Inspection Reports for Spring Mill Pointe
2002 Joshua Rd, Lafayette Hill, PA 19444, United States, PA, 19444
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Inspection Report
Renewal
Census: 43
Capacity: 107
Deficiencies: 4
Aug 6, 2025
Visit Reason
The inspection was conducted as a renewal inspection of the facility's license.
Findings
The inspection found several deficiencies including uncovered trash outside, improperly stored food, missing posted menus for the upcoming week, and a medication labeling error. The facility submitted and fully implemented a plan of correction to address these issues.
Deficiencies (4)
| Description |
|---|
| Trash outside the home was not kept in covered receptacles, with debris found next to an open dumpster. |
| Food was not stored in closed or sealed containers; lids on five of eight ice-cream cartons were not securely fastened. |
| Menus for the upcoming week were not posted as required; the menu for the week starting 8/11/25 was missing. |
| A resident's prescription medication label had incorrect administration instructions differing from the prescription. |
Report Facts
License Capacity: 107
Residents Served: 43
Residents Served in Secured Dementia Care Unit: 22
Capacity of Secured Dementia Care Unit: 33
Current Hospice Residents: 5
Residents with Mobility Need: 24
Total Daily Staff: 67
Waking Staff: 50
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Building and Grounds | Educated on trash regulation and responsible for daily dumpster inspections | |
| Director of Dining Services | Educated on food storage and menu posting regulations; responsible for inspections | |
| Administrator | Educated dining team on food storage regulation | |
| Director of Resident Services | Responsible for monthly medication cart audits | |
| Charge Nurse | Responsible for monthly medication cart audits |
Inspection Report
Renewal
Census: 45
Capacity: 107
Deficiencies: 3
Sep 25, 2024
Visit Reason
The inspection was conducted as a renewal visit to review the facility's compliance and licensing status.
Findings
The submitted plan of correction was determined to be fully implemented. Deficiencies were identified related to contract signatures, bedside lighting, and medication storage, all of which had corrective actions accepted and implemented.
Deficiencies (3)
| Description |
|---|
| The resident-home contract for residents #1 and #2 was not signed by the residents. |
| Resident #2 did not have access to a source of light that can be turned on/off at bedside. |
| Medication cards for residents #3, #4, and #5 were observed to have punctured blister foil with medication still present. |
Report Facts
Residents Served: 45
License Capacity: 107
Secured Dementia Care Unit Capacity: 36
Secured Dementia Care Unit Residents Served: 27
Hospice Current Residents: 3
Residents Age 60 or Older: 45
Residents with Mobility Need: 29
Total Daily Staff: 74
Waking Staff: 56
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Resident Services | Involved in discarding and reordering medications and re-education on medication storage regulation | |
| Nurse | Assisted in discarding medication for resident #5 | |
| Administrator | Re-educated on contract signature regulation and responsible for auditing resident contracts | |
| Director of Sales | Re-educated on contract signature regulation | |
| Director of Building and Grounds | Educated on bedside lamp regulation | |
| Resident Services Coordinator | Responsible for conducting audits related to bedside lamp and medication storage compliance |
Inspection Report
Renewal
Census: 47
Capacity: 107
Deficiencies: 6
May 24, 2023
Visit Reason
The inspection was conducted as a renewal visit to review compliance and verify the submitted plan of correction for the facility.
Findings
The facility was found to have several deficiencies related to evacuation times, medication labeling and administration, resident assessments, medical evaluations, and admission support plans. All deficiencies had plans of correction submitted and were determined to be fully implemented by the follow-up dates.
Deficiencies (6)
| Description |
|---|
| During the fire drill on 10/25/22 at 9:40AM, it took 7 minutes to evacuate the home, exceeding the maximum safe evacuation time of 6 minutes specified by a fire safety expert. |
| Resident 1's medication label and controlled substance log times did not match the prescribed administration times. |
| Resident 1’s controlled substance log did not include the initials of the staff person who administered medication on 5/24/23 at 1:11PM. |
| Resident 3’s initial assessment was not completed within 15 days of admission. |
| Resident 3’s medical evaluation did not include the need for the resident to be served in a secured dementia care unit. |
| Resident 3’s initial support plan was not completed within 72 hours of admission to the secured dementia care unit. |
Report Facts
Residents Served: 47
License Capacity: 107
Secured Dementia Care Unit Capacity: 36
Secured Dementia Care Unit Residents Served: 27
Hospice Current Residents: 4
Residents Age 60 or Older: 47
Residents with Mobility Need: 27
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Resident Services | Named in multiple findings related to medication labeling, medication administration, resident assessments, medical evaluations, and admission support plans. | |
| Administrator | Provided training and education related to evacuation drill deficiencies and resident assessments. | |
| Director of Building and Grounds | Received training regarding evacuation drill regulations and responsible for reporting evacuation drill durations. |
Inspection Report
Follow-Up
Census: 46
Capacity: 107
Deficiencies: 5
Jan 9, 2023
Visit Reason
The inspection visit on 01/09/2023 was a partial, unannounced review triggered by 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. Deficiencies included issues with contract signatures, signed statements acknowledging receipt of resident rights, treatment of residents without consent, labeling of over-the-counter medications, and resident education on the right to refuse medication. Corrective actions and staff education were completed and ongoing monitoring was planned.
Deficiencies (5)
| Description |
|---|
| The resident-home contract for resident #1 was not signed by the resident. |
| Resident #1's record did not contain a signed statement acknowledging receipt of resident rights and complaint procedures. |
| Staff person A treated resident #1 with diaper change and barrier cream despite resident refusal, causing distress. |
| A bottle of cough syrup in the memory care medication cart was not labeled with a resident's name. |
| Resident #1 had not been educated on the right to refuse medication if a medication error is suspected. |
Report Facts
License Capacity: 107
Residents Served: 46
Secured Dementia Care Unit Capacity: 33
Secured Dementia Care Unit Residents Served: 24
Hospice Current Residents: 2
Resident Support Staff: 106
Total Daily Staff: 176
Waking Staff: 132
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Sales | Educated on policies related to contract signatures, signed statements, and resident education | |
| Administrator | Reviewed contracts and responsible for monthly contract reviews and reporting to QAPI | |
| Nurse Supervisor | Will interview random team members monthly to review compliance with treatment of residents |
Notice
Capacity: 107
Deficiencies: 0
Oct 19, 2021
Visit Reason
The document serves as a renewal notification and issuance of a regular license for the Personal Care Home 'Spring Mill Pointe' following receipt of the renewal application dated October 19, 2021.
Findings
No inspection findings are reported; the document confirms the issuance of a regular license and advises that an onsite inspection will be conducted within the next twelve months as required by regulation.
Report Facts
Maximum licensed capacity: 107
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary, Office of Long-term Living | Signed the renewal notification letter |
Inspection Report
Renewal
Census: 50
Capacity: 107
Deficiencies: 18
Sep 8, 2021
Visit Reason
The inspection was an unannounced renewal inspection conducted on 09/08/2021 to assess compliance with licensing regulations at Spring Mill Pointe.
Findings
Multiple deficiencies were identified including privacy violations due to camera use, lack of criminal background checks for contractors, improper storage of poisonous materials, unsanitary conditions, ventilation issues, missing emergency telephone numbers, incomplete first aid kits, medication storage and labeling issues, documentation errors, and support plan signature deficiencies. Plans of correction were accepted for all findings.
Deficiencies (18)
| Description |
|---|
| Camera in resident room #144 violated resident privacy. |
| Five contractors were in the building without criminal background checks since May 2021. |
| Unlabeled bottle of cleaner unsecured on housekeeping cart in Cedar Brook. |
| Bleach Germicidal Wipes and Flex Disinfectant Wipes unlocked and accessible to residents in memory care unit. |
| Sticky substances in bottom of refrigerator in memory care kitchen; strong odors and soiled clothing in resident rooms #144 and #151. |
| Resident rooms 144 and 151 lacked operable ventilation; exhaust fans needed repair. |
| No emergency telephone numbers posted by telephone in room #106. |
| First aid kit in memory care unit missing required items. |
| Memory care staff did not know location of first aid kit. |
| Opened and unsealed food items in refrigerator. |
| Two loose pills found in medication cart in memory care unit. |
| No pharmacy label on Medline Skintegrity wound cleanser. |
| Glucometer readings for resident #1 were not documented correctly on medication administration record. |
| Resident #2's most recent assessment date missing. |
| Resident #3 participated in support plan development but did not sign the plan. |
| Resident #3's refusal or inability to sign support plan was not documented. |
| Directions for operating locking mechanism not posted near door in Secure Dementia Care Unit. |
| Correction fluid used on resident #4's contract. |
Report Facts
License Capacity: 107
Residents Served: 50
Residents in Secured Dementia Care Unit: 26
Capacity of Secured Dementia Care Unit: 33
Hospice Residents: 1
Contractors without background checks: 5
Inspection Report
Renewal
Census: 50
Capacity: 107
Deficiencies: 17
Sep 8, 2021
Visit Reason
The inspection was a renewal inspection conducted as a full, unannounced visit to assess compliance with licensing regulations.
Findings
Multiple deficiencies were identified including privacy violations due to a camera in a resident room, lack of criminal background checks for contractors, improper storage of poisonous materials, unsanitary conditions, ventilation issues, missing emergency telephone numbers, medication storage and labeling issues, and documentation deficiencies. Plans of correction were accepted and implemented for all findings.
Deficiencies (17)
| Description |
|---|
| Camera in resident room #144 violated resident privacy. |
| Five contractors were in the building without criminal background checks. |
| Unlabeled bottle of cleaner unsecured on housekeeping cart. |
| Poisonous materials (bleach wipes) unlocked and accessible in memory care unit. |
| Sticky substances in refrigerator and strong odors in resident rooms #144 and #151. |
| Resident rooms #144 and #151 lacked operable ventilation; exhaust fans needed repair. |
| No emergency telephone numbers posted by telephone in room #106. |
| First aid kit missing required items in memory care unit. |
| Staff in memory care unit unaware of first aid kit location. |
| Food stored in opened and unsealed containers in refrigerator. |
| Two loose pills found in medication cart in memory care unit. |
| Medline Skintegrity wound cleanser lacked pharmacy label. |
| Glucometer readings not documented correctly on medication administration record. |
| Resident #2's most recent assessment date missing. |
| Resident #3 did not sign support plan and refusal was not documented. |
| Directions for operating locking mechanism not posted near door in Secure Dementia Care Unit. |
| Correction fluid used on resident #4's contract. |
Report Facts
Deficiencies cited: 16
Residents served: 50
License capacity: 107
Staffing: 78
Waking staff: 59
Inspection Report
Census: 48
Capacity: 107
Deficiencies: 0
Jun 30, 2021
Visit Reason
The inspection was conducted as a partial, unannounced visit due to an incident.
Findings
No regulatory citations or deficiencies were identified during the inspection.
Report Facts
Residents Served: 48
License Capacity: 107
Secured Dementia Care Unit Capacity: 33
Secured Dementia Care Unit Residents Served: 22
Residents Age 60 or Older: 48
Residents with Mobility Need: 27
Residents with Physical Disability: 2
Total Daily Staff: 75
Waking Staff: 56
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