Deficiencies per Year
32
24
16
8
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Renewal
Census: 72
Capacity: 110
Deficiencies: 6
Jan 27, 2025
Visit Reason
The inspection was conducted as a renewal inspection with an incident review, including an unannounced full inspection on 01/27/2025 and 01/28/2025.
Findings
Multiple deficiencies were identified including uncovered trash outside, lack of ventilation in certain bathrooms, insufficient water pressure in a resident's room, snow accumulation on outdoor walkways, refrigerator temperature violations, and failure to follow prescriber's orders for a diabetic resident. Plans of correction were accepted and implemented with ongoing monitoring.
Deficiencies (6)
| Description |
|---|
| Trash outside the home was uncovered and overflowing outside dumpsters. |
| Bathrooms in rooms #116, #305, and #320 lacked operable windows or ventilation fans. |
| Insufficient water pressure in room #119 to accommodate resident needs. |
| Approximately 1 inch accumulation of snow on the patio of the memory care outdoor recreation area. |
| Temperature in the main walk-in refrigerator was above 40°F (49°F and 44°F). |
| Failure to notify prescriber of a high blood glucose reading ('HI') for resident #2 and not administering medication accordingly. |
Report Facts
License Capacity: 110
Residents Served: 72
Secured Dementia Care Unit Capacity: 28
Residents Served in Dementia Unit: 17
Current Hospice Residents: 2
Residents with Mobility Need: 43
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Resident Care Director | Resident Care Director (RCD) | Named in the finding related to follow prescriber's orders and glucometer calibration. |
| Executive Director | Executive Director (ED) | Involved in education and oversight of plan of correction implementations. |
| Director of Environmental Services | Director of Environmental Services (DES) | Named in findings related to trash management, ventilation, water pressure, snow removal, and environmental audits. |
| Dining Service Director | Dining Service Director (DSD) | Named in findings related to refrigerator temperature violations and dietary team education. |
Inspection Report
Complaint Investigation
Census: 110
Capacity: 110
Deficiencies: 0
Nov 19, 2024
Visit Reason
The inspection was conducted as a complaint and incident investigation during an unannounced partial licensing inspection.
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; no deficiencies or citations were found, indicating no substantiated violations.
Report Facts
License Capacity: 110
Residents Served: 110
Secured Dementia Care Unit Capacity: 28
Secured Dementia Care Unit Residents Served: 15
Hospice Current Residents: 6
Residents Age 60 or Older: 120
Residents with Mental Illness: 1
Residents with Intellectual Disability: 1
Residents with Physical Disability: 1
Residents with Mobility Need: 49
Inspection Report
Monitoring
Census: 65
Capacity: 110
Deficiencies: 0
Jul 24, 2024
Visit Reason
The inspection was a monitoring visit conducted by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing, to assess compliance at the facility.
Findings
No regulatory citations or deficiencies were identified during this unannounced partial inspection.
Report Facts
Residents Served: 65
License Capacity: 110
Secured Dementia Care Unit Capacity: 28
Secured Dementia Care Unit Residents Served: 17
Hospice Current Residents: 2
Resident Support Staff Hours: 121
Waking Staff Hours: 91
Inspection Report
Complaint Investigation
Census: 58
Capacity: 110
Deficiencies: 4
May 6, 2024
Visit Reason
The inspection was conducted as a complaint investigation following a complaint received by the Pennsylvania Department of Human Services.
Findings
The inspection found deficiencies related to failure to provide assistance with instrumental activities of daily living (IADLs), specifically transportation assistance/escorts, abuse related to leaving a resident unattended during transportation, lack of direct care staff training for transportation staff, and failure to provide an assistant to the driver during resident transport. The facility submitted and implemented a plan of correction addressing these issues.
Complaint Details
The complaint investigation substantiated issues with transportation assistance and resident safety during transport, including neglect and abuse when a resident was left unattended in a medical building.
Deficiencies (4)
| Description |
|---|
| Failure to provide assistance with IADLs including orientation cues and transportation escorts as indicated in resident support plans. |
| Resident was left alone and unattended during transportation contrary to the resident's support plan requiring assistance/escorts, constituting abuse. |
| Staff transporting residents had not completed required initial new hire direct care staff training. |
| Transportation did not include an assistant to the driver to escort residents and provide assistance during the trip as required. |
Report Facts
License Capacity: 110
Residents Served: 58
Secured Dementia Care Unit Capacity: 28
Residents Served in Dementia Unit: 13
Total Daily Staff: 97
Waking Staff: 73
Residents with Mobility Need: 39
Inspection Report
Renewal
Census: 62
Capacity: 110
Deficiencies: 13
Mar 11, 2024
Visit Reason
The inspection was conducted as a full, unannounced renewal and complaint investigation of the facility.
Findings
Multiple deficiencies were identified including unlocked resident records, missing carbon monoxide detector, lack of influenza poster, incomplete staff fire safety orientation, unsanitary conditions, hazards in surfaces, furniture and equipment in disrepair, fire extinguisher inspection lapses, missing first aid kit in transport vehicle, and medication self-administration assistance failures. All deficiencies had plans of correction accepted and implemented by April 9, 2024.
Complaint Details
The inspection included a complaint investigation component related to medication self-administration assistance failures for Resident 2, which was substantiated with findings of incorrect medication administration.
Deficiencies (13)
| Description |
|---|
| Resident face sheet binders were unlocked, unattended, and accessible at the receptionist desk. |
| No carbon monoxide detector near fossil fuel burning stove; influenza poster missing. |
| Staff person did not receive orientation on fire safety and emergency preparedness on first day. |
| Stairwell carpets had dark stains; ice maker had buildup of black substance. |
| Wall on second floor had opening with exposed wire; unattended can of air freshener in memory care bathroom. |
| Light blinking with cover on floor in stairwell; multiple kitchen cabinet doors falling off. |
| Resident mattress had factory plastic still covering it. |
| Open bottle of lemon juice that should be refrigerated found in dry storage. |
| Edy's ice cream in freezer was opened and unsealed. |
| Approximate 1/2-inch lint accumulation in lint trap of dryer in memory care. |
| Fire extinguishers in reminiscence neighborhood and vehicle not inspected since late 2022. |
| First aid kit missing in van used to transport residents. |
| Resident 2 did not receive proper assistance with medication self-administration, resulting in incorrect medications being taken. |
Report Facts
License Capacity: 110
Residents Served: 62
Capacity of Secured Dementia Care Unit: 28
Residents Served in Secured Dementia Care Unit: 11
Current Hospice Residents: 2
Residents Age 60 or Older: 62
Residents with Mobility Need: 42
Residents with Physical Disability: 2
Total Daily Staff: 104
Waking Staff: 78
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Resident Care Director | Resident Care Director (RCD) | Contacted CRNP regarding medication changes for Resident 2. |
| Director of Environmental Services | Director of Environmental Services (DES) | Installed carbon monoxide detector, cleaned carpets, inspected fire extinguishers, removed lint from dryers, and conducted multiple corrective actions. |
| Executive Director | Executive Director (ED) | Secured resident records, posted influenza poster, conducted audits and townhall meetings, and oversaw plan of correction implementation. |
| Assistant Executive Director | Assistant Executive Director (AED) | Conducted in-service training on confidentiality. |
| Director of Dining Services | Director of Dining Services (DDS) | Cleaned ice maker, disposed of contaminated food, and provided food safety training. |
| Personal Care Coordinator | Personal Care Coordinator (PCC) | Removed plastic mattress cover and inspected resident beds. |
| Reminiscence Coordinator | Reminiscence Coordinator (RC) | Conducted walk-throughs and in-service training on hazards in memory care. |
| Activities and Volunteer Coordinator | Activities and Volunteer Coordinator (AVC) | Will conduct monthly vehicle checks for first aid kits. |
| Wellness Nurses | Wellness Nurses | Re-trained on self-administration policy and will conduct monthly wellness visits. |
Inspection Report
Complaint Investigation
Census: 64
Capacity: 110
Deficiencies: 1
Dec 28, 2023
Visit Reason
The inspection was conducted as a complaint investigation to review compliance with regulations and verify the submitted plan of correction.
Findings
The submitted plan of correction was determined to be fully implemented with no additional concerns identified. The deficiency involved a direct care staff person providing unsupervised ADL services without completing the required department-approved direct care training and competency test.
Complaint Details
The visit was complaint-related and the plan of correction was fully implemented as of 12/28/2023.
Deficiencies (1)
| Description |
|---|
| Direct care staff person began providing unsupervised ADL services without completing and passing the Department-approved direct care training course and competency test. |
Report Facts
License Capacity: 110
Residents Served: 64
Secured Dementia Care Unit Capacity: 18
Secured Dementia Care Unit Residents Served: 13
Residents Age 60 or Older: 68
Residents with Mobility Need: 42
Inspection Report
Plan of Correction
Census: 67
Capacity: 110
Deficiencies: 1
Sep 7, 2023
Visit Reason
The inspection was conducted as a complaint investigation with a partial, unannounced visit on 09/07/2023 to review the facility's compliance and plan of correction submission.
Findings
The facility failed to report a resident fall incident to the Department within the required 24-hour timeframe. The Executive Director submitted a plan of correction, including staff training and ongoing monitoring to ensure compliance with reporting requirements.
Complaint Details
The visit was complaint-related, focusing on the failure to report a resident fall incident. The plan of correction was accepted and fully implemented by 10/13/2023.
Deficiencies (1)
| Description |
|---|
| Failure to report a resident fall incident to the Department within 24 hours as required. |
Report Facts
License Capacity: 110
Residents Served: 67
Secured Dementia Care Unit Capacity: 28
Secured Dementia Care Unit Residents Served: 16
Resident Mobility Need: 40
Inspection Report
Renewal
Census: 73
Capacity: 110
Deficiencies: 30
Mar 13, 2023
Visit Reason
The inspection was conducted as a renewal review of the facility's license, including unannounced full inspections on 03/13/2023, 03/14/2023, and 03/15/2023.
Findings
The inspection identified multiple deficiencies including medication errors, privacy violations, staffing inadequacies, fire safety orientation issues, sanitary and food safety violations, medication storage and administration errors, support plan documentation issues, and emergency procedure compliance. Plans of correction were accepted and implemented for all deficiencies.
Deficiencies (30)
| Description |
|---|
| Medication errors due to unavailable medications not reported to the department. |
| Privacy violations including lack of video surveillance signage and staff discussing resident medication in public areas. |
| Additional staffing required due to long call bell response times. |
| Staff person did not receive fire safety orientation on first day. |
| Direct care staff provided unsupervised ADL services without completing required training. |
| Direct care staff did not receive required annual training on medication self-administration and resident needs. |
| Sanitary conditions not maintained; discarded trash found in common areas. |
| Trash outside home not kept in covered receptacles; overflowing trash and uncovered dumpsters. |
| Furniture and equipment not in good repair; kitchenette sink handle required extra force. |
| Walls in resident room had large hole. |
| Food not protected from contamination; unsealed and uncovered food items found. |
| Leftover food unlabeled and undated in refrigerators. |
| Refrigerator/freezer lacked thermometer. |
| Food not stored in closed or sealed containers. |
| Outdated or spoiled food and dented cans found in storage areas. |
| Written emergency procedures not submitted annually to local emergency management agency. |
| Cats in facility lacked current rabies vaccination certificates. |
| Unannounced fire drills not held monthly during specified months. |
| Fire drills routinely held at end of month, not varied days/times. |
| Smoking room lacked proper cigarette receptacle. |
| Smoking outside designated smoking areas observed with discarded cigarette butts. |
| Resident medications stored unlocked and unattended in resident room. |
| Loose pills found on floor in resident room. |
| Medication labels did not match prescribed orders. |
| Medication administration record missing prescribed medication. |
| Medications not available in home for administration as prescribed. |
| Medication errors not reported to resident, designated person, and prescriber. |
| Medication administration training record incomplete for staff person. |
| Resident support plans lacked documentation of medical/dental/behavioral care services and missing signatures. |
| Preadmission cognitive screening completed after resident admission to secured dementia care unit. |
Report Facts
Inspection dates: 3
Resident Support Staff: 73
Total Daily Staff: 190
Waking Staff: 143
Licensed Capacity: 110
Residents Served: 73
Secured Dementia Care Unit Capacity: 24
Secured Dementia Care Unit Residents Served: 17
Residents with Mobility Need: 44
Residents Diagnosed with Mental Illness: 4
Residents Diagnosed with Intellectual Disability: 2
Residents with Physical Disability: 2
Residents Age 60 or Older: 73
Inspection Report
Follow-Up
Census: 71
Capacity: 110
Deficiencies: 2
Jan 26, 2023
Visit Reason
The inspection visit was conducted as a follow-up to review the submitted plan of correction related to an incident at the facility.
Findings
The submitted plan of correction was determined to be fully implemented, with continued compliance required. Deficiencies related to abuse reporting and resident record content were addressed and corrected.
Deficiencies (2)
| Description |
|---|
| The home did not report an abuse incident for resident 1 to the Department in a timely manner. |
| Resident 1's record does not include religious affiliation and social security number. |
Report Facts
License Capacity: 110
Residents Served: 71
Memory Care Unit Capacity: 28
Memory Care Unit Residents Served: 18
Inspection Report
Follow-Up
Census: 77
Capacity: 110
Deficiencies: 3
Mar 2, 2022
Visit Reason
The inspection was a partial, unannounced follow-up visit conducted on 03/02/2022 to review the submitted plan of correction related to an incident.
Findings
The facility was found to have fully implemented the submitted plan of correction regarding staffing requirements for CPR/First Aid certification and preadmission screening forms. Continued compliance is required.
Deficiencies (3)
| Description |
|---|
| At least one staff person for every 50 residents trained in first aid and certified in obstructed airway techniques and CPR was not present during night shifts on 2/10/22 and 2/16/22. |
| Staff member B failed to render assistance to an unresponsive resident in accordance with training; staff member A gave CPR but was not CPR certified. |
| Resident #1's preadmission screening form was completed after admission, not within 30 days prior to admission as required. |
Report Facts
Residents present during inspection: 77
Licensed capacity: 110
Residents served in secured dementia care unit: 20
Hospice residents: 2
Staffing hours: 105
Waking staff hours: 79
Inspection Report
Follow-Up
Census: 80
Capacity: 110
Deficiencies: 2
Oct 7, 2021
Visit Reason
The inspection was a partial, unannounced follow-up visit triggered by an incident to review the submitted plan of correction.
Findings
The facility was found to have failed in implementing safety precautions for a resident with dementia who exhibited aggressive behavior, leaving residents unattended with hazardous items, and challenges in staffing to meet residents' needs. The submitted plan of correction was accepted and deemed fully implemented by the follow-up date.
Deficiencies (2)
| Description |
|---|
| Failure to put safety precautions in place for a resident with dementia who exhibited aggressive behavior, resulting in physical altercations and unsafe conditions such as unattended scissors in memory care. |
| Challenges in meeting staffing needs to protect residents' health and safety, including unattended residents and inadequate supervision during meals. |
Report Facts
License Capacity: 110
Residents Served: 80
Memory Care Capacity: 28
Memory Care Residents Served: 22
Residents 60 Years or Older: 79
Residents with Mobility Need: 47
Residents with Mental Illness: 3
Residents with Intellectual Disability: 2
Residents with Physical Disability: 4
Total Daily Staff: 127
Waking Staff: 95
Inspection Report
Renewal
Census: 74
Capacity: 110
Deficiencies: 23
Sep 20, 2021
Visit Reason
The inspection was a renewal visit conducted by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing on 09/20/2021 and 09/21/2021 to review compliance with licensing requirements at Sunrise of Abington.
Findings
The inspection identified multiple deficiencies including failure to post 'No Smoking' signs, inadequate assistance with activities of daily living, unsigned resident contracts, insufficient overnight staffing, sanitary condition issues, missing emergency telephone numbers, broken furniture and equipment, unsecured poisonous materials, and medication management errors. Plans of correction were accepted and implemented with ongoing monitoring.
Deficiencies (23)
| Description |
|---|
| The home did not post a 'No Smoking' sign anywhere. |
| Resident #1 did not receive required two-person assistance with toileting as indicated in the support plan. |
| Resident #2's contract was not signed by the resident. |
| Resident #2's record did not contain a signed statement acknowledging receipt of resident rights and complaint procedures. |
| Insufficient staffing on overnight shift to safely evacuate all residents within designated time. |
| Wet towels with mold and sticky floors in secured dementia care unit; strong urine odor in resident bathroom. |
| Dumpsters behind the home were full and not covered. |
| Emergency telephone numbers were not posted by telephone in resident room #304. |
| Bathroom sink would not drain and toilet paper holder was broken in resident room #302; broken trash can in resident room #332. |
| Missing latch on one of the exits in the home's gated garden. |
| Accumulation of lint in lint trap of commercial dryer. |
| Obstruction in hallway leading to egress door and stairwell by furniture and items. |
| Medications prescribed to resident #5 were not available in the home. |
| Controlled substances count and documentation errors for resident #6's Tramadol medication. |
| Medication administration records for resident #6 missing staff initials for certain dates and times. |
| Resident #5 was administered medication without required blood pressure readings. |
| Resident #2 was not educated on the right to refuse medication if a medication error is suspected. |
| Resident #7's support plan lacked frequency and responsible party for hearing and social activity needs. |
| Resident #8 and #9 did not sign and date their support plans as required. |
| Resident #10's support plan did not identify the individual responsible for addressing certain needs. |
| Controlled substance log entries for residents #1 and #11 were illegible or improperly corrected. |
| Resident #5's record did not include a photograph no more than 2 years old. |
| Poisonous materials were unsecured and accessible to residents in laundry room and resident rooms. |
Report Facts
License Capacity: 110
Residents Served: 74
Secured Dementia Care Unit Capacity: 28
Secured Dementia Care Unit Residents Served: 20
Hospice Residents: 8
Total Daily Staff: 122
Waking Staff: 92
Residents with Mobility Need: 48
Residents 60 Years or Older: 73
Staff on Secured Dementia Unit Overnight: 2
Staff on Personal Care Side Overnight: 3
Fire Drill Evacuation Time: 7.15
Fire Drill Staff: 21
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director | Executive Director | Named in multiple findings including contract review, plan of correction monitoring, and compliance oversight. |
| Medication Care Manager | Medication Care Manager | Involved in medication administration findings and plan of correction implementation. |
| Personal Care Coordinator | Personal Care Coordinator | Involved in review and monitoring of resident support plans and toileting assistance. |
| Maintenance Director | Maintenance Director | Named in findings related to repairs, sanitation, and safety issues. |
| Reminiscence Coordinator | Reminiscence Coordinator | Responsible for posting emergency numbers and securing poisonous materials. |
| Resident Care Director | Resident Care Director | Involved in medication management and support plan reviews. |
| Senior Facilities Director | Senior Facilities Director | Involved in ensuring trash receptacles compliance. |
Inspection Report
Complaint Investigation
Census: 75
Capacity: 110
Deficiencies: 0
Sep 17, 2021
Visit Reason
The inspection was conducted as a complaint investigation during an unannounced partial licensing inspection.
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 substantiated issues were found.
Report Facts
Total Daily Staff: 124
Waking Staff: 93
License Capacity: 110
Residents Served: 75
Secured Dementia Care Unit Capacity: 28
Secured Dementia Care Unit Residents Served: 20
Residents Age 60 or Older: 74
Residents with Mobility Need: 49
Residents with Physical Disability: 3
Inspection Report
Follow-Up
Census: 74
Capacity: 110
Deficiencies: 7
Aug 3, 2021
Visit Reason
The inspection was a partial, unannounced visit conducted on 08/03/2021 due to an incident at the facility, with a follow-up plan of correction submission required.
Findings
The inspection identified multiple deficiencies including unsigned resident-home contracts, insufficient direct care staffing hours for residents with mobility needs, inadequate waking hours staffing, insufficient additional staffing during an incident involving residents, failure to follow prescriber's medication orders accurately, incomplete preadmission cognitive screening for a resident in the secured dementia care unit, and incomplete support plans addressing residents' physical, medical, social, cognitive, and safety needs.
Deficiencies (7)
| Description |
|---|
| Resident-home contract was not signed by the administrator or designee. |
| Direct care staff hours provided were less than the required 2 hours per day for residents with mobility needs. |
| Less than 75% of personal care service hours were provided during waking hours. |
| Insufficient additional staffing during an incident involving two residents in the secured dementia care unit. |
| Medications prescribed to a resident were not administered due to incorrect documentation of medication availability and resident refusals. |
| Written cognitive preadmission screening was not completed within 72 hours prior to admission to the secured dementia care unit. |
| Resident's support plan did not address social topics, was incomplete, and did not specify how to address behaviors of anxiety, disorientation, agitation, and confusion. |
Report Facts
Residents served: 74
License capacity: 110
Residents with mobility needs: 54
Direct care staffing hours required: 128
Direct care staffing hours provided: 113.32
Direct care hours required during waking hours: 96
Direct care hours provided during waking hours: 84.99
Residents in secured dementia care unit: 18
Total daily staff: 128
Waking staff: 96
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Claire Mendez | Licensing Official | Signed the initial licensing inspection letter |
| Resident Care Director | Resident Care Director (RCD) | Reviewed medication administration records and provided training on documentation |
| Executive Director | Executive Director (ED) | Reviewed staffing schedules, contract procedures, and support plan requirements; involved in plan of correction |
| Director of Operations | Director of Operations | Reviewed assignment of designee for contract signing |
| Directors of Sales | Directors of Sales (DOS) | Reviewed contract completeness within 24 hours of admission |
| Medication Care Manager | Medication Care Manager (MCM) | Administered medications and involved in documentation issues |
Inspection Report
Follow-Up
Census: 74
Capacity: 110
Deficiencies: 7
Aug 3, 2021
Visit Reason
The inspection was a partial, unannounced follow-up review conducted due to an incident to verify the implementation of a previously submitted plan of correction.
Findings
The facility was found to have multiple deficiencies including incomplete contract signatures, insufficient direct care staffing hours, inadequate additional staffing during an incident, failure to follow prescriber orders, incomplete preadmission screening, and incomplete support plans. Some plans of correction were accepted and implemented, while others were noted as not fully implemented.
Deficiencies (7)
| Description |
|---|
| The resident-home contract for resident 1 was not signed by the administrator or designee. |
| Direct care staff hours were insufficient; only 113.32 hours were provided versus the required 128 hours for residents with mobility needs. |
| At least 75% of personal care service hours during waking hours were not met; only 84.99 of 96 required hours were provided. |
| During an incident, only two staff were scheduled to assist 18 Secure Dementia Care Unit residents, which was insufficient. |
| Resident 1 was not administered prescribed medications because they were not available in the home. |
| Resident 1's written cognitive preadmission screening was completed late, after admission to the Secure Dementia Care Unit. |
| Resident 1's support plan did not address social topics or specify how to address behaviors of anxiety, disorientation, agitation, and confusion. |
Report Facts
Residents served: 74
License capacity: 110
Direct care hours required: 128
Direct care hours provided: 113.32
Waking hours care required: 96
Waking hours care provided: 84.99
SDCU residents assisted by staff during incident: 18
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