Inspection Report
Renewal
Census: 48
Capacity: 98
Deficiencies: 11
Mar 24, 2025
Visit Reason
The inspection was conducted as a renewal and complaint investigation to assess compliance with licensing regulations and to review the submitted plan of correction.
Findings
The facility had multiple deficiencies including failure to post required regulations, incomplete criminal background checks, inadequate staff training, unlocked poisonous materials accessible to residents, missing emergency telephone numbers, lack of operable bedside lamps, improper food storage, insufficient emergency water supply, incomplete menu postings, medication administration errors, and inaccurate resident support plans. All deficiencies had plans of correction accepted and were implemented by June 5, 2025.
Deficiencies (11)
| Description |
|---|
| No copy of the chapter 2600 regulations posted in a conspicuous and public place. |
| Staff person hired without a criminal background check conducted prior to employment. |
| Direct care staff person did not receive required annual training on medication self-administration, resident needs, and care for residents with mental illness or intellectual disability. |
| Poisonous materials (Ecolab laundry detergent) unlocked and accessible to residents in the Secure Dementia Care Unit. |
| Emergency telephone numbers not posted by resident's cell phone. |
| Resident did not have access to an operable lamp or source of lighting at bedside. |
| Food stored in dented can in dry food supply. |
| Home did not maintain at least a 3-day supply of nonperishable food and drinking water; water supply was below required gallons. |
| Weekly menus not posted one week in advance for certain dates. |
| Medication prescribed for resident was not administered due to unavailability in the home. |
| Resident support plan did not accurately reflect prescribed diet requirements. |
Report Facts
License Capacity: 98
Residents Served: 48
Residents in Secured Dementia Care Unit: 16
Hospice Residents: 7
Residents 60 Years or Older: 52
Residents Diagnosed with Mental Illness: 4
Residents Diagnosed with Intellectual Disability: 1
Residents with Mobility Need: 36
Residents with Physical Disability: 0
Emergency Drinking Water Required (gallons): 144
Emergency Drinking Water Available (gallons): 127
Inspection Report
Follow-Up
Census: 51
Capacity: 98
Deficiencies: 2
Nov 26, 2024
Visit Reason
The inspection was a partial, unannounced visit conducted on 11/26/2024 due to a complaint and incident involving resident care.
Findings
The facility was found to have fully implemented the submitted plan of correction related to two deficiencies: improper treatment of a resident by staff and failure to complete timely cognitive preadmission screenings for the secured dementia care unit. The staff member involved in the resident treatment violation was terminated, and corrective actions including staff training and audits were completed.
Complaint Details
The visit was complaint-related and incident-driven, focusing on allegations of improper resident treatment and procedural deficiencies in preadmission screening.
Deficiencies (2)
| Description |
|---|
| Improper treatment of a resident involving incorrect transfer and disrespectful handling by staff person A. |
| Failure to complete a written cognitive preadmission screening within 72 hours prior to admission to the secured dementia care unit for a resident. |
Report Facts
Residents Served: 51
License Capacity: 98
Capacity: 25
Residents Served: 16
Current Residents in Hospice: 9
Residents Age 60 or Older: 51
Residents with Mobility Need: 36
Residents Diagnosed with Intellectual Disability: 1
Inspection Report
Follow-Up
Census: 41
Capacity: 98
Deficiencies: 9
Jul 25, 2024
Visit Reason
The inspection was a partial, unannounced follow-up visit on 07/25/2024 to review the submitted plan of correction related to a prior incident.
Findings
The submitted plan of correction was determined to be fully implemented with continued compliance required. Multiple deficiencies were identified and addressed, including contract signature issues, abuse allegations, direct care training deficiencies, sanitary conditions, furniture and equipment maintenance, lighting, and resident education on medication refusal rights.
Deficiencies (9)
| Description |
|---|
| The resident-home contract was not signed by the resident. |
| Resident reported rough and forceful care by a staff member during overnight care. |
| Direct care staff person had an expired CNA certification and lacked proof of completing required training and competency test. |
| Direct care staff did not receive training in medication self-administration during training year 2023. |
| Training records lacked length of training and location details. |
| Refrigerator in resident room had unsanitary conditions with sticky red substance and brown caked substance. |
| Resident freezer compartment was frosted over and unusable; refrigerator door was coming off hinges and leaking water. |
| Resident did not have access to a source of light that can be turned on/off at bedside. |
| Resident had not been educated on the right to refuse medication if a medication error is suspected. |
Report Facts
License Capacity: 98
Residents Served: 41
Secured Dementia Care Unit Capacity: 25
Residents Served in Secured Dementia Care Unit: 11
Hospice Residents: 7
Residents 60 Years or Older: 39
Residents with Mobility Need: 26
Resident Contract Signature Missing: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff Member B | Named in abuse allegation and subsequent termination. | |
| Staff Member A | Reported resident's statement regarding Staff Member B's rough care. | |
| Executive Director | Placed Staff Member B on administrative leave, conducted investigation, and oversaw plan of correction implementation. | |
| Director of Sales | Retrained on resident signature requirements and audited resident contracts. | |
| Associate Director of Sales | Retrained on resident signature requirements and audited resident contracts. | |
| Business Office Coordinator | Educated staff on abuse and neglect, retrained on training form preparation, and conducted audits. | |
| Personal Care Coordinator | Involved in audits and retraining related to training records and suite checks. | |
| Reminiscence Coordinator | Involved in audits and retraining related to training records and suite checks. |
Inspection Report
Complaint Investigation
Census: 40
Capacity: 98
Deficiencies: 0
Mar 15, 2023
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 complaint-related, but no deficiencies were found and the complaint was not substantiated.
Report Facts
License Capacity: 98
Residents Served: 40
Secured Dementia Care Unit Capacity: 25
Residents Served in Dementia Care Unit: 12
Hospice Residents: 7
Residents Age 60 or Older: 39
Residents Diagnosed with Mental Illness: 2
Residents Diagnosed with Intellectual Disability: 1
Residents with Mobility Need: 22
Residents with Physical Disability: 0
Total Daily Staff: 62
Waking Staff: 47
Inspection Report
Renewal
Census: 45
Capacity: 98
Deficiencies: 16
Jan 12, 2023
Visit Reason
The inspection was conducted as a renewal review of the facility's compliance with licensing requirements.
Findings
The inspection identified multiple deficiencies including abuse and neglect by staff, sanitary and maintenance issues, medication management errors, and fire safety documentation lapses. The facility submitted plans of correction which were accepted and implemented by 02/27/2023.
Deficiencies (16)
| Description |
|---|
| Failure to provide required assistance with activities of daily living as per resident's support plan. |
| Resident was verbally abused and treated with disrespect by staff. |
| Staff training plan lacked age sensitivity training. |
| Unclean vents and broken pipe causing unsanitary conditions. |
| Inoperable bathroom exhaust fans causing lack of ventilation. |
| Missing light bulbs in bathroom fixtures. |
| Furniture and equipment not in good repair including leaking sink, broken toilet paper handles, and cracked pipe. |
| Resident bedroom lacked operable bedside lamp. |
| Carpet stained and not in good repair. |
| Lack of documentation of written notification to local fire department regarding emergency evacuation. |
| Failure to use alternate exit routes during fire drills. |
| Menu change not posted in advance of meal service. |
| Sample prescription medications lacked required prescriber information. |
| Medication storage procedures not followed; missing 'as needed' medication. |
| Medication records lacked purpose for medications and storage location not documented. |
| Failure to follow prescriber's orders; medication administration did not match prescription. |
Report Facts
License Capacity: 98
Residents Served: 45
Secured Dementia Care Unit Capacity: 17
Secured Dementia Care Unit Residents Served: 16
Current Hospice Residents: 11
Residents Age 60 or Older: 44
Residents Diagnosed with Mental Illness: 2
Residents Diagnosed with Intellectual Disability: 1
Residents with Mobility Need: 27
Deficiency Count: 16
Inspection Report
Follow-Up
Census: 47
Capacity: 98
Deficiencies: 2
Jun 7, 2022
Visit Reason
The visit was a partial, unannounced inspection conducted as a follow-up to verify the implementation of a previously submitted plan of correction related to an incident.
Findings
The submitted plan of correction was determined to be fully implemented, with continued compliance required. Deficiencies related to medication storage and resident record content were addressed with corrective actions and ongoing monitoring.
Deficiencies (2)
| Description |
|---|
| Resident 1 was prescribed Tylenol Extra Strength Tablet 500 mg, but the medication was not available in the home. |
| Resident 1's and 2's records did not include a record of incident reports for the individual resident. |
Report Facts
License Capacity: 98
Residents Served: 47
Secured Dementia Care Unit Capacity: 17
Residents Served in Dementia Care Unit: 16
Current Hospice Residents: 9
Residents Diagnosed with Mental Illness: 3
Residents Diagnosed with Intellectual Disability: 1
Residents with Mobility Need: 32
Residents Age 60 or Older: 46
Inspection Report
Plan of Correction
Census: 46
Capacity: 98
Deficiencies: 3
Apr 8, 2022
Visit Reason
The inspection was a partial, unannounced visit conducted on 04/08/2022 as a follow-up to verify the implementation of a submitted plan of correction related to an incident involving alleged resident abuse.
Findings
The facility was found to have delayed reporting an allegation of inappropriate touch involving a resident to the Area Agency on Aging and the Department of Human Services. Staff failed to immediately suspend the implicated staff member pending investigation. The submitted plan of correction was accepted and fully implemented, including staff training and administrative leave for the involved staff member. The violation was later withdrawn.
Deficiencies (3)
| Description |
|---|
| Failure to immediately report suspected abuse of a resident to the Area Agency on Aging and Department of Human Services. |
| Failure to immediately suspend the staff person involved in the alleged abuse pending investigation. |
| Failure to report the incident to the Department within 24 hours as required. |
Report Facts
License Capacity: 98
Residents Served: 46
Secured Dementia Care Unit Capacity: 25
Secured Dementia Care Unit Residents Served: 16
Total Daily Staff: 75
Waking Staff: 56
Residents Age 60 or Older: 45
Residents Diagnosed with Mental Illness: 3
Residents Diagnosed with Intellectual Disability: 1
Residents with Mobility Need: 29
Inspection Report
Complaint Investigation
Census: 49
Capacity: 98
Deficiencies: 0
Feb 8, 2022
Visit Reason
The inspection was conducted as a complaint investigation at the facility.
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
Total Daily Staff: 86
Waking Staff: 65
Residents Served: 49
License Capacity: 98
Secured Dementia Care Unit Capacity: 25
Residents Served in Dementia Care Unit: 17
Residents Age 60 or Older: 48
Residents Diagnosed with Mental Illness: 3
Residents Diagnosed with Intellectual Disability: 1
Residents with Mobility Need: 37
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Michele Swisher | Lead Inspector | Lead inspector for the complaint investigation |
Inspection Report
Complaint Investigation
Census: 46
Capacity: 98
Deficiencies: 0
Jan 26, 2022
Visit Reason
The inspection was conducted as a complaint investigation with an unannounced partial inspection over three days from 01/26/2022 to 01/28/2022.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Complaint Details
The inspection was complaint-related, but no deficiencies were found and no follow-up was required.
Report Facts
Total Daily Staff: 83
Waking Staff: 62
Residents Served: 46
License Capacity: 98
Secured Dementia Care Unit Capacity: 25
Secured Dementia Care Unit Residents Served: 16
Hospice Current Residents: 11
Residents 60 Years or Older: 46
Residents Diagnosed with Mental Illness: 3
Residents Diagnosed with Intellectual Disability: 1
Residents with Mobility Need: 37
Residents with Physical Disability: 0
Inspection Report
Renewal
Census: 50
Capacity: 98
Deficiencies: 15
Sep 20, 2021
Visit Reason
The inspection was a full, unannounced renewal inspection conducted on 09/20/2021 and 09/21/2021 to review compliance with licensing requirements.
Findings
The inspection identified multiple deficiencies related to sanitary conditions, physical site maintenance, nutrition, and medication management. Plans of correction were accepted and implemented to address issues such as glucometer calibration, trash dumpster lids, ventilation fans, emergency telephone numbers, food storage and labeling, medication labeling, storage, administration documentation, and following prescriber's orders.
Deficiencies (15)
| Description |
|---|
| Resident #4's medication administration records showed a glucometer reading not matching the resident's glucometer. |
| Outdoor dumpster lids were open and not in use. |
| Resident bathrooms lacked operable ventilation fans or windows in rooms 105, 116, 220, 223, 304. |
| No emergency telephone numbers posted on or by the telephone in bedroom 223. |
| No thermometer in the ice cream freezer. |
| Five unsealed tubs of ice cream in the ice cream freezer. |
| Opened, undated bags of frozen burgers and frozen salmon in the main kitchen walk-in freezer; expired pudding in reminiscence kitchen. |
| Weekly menu for 9/19/21 to 9/25/21 was not posted. |
| Discontinued medication found in medication cart for resident #2. |
| Medication labels did not match prescribed directions for residents #1, #2, and #3. |
| Glucometer calibration errors and unavailable prescribed medications for residents #1, #2, #3, and #4. |
| Medication administration record missing staff initials for resident #2 on 9/17/21. |
| Refusal of prescribed accuchecks by residents #1 and #4 was not reported to the prescriber. |
| Prescribed medication not given as ordered for resident #1; glucometer reading not documented correctly. |
| Prescribed medication for resident #3 was not available in the home on 9/21/21. |
Report Facts
Total Daily Staff: 85
Waking Staff: 64
License Capacity: 98
Residents Served: 50
Secured Dementia Care Unit Capacity: 25
Secured Dementia Care Unit Residents Served: 15
Hospice Current Residents: 11
Residents 60 Years or Older: 51
Residents with Mobility Need: 35
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Resident Care Director | Resident Care Director (RCD) | Named in multiple medication and care process findings and corrective actions |
| Executive Director | Executive Director (ED) | Named in oversight and education related to findings and plans of correction |
| Maintenance Coordinator | Maintenance Coordinator (MC) | Named in findings related to physical site maintenance and corrective actions |
| Dietary Services Coordinator | Dietary Services Coordinator (DSC) | Named in findings related to food storage, nutrition, and corrective actions |
| Medication Care Managers | Medication Care Managers (MCMs) | Named in medication administration and documentation findings and corrective actions |
| Wellness Nurses | Wellness Nurses | Named in medication administration and documentation findings and corrective actions |
Notice
Capacity: 98
Deficiencies: 0
Sep 16, 2021
Visit Reason
This document serves as a renewal notification and issuance of a regular license for the Personal Care Home 'Sunrise of Haverford' following receipt of the renewal application dated September 14, 2021.
Findings
The Department advises that an onsite inspection will be conducted within the next twelve months as required by regulation. No findings or deficiencies are reported in this document.
Report Facts
Maximum licensed capacity: 98
Secure Dementia Care Unit capacity: 25
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary | Signed the renewal notification letter |
Inspection Report
Census: 44
Capacity: 98
Deficiencies: 0
Sep 3, 2021
Visit Reason
The inspection was a partial, unannounced visit conducted due to an incident at the facility on 09/03/2021.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
License Capacity: 98
Residents Served: 44
Secured Dementia Care Unit Capacity: 25
Secured Dementia Care Unit Residents Served: 16
Hospice Residents: 9
Residents 60 Years or Older: 43
Residents with Mental Illness: 1
Residents with Intellectual Disability: 1
Residents with Mobility Need: 33
Residents with Physical Disability: 1
Total Daily Staff: 77
Waking Staff: 58
Inspection Report
Complaint Investigation
Census: 40
Capacity: 98
Deficiencies: 5
May 24, 2021
Visit Reason
The inspection was conducted as a complaint investigation with multiple off-site review dates to assess compliance and plan of correction implementation.
Findings
The facility was found to have multiple deficiencies related to missing resident contract signatures, missing signed statements regarding rent rebate and resident rights, lack of resident education on the right to refuse medication, and illegible record entries. The submitted plan of correction was determined to be fully implemented.
Complaint Details
The inspection was complaint-driven, with multiple off-site review dates. The plan of correction was accepted and fully implemented, addressing the deficiencies found related to resident contract signatures, signed statements, resident education, and record legibility.
Deficiencies (5)
| Description |
|---|
| Resident-home contracts for Resident 1 and Resident 2 were not signed by the residents. |
| Resident-home contracts for Resident 1 and Resident 2 did not include a signed statement informing residents about rent rebate information kept in records. |
| Resident 1 and Resident 2's records did not contain signed statements acknowledging receipt of resident rights and complaint procedures. |
| Resident 1 and Resident 2 were not educated on their right to refuse medication if they believed there was a medication error. |
| The number nine was rewritten in bold over the number three on Resident 2's Cognitive Screen dated 2/9/2021, violating legibility requirements. |
Report Facts
Licensed Capacity: 98
Resident Census: 40
Secured Dementia Care Unit Capacity: 25
Secured Dementia Care Unit Residents Served: 16
Hospice Current Residents: 9
Residents Age 60 or Older: 39
Residents Diagnosed with Mental Illness: 1
Residents with Mobility Need: 26
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sandi Wooters | Signed the letter confirming plan of correction implementation | |
| Director of Sales | Trained on residency contract requirements and responsible for verifying contract signatures | |
| Business Office Coordinator | Responsible for auditing resident records for contract signatures | |
| Executive Director | Responsible for reviewing contracts and monitoring plan of correction effectiveness | |
| Resident Care Director | Provided education and audit related to resident cognitive screening forms and record entries | |
| Wellness Nurses | Involved in education and auditing resident record entries |
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