Inspection Reports for St. Mary Villa for Independent & Retirement Living
701 LANSDALE AVENUE,, PA, 19446
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
26.4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
462% worse than Pennsylvania average
Pennsylvania average: 4.7 deficiencies/yearDeficiencies per year
32
24
16
8
0
Census
Latest occupancy rate
68% occupied
Based on a August 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Notice
Deficiencies: 0
Oct 8, 2025
Visit Reason
The document serves to notify St. Mary Villa for Independent & Retirement Living that their request to waive the education qualification requirement for direct care staff has been granted under specified conditions.
Findings
The waiver is granted based on submitted documentation showing equivalent education to a U.S. high school diploma, with conditions for maintaining documentation and annual review during inspections.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Theresa Hartman | Bureau Director, Human Services Licensing | Signed the waiver approval letter. |
Inspection Report
Monitoring
Census: 61
Capacity: 90
Deficiencies: 7
Aug 21, 2025
Visit Reason
The visit was an unannounced partial inspection conducted as a monitoring review of the facility to verify compliance and implementation of the submitted plan of correction.
Findings
The inspection found multiple deficiencies including failure to timely report an incident, unqualified direct care staff, improper storage and locking of poisonous materials, obstructed emergency egress, medication administration errors, and incomplete preadmission screening forms. The submitted plan of correction was determined to be fully implemented as of the follow-up review.
Deficiencies (7)
| Description |
|---|
| Failure to report an incident of alleged abuse to the Department within 24 hours. |
| Direct care staff person did not have a high school diploma, GED, or active registry status on the Pennsylvania nurse aide registry. |
| Poisonous materials were stored in unlabeled, non-original containers on a utility cart. |
| Poisonous materials were not kept locked and inaccessible to residents; lock on utility cart was broken. |
| Emergency exit door was obstructed by a stop sign that could deter exit in an emergency. |
| Medication errors including medications without current orders, medications not available in the home, and medication administration not properly documented. |
| Preadmission screening form did not include a determination that the resident's needs could be met by the services provided. |
Report Facts
License Capacity: 90
Residents Served: 61
Secured Dementia Care Unit Capacity: 20
Secured Dementia Care Unit Residents Served: 20
Current Hospice Residents: 4
Residents with Mobility Need: 27
Total Daily Staff: 88
Waking Staff: 66
Inspection Report
Monitoring
Census: 54
Capacity: 90
Deficiencies: 3
Sep 24, 2024
Visit Reason
The inspection was a partial, unannounced monitoring visit conducted to review the facility's compliance and implementation of the submitted plan of correction.
Findings
The inspection identified deficiencies related to unsafe storage of poisonous materials, smoking area violations, and improper storage of medications. All deficiencies were addressed with plans of correction accepted and implemented by 10/29/2024.
Deficiencies (3)
| Description |
|---|
| Poisonous materials were found unlocked and accessible in a resident's bedside table, with residents not assessed as capable of safely using or avoiding poisons. |
| Eighteen cigarette butts were found outside on a patio area that is not a designated smoking area, violating smoking area guidelines. |
| Medication blister packs were observed with punctured foil exposing medication to contamination or improper sanitation. |
Report Facts
License Capacity: 90
Residents Served: 54
Secured Dementia Care Unit Capacity: 20
Secured Dementia Care Unit Residents Served: 14
Resident with Mental Illness: 6
Resident with Mobility Need: 14
Resident Age 60 or Older: 54
Resident with Supplemental Security Income: 0
Resident with Intellectual Disability: 0
Resident with Physical Disability: 0
Inspection Report
Complaint Investigation
Census: 58
Capacity: 90
Deficiencies: 6
Aug 29, 2024
Visit Reason
The inspection was conducted as a complaint investigation with an unannounced partial inspection on 08/29/2024 to review compliance and follow up on submitted plans of correction.
Findings
The inspection identified multiple deficiencies including failure to immediately report suspected resident abuse, incomplete staff training in required topics, inaccurate medical evaluation documentation, and missing resident signatures on support plans. Plans of correction were accepted and implemented by 11/19/2024.
Complaint Details
The inspection was complaint-driven, triggered by allegations of suspected resident abuse that was not reported timely by staff. The complaint was substantiated with findings of delayed reporting and failure to notify the Department.
Deficiencies (6)
| Description |
|---|
| Failure to immediately report suspected abuse of a resident according to the Older Adult Protective Services Act. |
| Failure to report the incident or condition to the Department’s personal care home regional office within 24 hours as required. |
| Direct care staff person did not receive required annual training in medication self-administration, dementia care, infection control, and care for residents with mental illness or intellectual disability. |
| Direct care staff person did not receive required annual training in fire safety and emergency preparedness. |
| Medical evaluation documentation was inaccurate; 'none' was selected under Special Health or Dietary Needs when it should have indicated secured dementia care and diagnosis. |
| Resident participated in the development of their support plan but did not sign the support plan. |
Report Facts
License Capacity: 90
Residents Served: 58
Secured Dementia Care Unit Capacity: 20
Secured Dementia Care Unit Residents Served: 18
Current Hospice Residents: 2
Residents Age 60 or Older: 57
Residents with Mobility Need: 51
Residents Diagnosed with Mental Illness: 1
Residents Diagnosed with Intellectual Disability: 1
Inspection Report
Renewal
Census: 56
Capacity: 90
Deficiencies: 31
Jul 10, 2024
Visit Reason
The inspection was conducted as a renewal visit to review compliance with licensing requirements at St. Mary Villa for Independent & Retirement Living.
Findings
The inspection identified multiple deficiencies including issues with incident reporting, compliance with health and safety laws, contract signatures, staff training, fire safety drills, medication management, and documentation. Plans of correction were accepted and implemented with ongoing audits and education.
Deficiencies (31)
| Description |
|---|
| Failure to report an incident involving a resident found on the floor within 24 hours. |
| Boiler failed inspection and was not fully repaired or certified. |
| Resident-home contracts not properly signed by residents or home. |
| Resident records lacked signed statements acknowledging receipt of resident rights and complaint procedures. |
| Insufficient number of staff certified in CPR/First Aid present during shifts with census above 50. |
| New staff did not receive complete orientation on fire safety and emergency preparedness topics. |
| Direct care staff did not complete required training on resident rights, emergency medical plan, and abuse reporting within 40 hours. |
| Direct care staff provided unsupervised ADL services without completing required training and competency testing. |
| Direct care staff did not receive required annual training hours or training on specific topics including medication administration and care for residents with dementia. |
| Staff training plan did not include required training courses for each staff person. |
| Unsafe bed rail installation creating hazardous conditions for a resident. |
| Poisonous materials not stored in original labeled containers or kept locked and inaccessible to residents. |
| Unsanitary conditions including rust stains, debris, and improperly stored personal belongings. |
| Furniture and equipment not in good repair, including leaking washer and broken towel bar. |
| Obstructions such as tree branches found in emergency exit walkways. |
| Failure to provide proof of annual submission of emergency procedures to local emergency management agency. |
| Fire drills not conducted properly or documented accurately, including missing evacuation times, exit routes, and resident evacuation counts. |
| Residents not evacuated to designated meeting places during fire drills. |
| Residents did not receive annual medical evaluations timely. |
| Medications stored improperly with punctured blister packs exposing medication to contamination. |
| Medication labels did not match physician orders. |
| Discrepancies in narcotics counts and documentation of medication administration. |
| Medications not administered as prescribed, with no explanation provided. |
| Staff person failed to complete required medication administration training and competency testing. |
| Residents not educated on their right to refuse medication if they believe there is an error. |
| Preadmission screening forms and support plans not signed by required personnel. |
| No documentation that residents or their designated persons objected to admission to secured dementia care unit. |
| No written approval from authorities for magnetic locks on secured dementia care unit exit doors. |
| No manufacturer statement verifying magnetic locks will release upon fire alarm activation, power failure, or lock override. |
| Admission support plan not completed within required 72 hours of admission to secured dementia care unit. |
| Direct care staff in secured dementia care unit lacked required dementia care training hours. |
Report Facts
Residents served: 56
License capacity: 90
Residents served in secured dementia care unit: 16
Current hospice residents: 2
Residents with mobility need: 16
Residents aged 60 or older: 56
Residents diagnosed with mental illness: 6
Staff total daily: 72
Staff waking: 54
Deficiency count: 40
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff person A | Named in findings related to fire safety orientation and abuse reporting training deficiencies | |
| Staff person B | Named in findings related to fire safety orientation and abuse reporting training deficiencies | |
| Staff person C | Named in findings related to fire safety orientation, direct care training, medication administration competency, and medication errors | |
| Staff person D | Named in findings related to annual training hours, dementia care training, and medication training deficiencies | |
| Resident #2 | Named in multiple findings related to contract signatures, medication labeling, medication administration, right to refuse education, preadmission screening, support plan signatures, and no objection statement | |
| Resident #3 | Named in findings related to contract signatures, medication storage, right to refuse education, no objection statement, and admission support plan | |
| Resident #4 | Named in findings related to contract signatures, medication administration, right to refuse education, preadmission screening, and support plan signatures | |
| Resident #5 | Named in finding related to annual medical evaluation | |
| Resident #6 | Named in finding related to annual medical evaluation | |
| Resident #7 | Named in medication administration and storage findings | |
| Resident #8 | Named in medication storage and narcotics count findings |
Inspection Report
Monitoring
Census: 51
Capacity: 90
Deficiencies: 5
Apr 26, 2023
Visit Reason
The inspection was a monitoring visit conducted as a partial, unannounced review to verify continued compliance and implementation of the submitted plan of correction.
Findings
The facility was found to have implemented the submitted plan of correction fully. Several deficiencies were identified related to direct care staff qualifications, sanitary conditions, lint removal and duct cleaning, and medication storage and equipment calibration, all of which had corrective plans accepted and implemented.
Deficiencies (5)
| Description |
|---|
| Direct care staff person did not have a high school diploma, GED, or active registry status on the Pennsylvania nurse aide registry. |
| No paper towels were found in the bathroom for the shared bathroom for residents in room 72b. |
| Approximately 1/4 inch accumulation of lint and debris in the lint trap of the lint tray of the clothes dryer. |
| Resident #2's prescribed cough medication was not available in the home. |
| The glucometer for resident #2 was not calibrated to the correct date and time. |
Report Facts
License Capacity: 90
Residents Served: 51
Memory Care Capacity: 20
Memory Care Residents Served: 14
Current Hospice Residents: 5
Residents Age 60 or Older: 53
Residents with Mobility Need: 14
Residents Diagnosed with Mental Illness: 1
Residents Diagnosed with Intellectual Disability: 1
Inspection Report
Renewal
Census: 49
Capacity: 90
Deficiencies: 27
Feb 6, 2023
Visit Reason
The inspection was conducted as a renewal visit to review compliance with licensing requirements for ST. MARY VILLA FOR INDEPENDENT & RETIREMENT LIVING.
Findings
The inspection identified multiple deficiencies including contract signature omissions, refund delays, missing posted telephone numbers, staff qualification issues, sanitary and safety concerns, medication management errors, incomplete resident records, and fire safety violations. Plans of correction were accepted and fully implemented by the follow-up date.
Deficiencies (27)
| Description |
|---|
| Resident-home contracts for residents #1, #2, and #3 were not signed by the residents. |
| Resident refunds were not made within 30 days of discharge for residents #4 and #5. |
| Telephone numbers for regulatory and protective agencies were not posted in a conspicuous place. |
| Direct care staff person A lacked a high school diploma, GED, or active registry status; diploma was in Arabic without waiver request. |
| No staff training plan was developed for 2022 or 2023. |
| Sanitary conditions issues including mold in bathrooms, unlabeled hygiene items, and mildew stains in shower. |
| Stained ceiling tiles and carpet in resident areas. |
| Bathroom sink in resident room #71 had no running water due to valve being turned off. |
| Non-working landline phones in hallways and unsafe bed enabler in resident room #22. |
| First aid kit in main kitchen lacked a thermometer and no separate first aid kit was present. |
| Use of common towels without identifying labels in shared bathroom of resident room #72. |
| Lint trap of dryer in Secured Dementia Care Unit was heavily covered with lint. |
| No fire safety inspection or fire drill conducted by a fire safety expert in 2021 or 2022. |
| Fire drill records missing number of residents present and evacuated for multiple drills. |
| Fire drills routinely held on the last day of each month, not varying days or times. |
| Residents did not fully evacuate to designated meeting places during fire drills on multiple occasions. |
| Resident #2's medical evaluation incorrectly marked 'none' instead of 'Secured Dementia Care' for special health or dietary needs. |
| Medications prescribed for resident #6 were found in med cart but not listed on current medication order. |
| Opened bottle of eye drops without open date found; should be discarded 28 days after opening. |
| Resident #6's prescribed medication was not available in the home when needed. |
| Resident #6's glucometer was not calibrated to the correct date and time. |
| Resident #6's medication was signed out twice on one date without explanation and not documented on controlled substance log. |
| Resident #7's medication order changed but resident was given only one tab on one date. |
| Directions for operating key-locking devices in Secured Dementia Care Unit were not conspicuously posted. |
| Resident #1's support plan incorrectly indicated minimal supervision and mobility needs while residing in SDCU. |
| Resident #6's controlled substance record had an entry crossed off and written over. |
| Resident #3's record did not include the preadmission screening. |
Report Facts
Residents served: 49
License capacity: 90
Residents served in secured dementia care unit: 12
Capacity of secured dementia care unit: 20
Current hospice residents: 1
Residents aged 60 or older: 48
Residents diagnosed with mental illness: 1
Residents diagnosed with intellectual disability: 1
Residents with mobility need: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Provided education on contract signatures, telephone number postings, staff qualifications, medication management, and other compliance areas | |
| Admissions Director | Monitors admission process and carpet replacement | |
| Admissions Coordinator | Received education on contract signatures | |
| RCC (Resident Care Coordinator) | Conducted audits, provided education, and involved in medication and documentation compliance | |
| Business Office Manager | Completed audit of resident refunds | |
| Director of Environmental Services | Cleaned showers and removed lint | |
| HSK Director | Provided education and audits related to housekeeping and sanitary conditions | |
| Director of Maintenance | Replaced ceiling tiles, removed phones, scheduled fire drills, and conducted audits | |
| Human Resources Director | Completed audit of direct care staff files | |
| Med Technicians | Received education and involved in medication audits | |
| Director of Dietary | Monitors first aid kits and linen/towel monitoring | |
| Director of Laundry | Monitors lint removal and linen labeling |
Inspection Report
Complaint Investigation
Census: 51
Capacity: 90
Deficiencies: 1
Jan 11, 2023
Visit Reason
The inspection was conducted as a complaint and incident investigation at ST. MARY VILLA FOR INDEPENDENT & RETIREMENT LIVING.
Findings
The facility was found to have delayed reporting an incident where Resident #1 was pushed down by nursing staff. The plan of correction was accepted and fully implemented, including staff education on abuse reporting and prevention.
Complaint Details
The complaint involved an incident where Resident #1 was pushed down by nursing staff. The home did not report this incident to the department until after the required 24-hour timeframe. The allegation was investigated, statements were obtained, and no signs of abuse were identified by the resident. The alleged perpetrator was removed from the schedule immediately following the report.
Deficiencies (1)
| Description |
|---|
| Failure to report an incident of abuse involving Resident #1 being pushed down by nursing staff within 24 hours as required. |
Report Facts
License Capacity: 90
Residents Served: 51
Secured Dementia Care Unit Capacity: 20
Secured Dementia Care Unit Residents Served: 13
Current Hospice Residents: 2
Residents Age 60 or Older: 50
Residents Diagnosed with Mental Illness: 1
Residents with Mobility Need: 19
Inspection Report
Complaint Investigation
Census: 52
Capacity: 90
Deficiencies: 2
Jun 16, 2022
Visit Reason
The inspection was conducted as a complaint investigation to review sanitary and ventilation conditions at the facility.
Findings
The inspection found unsanitary conditions including wet and urine-stained bathroom floors, stained carpets, and strong urine odor in the memory care unit. Additionally, there was inadequate ventilation in a resident's bathroom due to lack of operable windows or vents. Corrective actions were immediately taken and accepted.
Complaint Details
The inspection was triggered by a complaint. The plan of correction was submitted and fully implemented as of 12/28/2022.
Deficiencies (2)
| Description |
|---|
| Bathroom floors in resident 1's room were wet with water and urine; toilet had stains and wet seat; carpets in Memory Care unit entrance and hallways had stains; strong urine odor throughout memory care unit. |
| No operable window, air conditioner, or working vent in resident 1's bathroom to ensure airflow. |
Report Facts
License Capacity: 90
Residents Served: 52
Memory Care Unit Capacity: 20
Memory Care Unit Residents Served: 17
Inspection Report
Complaint Investigation
Census: 53
Capacity: 90
Deficiencies: 0
Jun 2, 2022
Visit Reason
The inspection was conducted as a complaint investigation at St. Mary Villa for Independent & Retirement Living.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Complaint Details
The inspection was complaint-related, but no deficiencies or citations were found, and follow-up was not required.
Report Facts
License Capacity: 90
Residents Served: 53
Secured Dementia Care Unit Capacity: 20
Secured Dementia Care Unit Residents Served: 17
Total Daily Staff: 70
Waking Staff: 53
Residents 60 Years or Older: 52
Residents with Mobility Need: 17
Inspection Report
Complaint Investigation
Census: 50
Capacity: 90
Deficiencies: 12
Apr 11, 2022
Visit Reason
The inspection was conducted as a complaint investigation following an unannounced partial inspection on 04/11/2022.
Findings
Multiple deficiencies were found including unlocked poisonous materials accessible to residents, unsanitary conditions with urine stains and odors, evidence of rodent infestation, furniture and equipment in disrepair, inadequate bedroom furnishings, and incomplete resident support plans related to toileting and admission procedures.
Complaint Details
The inspection was complaint-driven as indicated by the reason 'Complaint' and the unannounced partial inspection on 04/11/2022.
Deficiencies (12)
| Description |
|---|
| Unlocked poisonous materials accessible to residents in multiple medicine cabinets. |
| Unsanitary conditions including urine stains, strong urine odors, dried urine on floors, lack of hand drying in bathrooms, trash on floors, and overflowing toilets. |
| Evidence of mouse droppings in multiple resident rooms indicating infestation. |
| Overflowing, uncovered trash can in women's tub room. |
| Furniture and equipment issues including loose headboard, leaking and non-flushing toilets, and stained sinks. |
| Bedrooms lacking adequate chairs for residents. |
| Residents' beds did not have clean bed linens. |
| Residents lacked operable lamps or lighting at bedside. |
| Bedrooms had dirty floors with grime, dust, brown stains, and bowing ceiling tiles. |
| No thermometer in ice cream freezer in main dining room. |
| Resident support plans did not document actual toileting plans, causing staff unawareness. |
| Resident admitted to secured dementia care unit did not have initial support plan completed within required 72 hours. |
Report Facts
License Capacity: 90
Residents Served: 50
Secured Dementia Care Unit Capacity: 20
Residents Served in Dementia Unit: 18
Total Daily Staff: 75
Waking Staff: 56
Residents 60 Years or Older: 48
Residents with Mobility Need: 25
Inspection Report
Complaint Investigation
Census: 27
Capacity: 90
Deficiencies: 0
Nov 19, 2021
Visit Reason
The inspection was conducted as a complaint investigation with unannounced partial licensing inspections on 11/19/2021, 11/22/2021, and 11/23/2021.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Complaint Details
The inspection was complaint-related as stated, but no substantiation status or further complaint details were provided.
Report Facts
Total Daily Staff: 50
Waking Staff: 38
Residents Served: 27
License Capacity: 90
Secured Dementia Care Unit Capacity: 19
Secured Dementia Care Unit Residents Served: 14
Residents Age 60 or Older: 76
Residents Diagnosed with Mental Illness: 21
Residents with Mobility Need: 23
Inspection Report
Renewal
Census: 58
Capacity: 90
Deficiencies: 27
Sep 28, 2021
Visit Reason
The inspection was a full, unannounced renewal inspection conducted on 09/28/2021 to assess compliance with licensing requirements for St. Mary Villa for Independent & Retirement Living.
Findings
The inspection identified multiple deficiencies including missing resident-home contracts, incomplete medication records, failure to post influenza information, unsafe storage of poisonous materials, sanitary issues, hot water temperature violations, and failure to report incidents timely. Plans of correction were accepted or directed for all deficiencies.
Deficiencies (27)
| Description |
|---|
| Personal care and assisted living homes must post the required influenza information in a public place year-round; the home did not have an influenza poster on 9/29/21. |
| Resident 3 did not have a resident-home contract at admission. |
| Resident-home contracts for residents 4, 5, 6, 7, and 8 did not include a fee schedule of actual amounts charged for available services. |
| Refunds for deceased residents 9, 10, 11, and 12 were delayed or not issued as required by the Elder Care Payment Restitution Act. |
| Residents 3, 6, and 8 did not have signed statements acknowledging receipt of resident rights and complaint procedures. |
| Direct care staff person A provided unsupervised ADL services without completing required training and competency testing. |
| Laundry room in the memory care unit was unlocked and accessible to residents with poisonous materials stored inside. |
| Sanitary conditions: rugs had large dark stains; toilet bowl in bedroom 66 had dark black stains. |
| Hot water temperature in bathrooms of rooms 65 and 66 exceeded 120°F. |
| Bathroom sink in room 65 had a clogged drainage pipe; hand towel dispenser in public resident bathroom was broken. |
| Tripping hazards on memory care unit patio due to damp hand towel and wild plants impeding pathway. |
| Memory care unit had only 1 shower for 18 users, below required ratio. |
| Toilet paper was missing in public resident bathroom at St. Joseph Wing and bedroom 65. |
| Food stored on the floor in emergency food stockpile. |
| Large accumulation of lint in lint traps of all four dryers. |
| Written emergency procedures were not reviewed, updated, or submitted annually to local emergency management agency. |
| Resident 14's medication administration record documentation was not available for prescribed medications. |
| Staff person B administered medications without completing Department-approved medication administration course. |
| Directions for operating locking mechanism were not conspicuously posted near Secure Dementia Care Unit door. |
| Incidents involving residents 1 and 2 sustaining injuries from falls were not reported to the department timely. |
| No emergency telephone numbers posted by telephone in bedroom 65. |
| Resident 13 did not have access to a source of light that can be turned on/off at bedside. |
| Freezer temperatures in memory care kitchenette and main kitchen exceeded required limits. |
| Medical evaluations for residents 3, 5, and 8 did not include the date when completed. |
| Resident 3’s preadmission screening form was not completed at time of admission. |
| Resident 6’s most recent additional assessment was not completed timely. |
| Resident 3's record did not include a home contract. |
Report Facts
Residents Served: 58
License Capacity: 90
Memory Care Capacity: 20
Memory Care Residents Served: 18
Total Daily Staff: 76
Waking Staff: 57
Deficiencies Cited: 26
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff person A | Named in deficiency for providing unsupervised ADL services without required training | |
| Staff person B | Named in deficiency for administering medications without completing required medication administration course |
Notice
Capacity: 90
Deficiencies: 0
Sep 7, 2021
Visit Reason
The document serves as a renewal notification and license issuance for the Personal Care Home, St. Mary Villa for Independent & Retirement Living, and informs that an annual inspection will be conducted 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: 90
Secure Dementia Care Unit capacity: 20
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary, Office of Long-term Living | Signed the renewal notification letter |
Inspection Report
Renewal
Census: 54
Capacity: 79
Deficiencies: 11
Jun 24, 2021
Visit Reason
The inspection was conducted as a renewal and complaint investigation of Wesley Enhanced Living at Stapeley on 06/24/2021, 06/25/2021, and 06/28/2021.
Findings
Multiple deficiencies were found including failure to post the resident's rights poster conspicuously, administrator lacking required qualifications documentation, insufficient certified first aid/CPR trained staff during night hours, facility maintenance issues such as torn tiles and water-damaged ceiling tiles, hot water temperature exceeding allowed limits, use of common towels, lack of thermometer in refrigerator, improper use of chairs to block dining room entrance, and incomplete or untimely medical evaluations and support plans for residents in the secured dementia care unit.
Complaint Details
The inspection included a complaint investigation as indicated by the reason for visit: Renewal, Complaint.
Deficiencies (11)
| Description |
|---|
| Resident's rights poster was not posted in a conspicuous and public place in the home. |
| Administrator could not provide required qualifications documentation such as nursing license or degree. |
| Only one staff person certified in first aid, obstructed airway techniques and CPR was present during night hours for 52 residents. |
| Stairwell #4 had torn tiles presenting a tripping hazard; ceiling tiles in closet of room 327 were dirty and warped from water damage. |
| Hot water temperature at bathroom sink in room 320 exceeded 120°F, measuring 129.0°F and 128.4°F. |
| Unlabeled wash cloths and towels were hanging in the shared bathroom of room 320. |
| No thermometer was present in the line prep refrigerator in the kitchen. |
| Chairs were used to block the entrance to the dining room to prevent residents from entering during cleaning. |
| Resident #1's medical evaluation documenting diagnosis and need for secured dementia care unit was incomplete or untimely. |
| Resident #1's written cognitive preadmission screening was completed late, after admission to the secured dementia care unit. |
| Resident #1's initial support plan was completed late and did not meet the 72-hour requirement for secured dementia care unit residents. |
Report Facts
Residents served: 54
License capacity: 79
Residents served in secured dementia care unit: 23
Current hospice residents: 1
Staffing hours: 77
Waking staff: 58
Residents present during CPR deficiency: 52
Hot water temperature: 129
Hot water temperature: 128.4
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