: 122
Deficiencies: 2
Jun 3, 2025
Visit Reason
The inspection was conducted as a partial, unannounced incident review on 06/03/2025 to evaluate compliance and the implementation of the submitted plan of correction.
Findings
Two deficiencies were identified: failure of residents to evacuate to a designated meeting place during a fire drill, and failure to complete a written cognitive preadmission screening for a resident admitted to the secured dementia care unit. Both deficiencies had corrective actions implemented and accepted by the licensee.
Deficiencies (2)
| Description |
|---|
| Residents refused to evacuate the building during the fire drill conducted on 5/31/25 at 10:15pm. |
| A resident admitted to the Secure Dementia Care Unit on 5/9/25 did not have a written cognitive preadmission screening completed. |
Report Facts
License Capacity: 122
Residents Served: 58
Residents in Secured Dementia Care Unit: 19
Current Hospice Residents: 2
Residents who have mobility need: 26
Residents 60 Years or Older: 58
Residents Diagnosed with Mental Illness: 1
Residents Diagnosed with Intellectual Disability: 0
Residents with Physical Disability: 1
Resident Support Staff: 26
Total Daily Staff: 110
Waking Staff: 83
Residents safely evacuated during fire drill: 54
Staff present during fire drill: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Justine Sweeting | Administrator | Responsible for maintaining compliance with fire drill evacuation regulation and preadmission screening regulation |
| John Mercincavage | Maintenance Director | Present during the fire drill on 6/10/2025 |
| Joan Savakinas | Resident Care Director | Completed new DME and RASP for resident transferred to secured memory care unit and responsible for compliance with preadmission screening regulation |
Inspection Report
Follow-Up
Census: 59
Capacity: 122
Deficiencies: 1
May 20, 2025
Visit Reason
The inspection was conducted as a follow-up review of the submitted plan of correction for the facility after an incident.
Findings
The facility was found to have previously violated the requirement to follow prescriber's orders related to blood glucose readings and medication dosage. The submitted plan of correction was accepted and fully implemented by 06/05/2025.
Deficiencies (1)
| Description |
|---|
| Residents were not administered their prescribed blood glucose readings at 4:00 P.M. and one resident received an incorrect medication dosage at bedtime. |
Report Facts
License Capacity: 122
Residents Served: 59
Secured Dementia Care Unit Capacity: 24
Secured Dementia Care Unit Residents Served: 20
Hospice Current Residents: 4
Resident Support Staff: 27
Total Daily Staff: 113
Waking Staff: 85
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Resident Care Director | Conducted education with employee regarding medication error | |
| Administrator | Responsible for maintaining ongoing compliance with regulation |
Inspection Report
Renewal
Census: 58
Capacity: 122
Deficiencies: 13
Apr 9, 2025
Visit Reason
The inspection was conducted as a renewal visit with an incident review, including a full unannounced inspection on 04/09/2025 and an exit conference on 04/18/2025.
Findings
The facility was found to have multiple deficiencies related to hospice care evacuation procedures, fire safety inspections and drills, menu posting, medication self-administration assessments, medication storage and administration errors, and failure to follow prescriber's orders. The submitted plan of correction was accepted and fully implemented by 06/17/2025.
Deficiencies (13)
| Description |
|---|
| Resident #1 receiving hospice care was not evacuated during fire drills without required physician certification of active dying status. |
| No informed consent statement from Resident #1 or power of attorney regarding non-evacuation during fire drills. |
| Designated person did not notify Resident #1 or staff during fire drills that the resident was not to be evacuated. |
| Resident #1 was not evacuated during fire drills despite failure to meet provisions requiring non-evacuation. |
| Resident #1's assessment and support plan did not address exclusion from evacuation during fire drills due to active dying status. |
| Documentation required for hospice care non-evacuation was not kept with fire drill logs, including physician certification and informed consent. |
| Annual fire safety inspection noted an exit sign was not visible; home initially did not install new sign but corrected before inspection. |
| Fire drill records lacked evacuation time for drills conducted on 5/22/24 and 6/4/24; inaccurate reporting of Resident #1 evacuation status. |
| Fire drills were routinely held on Fridays and every 3 weeks, not rotated by day/time as required. |
| Menus for current and following week were not posted with correct dates. |
| Resident #7 self-administers medications without assessment by qualified medical professional. |
| Resident #4's blood glucose reading was inaccurately documented on medication administration record. |
| Resident #5 was administered medication despite heart rate below prescribed threshold; Resident #6 was administered medication despite systolic blood pressure above prescribed threshold. |
Report Facts
License Capacity: 122
Residents Served: 58
Secured Dementia Care Unit Capacity: 28
Secured Dementia Care Unit Residents Served: 20
Hospice Residents: 2
Staffing Hours - Total Daily Staff: 84
Staffing Hours - Waking Staff: 63
Deficiencies cited: 13
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Named as responsible for maintaining compliance with evacuation policies, fire safety, medication administration, and other regulatory requirements. | |
| Resident Care Director | Named as responsible for maintaining compliance with evacuation policies, medication administration, and other regulatory requirements. | |
| Maintenance Director | Named as responsible for maintaining compliance with fire safety regulations and fire drill documentation. | |
| Dietary Manager | Named as responsible for menu posting compliance. | |
| Business Office Manager | Mentioned in relation to medication self-administration deficiency. |
Inspection Report
Census: 51
Capacity: 122
Deficiencies: 0
Feb 7, 2025
Visit Reason
The inspection was conducted as a partial, unannounced visit due to an incident at the facility.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
License Capacity: 122
Residents Served: 51
Secured Dementia Care Unit Capacity: 20
Secured Dementia Care Unit Residents Served: 17
Current Hospice Residents: 2
Residents Receiving Supplemental Security Income: 2
Residents Age 60 or Older: 51
Residents with Mobility Need: 22
Residents with Physical Disability: 1
Inspection Report
Census: 49
Capacity: 122
Deficiencies: 0
Jun 5, 2024
Visit Reason
The inspection was conducted as a licensing inspection due to an incident at the facility.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
License Capacity: 122
Residents Served: 49
Secured Dementia Care Unit Capacity: 20
Secured Dementia Care Unit Residents Served: 17
Hospice Current Residents: 1
Residents Receiving Supplemental Security Income: 2
Residents Diagnosed with Mental Illness: 1
Residents Age 60 or Older: 48
Inspection Report
Renewal
Census: 51
Capacity: 122
Deficiencies: 6
May 23, 2024
Visit Reason
The inspection was conducted as a renewal visit with an incident review, including unannounced full inspections on 05/23/2024 and 05/29/2024, and an off-site exit conference on 06/04/2024.
Findings
The report found multiple violations including unlocked medication storage areas compromising resident confidentiality, a resident-to-resident altercation, improper use of glucose monitors, cigarette butts found outside designated smoking areas, medication labeling discrepancies, and missing PRN medication. All violations had accepted plans of correction and were implemented by 06/11/2024.
Deficiencies (6)
| Description |
|---|
| Medication room door was unlocked and unattended; medication cart left unattended with blister pack visible, compromising resident confidentiality. |
| Resident-to-resident altercation where one resident hit another; both separated and monitored with no injuries. |
| Staff used one resident's glucometer to test another resident's blood glucose level. |
| Cigarette butts found outside designated smoking area due to employees smoking behind dumpster. |
| Medication label for Metoprolol Succ ER did not match the Medication Administration Record. |
| PRN medication (polyethylene glycol 3350 powder) was not available in the medication cart. |
Report Facts
License Capacity: 122
Residents Served: 51
Memory Care Capacity: 20
Memory Care Residents Served: 14
Hospice Residents: 2
Residents with Mobility Need: 18
Residents Receiving Supplemental Security Income: 2
Residents Age 60 or Older: 1
Residents Diagnosed with Mental Illness: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Resident Care Director | Named as responsible for maintaining ongoing compliance with multiple regulations and violations. | |
| Administrator | Named as responsible for maintaining ongoing compliance with multiple regulations and violations. |
Inspection Report
Census: 56
Capacity: 122
Deficiencies: 0
Mar 12, 2024
Visit Reason
The inspection was a partial, unannounced visit conducted due to an incident at the facility on 03/12/2024.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
License Capacity: 122
Residents Served: 56
Secured Dementia Care Unit Capacity: 20
Secured Dementia Care Unit Residents Served: 15
Resident Support Staff: 0
Total Daily Staff: 72
Waking Staff: 54
Residents Receiving Supplemental Security Income: 2
Residents Age 60 or Older: 55
Residents Diagnosed with Mental Illness: 2
Residents with Mobility Need: 16
Inspection Report
Census: 54
Capacity: 122
Deficiencies: 0
Dec 6, 2023
Visit Reason
The inspection was conducted as a partial, unannounced visit due to an incident at the facility.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Residents Served: 54
License Capacity: 122
Secured Dementia Care Unit Capacity: 28
Residents Served in Dementia Care Unit: 15
Inspection Report
Follow-Up
Census: 57
Capacity: 122
Deficiencies: 1
Nov 27, 2023
Visit Reason
The inspection was a partial, unannounced follow-up visit conducted due to an incident, with a focus on reviewing the submitted plan of correction.
Findings
The submitted plan of correction was determined to be fully implemented. The report details a violation involving a resident using profane language against another resident, with corrective actions including monitoring and care plan updates.
Deficiencies (1)
| Description |
|---|
| A resident used profane language against another resident in the home's activity room, violating the requirement that residents be treated with dignity and respect. |
Report Facts
License Capacity: 122
Residents Served: 57
Secured Dementia Care Unit Capacity: 20
Secured Dementia Care Unit Residents Served: 17
Total Daily Staff: 75
Waking Staff: 56
Residents Age 60 or Older: 56
Residents with Mobility Need: 18
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Justine Sweeting | Administrator | Responsible for maintaining compliance with the regulation regarding treatment of residents |
Inspection Report
Follow-Up
Census: 57
Capacity: 122
Deficiencies: 1
Nov 27, 2023
Visit Reason
The inspection was a partial, unannounced follow-up visit conducted due to an incident to verify the implementation of a previously submitted plan of correction.
Findings
The submitted plan of correction was determined to be fully implemented, addressing a violation where a resident used profane language against another resident. The facility maintained compliance with the regulation requiring residents to be treated with dignity and respect.
Deficiencies (1)
| Description |
|---|
| Resident #1 used profane language against Resident #2 in the home's activity room, violating the requirement that a resident shall be treated with dignity and respect. |
Report Facts
License Capacity: 122
Residents Served: 57
Secured Dementia Care Unit Capacity: 20
Secured Dementia Care Unit Residents Served: 17
Residents on 15-minute checks: 1
Monitoring Duration (hours): 72
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Resident Care Director | Made changes to resident's care plan regarding behaviors | |
| Administrator | Had verbal conversation with resident and family regarding violation and responsible for maintaining compliance |
Inspection Report
Complaint Investigation
Census: 57
Capacity: 122
Deficiencies: 5
Nov 7, 2023
Visit Reason
The inspection was conducted as a complaint and incident investigation at Serenity Care Kingston on 11/07/2023.
Findings
The inspection found multiple violations including abuse of a resident by a direct care employee, failure to complete fire safety orientation on the first day of work, prohibited seclusion of a resident, incomplete preadmission screening documentation, and incomplete admission support plans. Corrective actions were accepted and implemented by 01/11/2024.
Complaint Details
The visit was complaint-related and substantiation is implied by the findings of abuse and seclusion involving Direct Care Employee A. The employee was immediately removed and terminated on 10/23/23. All relevant parties including family, PCP, DHS, and AAA were notified on 10/23/23.
Deficiencies (5)
| Description |
|---|
| Resident #1 was physically abused by Direct Care Employee A who pushed the resident into a room causing injury and yelled at the resident. |
| Direct Care Employee A did not complete required fire safety training components on the first day of work. |
| Direct Care Employee A forcibly held Resident #1's door shut, constituting prohibited seclusion. |
| Resident #2's preadmission screening form did not indicate the home was able to meet her needs in the Personal Care Section. |
| Resident #3's admission support plan was not completed within the required timeframe for the secured dementia care unit. |
Report Facts
License Capacity: 122
Residents Served: 57
Secured Dementia Care Unit Capacity: 20
Secured Dementia Care Unit Residents Served: 17
Residents with Supplemental Security Income: 9
Residents Age 60 or Older: 56
Residents Diagnosed with Mental Illness: 2
Residents with Mobility Need: 18
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Justine Sweeting | Administrator | Named as responsible for terminating employee involved in abuse incident and for ongoing compliance monitoring |
Inspection Report
Census: 57
Capacity: 122
Deficiencies: 0
Sep 29, 2023
Visit Reason
The inspection was conducted as a partial, unannounced visit due to an incident.
Findings
No regulatory citations or deficiencies were identified as a result of the inspection conducted on 09/29/2023, 10/02/2023, and 10/06/2023.
Report Facts
Resident Support Staff: 57
Total Daily Staff: 132
Waking Staff: 99
License Capacity: 122
Residents Served: 57
Secured Dementia Care Unit Capacity: 28
Secured Dementia Care Unit Residents Served: 17
Residents Receiving Supplemental Security Income: 9
Residents 60 Years of Age or Older: 56
Residents Diagnosed with Mental Illness: 9
Residents Diagnosed with Intellectual Disability: 0
Residents with Mobility Need: 18
Residents with Physical Disability: 0
Inspection Report
Complaint Investigation
Census: 56
Capacity: 122
Deficiencies: 0
Jun 6, 2023
Visit Reason
The inspection was conducted as a result of an incident, with an unannounced partial licensing inspection performed on 06/06/2023.
Findings
No regulatory citations or deficiencies were identified during the inspection.
Complaint Details
The inspection was incident-related and no deficiencies were found, indicating no substantiated issues.
Report Facts
License Capacity: 122
Residents Served: 56
Residents Served in Secured Dementia Care Unit: 14
Current Hospice Residents: 1
Residents Receiving Supplemental Security Income: 10
Residents Age 60 or Older: 55
Residents with Mobility Need: 17
Residents Diagnosed with Mental Illness: 0
Residents Diagnosed with Intellectual Disability: 0
Residents with Physical Disability: 0
Inspection Report
Follow-Up
Census: 55
Capacity: 122
Deficiencies: 9
May 25, 2023
Visit Reason
The visit was a follow-up review conducted on 05/25/2023 to determine if the submitted plan of correction for the facility was fully implemented.
Findings
The report found that the submitted plan of correction was fully implemented. Several specific violations related to medical evaluations, medication records, prescriber orders, support plans, and screenings were identified and corrected with detailed plans of correction and completion dates.
Deficiencies (9)
| Description |
|---|
| Resident #1's medical evaluation did not include the physician's license number. |
| Resident #3 was administered PRN medications without documentation of effectiveness. |
| Resident #4's medication administration records (MARs) were not initialed for certain medications. |
| Resident #5's MAR was not initialed to confirm medication administration; MAR was not documented with resident's pulse rate and did not indicate if medication was held due to low pulse rate. |
| Resident #5's medication orders were not properly followed as MAR documentation was incomplete regarding pulse rate and medication holding. |
| Resident #2's assessment and support plan were not updated to indicate changes in therapy services. |
| Resident #2's cognitive preadmission screening was completed after admission. |
| Resident 32's record did not contain documentation that the responsible party did not object to secured dementia unit placement. |
| Resident #2 did not have a support plan developed within the required timeframe after admission to the secured dementia unit. |
Report Facts
License Capacity: 122
Residents Served: 55
Secured Dementia Care Unit Capacity: 20
Secured Dementia Care Unit Residents Served: 14
Inspection Report
Renewal
Deficiencies: 0
May 31, 2022
Visit Reason
The inspection was conducted as a licensing inspection by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing on 05/31/2022.
Findings
No regulatory citations were identified as a result of this inspection.
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