Deficiencies (last 5 years)
Deficiencies (over 5 years)
5.4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
15% worse than Pennsylvania average
Pennsylvania average: 4.7 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
39% occupied
Based on a January 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 30
Capacity: 77
Deficiencies: 0
Jan 14, 2025
Visit Reason
The inspection was conducted as a complaint and incident investigation at the facility.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Complaint Details
The inspection was triggered by a complaint and incident, but no deficiencies or citations were found.
Report Facts
License Capacity: 77
Residents Served: 30
Secured Dementia Care Unit Capacity: 30
Secured Dementia Care Unit Residents Served: 30
Current Hospice Residents: 4
Residents Age 60 or Older: 60
Residents Diagnosed with Intellectual Disability: 1
Residents with Mobility Need: 30
Inspection Report
Follow-Up
Census: 60
Capacity: 77
Deficiencies: 8
Dec 5, 2024
Visit Reason
The inspection was a follow-up review of a previously submitted plan of correction related to a complaint and incident at the facility.
Findings
The report details multiple deficiencies related to resident abuse reporting, supervision of staff, incident reporting, abuse prevention, positive interventions, prohibitions on restraints, medical evaluations, and support plan needs. The facility implemented corrective actions including staff suspension and termination, education, audits, and ongoing monitoring.
Complaint Details
The visit was complaint-related, triggered by an incident where a resident was upset, unsteady, refused assistance, kicked a staff member, and was found locked in a bathroom. The abuse allegation was initially not reported timely. Staff person A was suspended and later terminated. Education and monitoring plans were implemented.
Deficiencies (8)
| Description |
|---|
| Failure to immediately report suspected abuse of a resident to the local Area Agency on Aging. |
| Failure to immediately submit a plan of supervision or notice of suspension of the affected staff person to the Department. |
| Failure to report the incident or condition to the Department’s personal care home regional office or complaint hotline within 24 hours. |
| Resident subjected to abuse including being kicked by staff and locked in a bathroom with a chair blocking the door. |
| Failure to use positive interventions to modify or eliminate behavior that endangers the resident or others. |
| Use of prohibited procedures including seclusion and restraints. |
| Resident medical evaluation not completed within 60 days prior to admission and did not indicate the need for secured dementia care unit (SDCU). |
| Support plan did not identify resident’s physical, medical, social, cognitive and safety needs including falls and behavioral issues. |
Report Facts
License Capacity: 77
Residents Served: 60
Secured Dementia Care Unit Capacity: 30
Residents Served in SDCU: 29
Current Hospice Residents: 5
Residents Age 60 or Older: 60
Residents with Intellectual Disability: 1
Residents with Mobility Need: 29
Total Daily Staff: 89
Waking Staff: 67
Inspection Report
Renewal
Census: 58
Capacity: 77
Deficiencies: 4
Oct 28, 2024
Visit Reason
The inspection was conducted as a renewal inspection of the Sherwood Oaks facility to assess compliance with licensing requirements.
Findings
The inspection identified several deficiencies including failure of a direct care staff person to complete required training before providing unsupervised ADL services, unsecured poisonous materials accessible to residents in the secured dementia care unit, lack of annual medical evaluations for a resident, and missing posted codes for key-locking devices. Plans of correction were accepted and fully implemented by February 26, 2025.
Deficiencies (4)
| Description |
|---|
| Direct care staff person provided unsupervised ADL services without completing Department-approved direct care training and competency test. |
| Poisonous materials were unlocked, accessible, and unattended in the secured dementia care unit, with the soiled utility room door left wide open. |
| Resident did not have annual medical evaluation completed within required timeframe. |
| No code visible for locking mechanism for gate leading out of the outside garden and no code posted for door from outside garden into dining room in secured dementia care unit. |
Report Facts
License Capacity: 77
Residents Served: 58
Secured Dementia Care Unit Capacity: 30
Residents Served in Secured Dementia Care Unit: 30
Current Hospice Residents: 3
Total Daily Staff: 88
Waking Staff: 66
Inspection Report
Census: 58
Capacity: 77
Deficiencies: 0
Jul 17, 2024
Visit Reason
The inspection was a partial, unannounced visit conducted due to an incident at the facility on 07/17/2024.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
License Capacity: 77
Residents Served: 58
Secured Dementia Care Unit Capacity: 30
Secured Dementia Care Unit Residents Served: 30
Hospice Current Residents: 5
Residents Age 60 or Older: 58
Residents with Intellectual Disability: 1
Residents with Mobility Need: 30
Residents with Physical Disability: 1
Total Daily Staff: 88
Waking Staff: 66
Inspection Report
Renewal
Census: 57
Capacity: 77
Deficiencies: 7
Oct 11, 2023
Visit Reason
The inspection was conducted as a renewal inspection of the Sherwood Oaks facility on 10/11/2023 and 10/12/2023 to review compliance with licensing requirements.
Findings
The inspection identified several deficiencies related to sanitary conditions, trash management, bathroom ventilation, lighting, food storage, and medication labeling and administration. The facility submitted a plan of correction which was determined to be fully implemented by the follow-up date.
Deficiencies (7)
| Description |
|---|
| Two black packages of pre pureed foods were found on the floor of the walk-in freezer, one partially unsealed. |
| The right lid of the furthest right dumpster was pushed in, creating an opening approximately 2.5 by 4 feet, allowing potential insect and rodent penetration. |
| The continuous air draw vent in a private bathroom was not operational and there was no window for ventilation. |
| Resident #1 did not have access to an operable bedside source of light due to headboard placement. |
| Partially covered shredded Swiss cheese and tilapia were found in the walk-in refrigerator with seals not completely covering the edges. |
| Resident #1's medication container label did not match the prescribed directions. |
| Resident #2 was administered medication differently than documented on the medication administration record, though administration was per physician orders. |
Report Facts
License Capacity: 77
Residents Served: 57
Staffing Hours: 87
Waking Staff: 65
Secured Dementia Care Unit Capacity: 30
Residents with Mobility Need: 30
Residents 60 Years or Older: 57
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Dining Services | Named in relation to food storage and sanitary condition findings | |
| Grounds Supervisor | Responsible for monitoring dumpster lids as part of plan of correction | |
| Maintenance Manager | Involved in correcting dumpster lid and bathroom fan issues | |
| Nurse Supervisor | Placed lamp for resident and involved in medication administration education | |
| Nurse Care Manager | Responsible for medication cart and MAR audits |
Inspection Report
Renewal
Census: 65
Capacity: 77
Deficiencies: 2
Oct 11, 2022
Visit Reason
The inspection was conducted as a renewal inspection of the Sherwood Oaks facility to review compliance and verify the submitted plan of correction.
Findings
The submitted plan of correction was found to be fully implemented. Two deficiencies were noted: unlocked resident count sheets compromising confidentiality, and an incomplete annual medical evaluation missing the resident's pulse rate. Both deficiencies were corrected with staff education and audits.
Deficiencies (2)
| Description |
|---|
| Resident #1 and resident #2's count sheets were unlocked, unattended, and accessible outside the secured dementia care unit nursing office. |
| Resident #3’s annual medical evaluation did not indicate the resident’s pulse rate; this section of the form was blank. |
Report Facts
License Capacity: 77
Residents Served: 65
Secured Dementia Care Unit Capacity: 30
Secured Dementia Care Unit Residents Served: 29
Current Hospice Residents: 5
Residents Age 60 or Older: 65
Residents with Intellectual Disability: 1
Residents with Mobility Need: 29
Inspection Report
Census: 64
Capacity: 77
Deficiencies: 0
Jul 5, 2022
Visit Reason
The inspection was a partial, unannounced visit conducted due to an incident.
Findings
No deficiencies were found during this inspection.
Report Facts
Resident census: 64
Total licensed capacity: 77
Secured Dementia Care Unit capacity: 30
Secured Dementia Care Unit census: 28
Current Hospice Residents: 5
Inspection Report
Census: 64
Capacity: 77
Deficiencies: 0
Nov 5, 2021
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 as a result of this inspection.
Report Facts
Residents Served: 64
License Capacity: 77
Residents Served in Secured Dementia Care Unit: 28
Capacity of Secured Dementia Care Unit: 30
Current Hospice Residents: 3
Total Daily Staff: 92
Waking Staff: 69
Resident Support Staff: 0
Inspection Report
Renewal
Census: 65
Capacity: 77
Deficiencies: 6
Oct 22, 2021
Visit Reason
The inspection was an unannounced full renewal inspection conducted on 10/22/2021 to review the facility's compliance with licensing requirements.
Findings
The inspection identified multiple deficiencies including unsecured bed enablers posing fall hazards, uncovered trash receptacles in kitchens and outside, food stored on the floor, exit signs with improper letter size, and medication labeling issues. Plans of correction were directed and implemented with follow-up submissions.
Deficiencies (6)
| Description |
|---|
| Bed enablers attached to resident beds were not securely fastened, posing potential fall hazards. |
| Uncovered trash cans and containers in the country kitchen allowing penetration of insects and rodents. |
| Four dumpsters outside the home did not have lids, allowing penetration of insects and rodents. |
| Food (2 containers of ice cream) stored on the walk-in freezer floor. |
| Exit sign letters were only ¾" x ¾", smaller than required size for a home serving 65 residents. |
| Prescription medication for resident #2 lacked proper pharmacy labeling. |
Report Facts
License Capacity: 77
Residents Served: 65
Secured Dementia Care Unit Capacity: 30
Secured Dementia Care Unit Residents Served: 29
Hospice Current Residents: 5
Staffing Hours - Total Daily Staff: 94
Staffing Hours - Waking Staff: 71
Number of Residents with Mobility Need: 29
Number of Residents 60 Years or Older: 65
Number of Residents Diagnosed with Intellectual Disability: 1
Notice
Capacity: 77
Deficiencies: 0
Sep 13, 2021
Visit Reason
The document serves as a license renewal approval for the Personal Care Home 'Sherwood Oaks' and notifies the facility that an onsite inspection will be conducted within the next twelve months as required by state regulations.
Findings
No inspection findings are reported in this document; it confirms issuance of a regular license following receipt of the renewal application and outlines the requirement for a future annual inspection.
Report Facts
Maximum licensed capacity: 77
Secure Dementia Care Unit capacity: 30
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary, Office of Long-term Living | Signed the renewal approval letter. |
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