Inspection Reports for South Mountain Memory Care
201 Seventh St, Emmaus, PA 18049, PA, 18049
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Inspection Report
Census: 23
Capacity: 28
Deficiencies: 0
Jan 29, 2025
Visit Reason
The inspection was an unannounced partial licensing inspection conducted as an interim review by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
License Capacity: 28
Residents Served: 23
Current Residents in Hospice: 6
Total Daily Staff: 46
Waking Staff: 35
Inspection Report
Renewal
Census: 24
Capacity: 28
Deficiencies: 17
Oct 1, 2024
Visit Reason
The inspection was conducted as a renewal inspection of the South Mountain Memory Care facility to assess compliance with licensing requirements.
Findings
The inspection identified multiple deficiencies including improper posting of current license documents, confidentiality breaches with resident records, lack of staff CPR/First Aid certification during a shift, missing annual training topics for staff, unsafe storage of poisonous materials, furniture and equipment hazards, food safety violations, fire safety equipment and drill deficiencies, medication record inaccuracies, and incomplete resident support plans. All deficiencies had plans of correction accepted and were implemented by March 20, 2025.
Deficiencies (17)
| Description |
|---|
| Binder containing previous year’s License Inspection Summary reports was not stored in a public and conspicuous area. |
| Confidential resident information found in unlocked cabinet in dining area. |
| No staff on third shift had current First Aid and CPR training certification. |
| Staff did not receive required annual training on medication self-administration. |
| Staff did not receive required annual fire safety training by a fire safety expert. |
| Laundry detergent pods stored in a clear container without original label. |
| Bed rail in room 109 was not securely fastened and was very loose. |
| Container of ice cream found uncovered and unlabeled in freezer. |
| No fire extinguisher stored in the basement of the home. |
| Fire extinguisher in laundry area had expired inspection tag marked 'FAIL'. |
| No documentation of fire drills from December 2023 through August 2024. |
| Fire safety inspection and supervised fire drill not conducted annually as required. |
| No documentation of fire drill during sleeping hours every six months. |
| Incorrect documentation of blood glucose readings on Medication Administration Record. |
| Medication records missing documentation of vital signs used to determine medication holds. |
| No code posted near keypad used to open exit gate for outdoor garden area. |
| Resident Assessment Support Plan did not reflect resident's inability to safely avoid poisonous materials or use of bedside mobility device. |
Report Facts
License Capacity: 28
Residents Served: 24
Current Hospice Residents: 3
Total Daily Staff: 48
Waking Staff: 36
Inspection Report
Renewal
Census: 23
Capacity: 28
Deficiencies: 5
Dec 13, 2023
Visit Reason
The inspection was an unannounced full renewal inspection conducted to review compliance with licensing requirements and verify the submitted plan of correction.
Findings
The facility was found to have multiple deficiencies including failure to post the current license and inspection summary conspicuously, unlocked poisonous materials accessible to residents, missing light bulbs in bedside lamps, inaccuracies in medication storage procedures, and incomplete support plan documentation. All deficiencies had accepted plans of correction which were fully implemented by the follow-up dates.
Deficiencies (5)
| Description |
|---|
| The most recent license inspection summary and Chapter 2600 regulations were not posted in a conspicuous area but were found in a binder behind a piano. |
| A can of Clorox Disinfectant Spray was found unlocked in a kitchen cupboard accessible to residents, posing a poisoning hazard. |
| The bedside lamp in Resident room 105 was missing a light bulb with no other source of illumination near the bed. |
| Review of Resident #1's glucometer showed discrepancies with the MAR indicating inaccurate blood sugar levels due to human error. |
| The Resident Assessment Support Plan (RASP) for Resident #1 did not indicate the resident’s date of admission. |
Report Facts
Residents Served: 23
License Capacity: 28
Current Residents in Hospice: 3
Residents Age 60 or Older: 23
Residents with Mobility Need: 23
Residents with Physical Disability: 1
Staffing Hours - Resident Support Staff: 1
Staffing Hours - Total Daily Staff: 47
Staffing Hours - Waking Staff: 35
Inspection Report
Plan of Correction
Deficiencies: 0
Sep 13, 2022
Visit Reason
The visit was conducted to review the submitted plan of correction for the facility following a prior inspection.
Findings
The submitted plan of correction was determined to be fully implemented, and continued compliance must be maintained.
Inspection Report
Follow-Up
Census: 21
Capacity: 28
Deficiencies: 1
Aug 8, 2022
Visit Reason
The visit was a partial, unannounced follow-up inspection triggered by an incident involving an allegation of sexual assault by a staff member on a resident.
Findings
The facility was found to have fully implemented the submitted plan of correction related to the abuse allegation. The staff member involved was suspended and terminated following internal and external investigations, with no physical evidence found to support the claim initially. The facility retrained staff on resident rights and maintained compliance with abuse reporting policies.
Complaint Details
The visit was complaint-related due to an allegation of sexual assault by Staff Member A on Resident #1. The staff member was suspended and terminated after investigations by the facility, police, and other agencies. Preliminary findings noted no physical evidence, but later evidence from a specimen kit led to an arrest. The facility cooperated fully with investigations and retrained staff on resident rights.
Deficiencies (1)
| Description |
|---|
| A resident may not be neglected, intimidated, physically or verbally abused, mistreated, subjected to corporal punishment or disciplined in any way. |
Report Facts
License Capacity: 28
Residents Served: 21
Resident Support Staff: 21
Total Daily Staff: 63
Waking Staff: 47
Inspection Report
Routine
Deficiencies: 0
Jun 24, 2022
Visit Reason
The inspection was conducted as part of the Pennsylvania Department of Human Services, Bureau of Human Service Licensing routine licensing inspections on 06/24/2022 and 07/01/2022.
Findings
No regulatory citations were identified as a result of this inspection.
Inspection Report
Routine
Deficiencies: 0
Feb 22, 2022
Visit Reason
The inspection was conducted as part of licensing inspections by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing on multiple dates in February 2022.
Findings
No regulatory citations were identified as a result of the inspections conducted on 02/04/2022, 02/07/2022, 02/10/2022, and 02/22/2022 at the facility.
Report Facts
Inspection dates: 4
Inspection Report
Routine
Deficiencies: 0
Dec 14, 2021
Visit Reason
The inspection was conducted as a routine licensing inspection by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Notice
Capacity: 28
Deficiencies: 0
Aug 27, 2021
Visit Reason
The document serves as a renewal notification and license issuance for South Mountain Memory Care, a 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 an administrative notice confirming license renewal and outlining the Department's inspection requirements.
Report Facts
Maximum capacity: 28
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary, Office of Long-term Living | Signed the renewal notification letter |
Inspection Report
Renewal
Census: 25
Capacity: 28
Deficiencies: 3
Aug 3, 2021
Visit Reason
The inspection was conducted as a renewal inspection of the South Mountain Memory Care facility to assess compliance with licensing requirements.
Findings
The inspection found deficiencies related to refund procedures following a resident's death, improper food storage, and missing documentation of resident education regarding the right to refuse medication. Plans of correction were accepted and implemented for all deficiencies.
Deficiencies (3)
| Description |
|---|
| Refund to resident's estate after death was not prorated correctly according to the Elder Care Payment Restitution Act. |
| An uncovered bowl of oatmeal was found in the kitchen freezer, violating food storage requirements. |
| Records for several residents did not include documentation that they were educated about their right to question or refuse medications. |
Report Facts
License Capacity: 28
Residents Served: 25
Monthly Bill: 6365
Residents Missing Education Documentation: 16
Staffing: 50
Waking Staff: 38
Inspection Report
Routine
Deficiencies: 0
Jun 24, 2021
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.
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