Inspection Report
Renewal
Census: 64
Capacity: 95
Deficiencies: 10
Jan 22, 2025
Visit Reason
The inspection was conducted as a renewal visit for the facility license at Sunrise Senior Living of Lower Makefield.
Findings
The inspection identified multiple deficiencies including sanitary conditions, food labeling, pet vaccination records, annual medical evaluations, menu posting, medication storage and labeling, adherence to prescriber's orders, mobility assessments, and support plan revisions. All deficiencies had plans of correction accepted and were implemented by March 17, 2025.
Deficiencies (10)
| Description |
|---|
| Carpet in room #130 was stained with an unknown substance. |
| Several unlabeled, undated bags of food items found in walk-in refrigerator and freezer. |
| Resident cat did not have a current certificate of rabies vaccination. |
| Resident #4’s most recent medical evaluation was missing or incomplete. |
| Home's menu was not posted in a conspicuous and public place; reminiscence area lacked current week menu. |
| Resident #5's Refresh Tear Drops medication was expired beyond 90 days of opening. |
| Resident #6's medication label did not match physician's order regarding blood sugar instructions. |
| Resident #1 was not administered Lorazepam as prescribed on 01/11/25 at 8am. |
| Resident #7's assessment did not include a bedside mobility device despite doctor's order. |
| Support plan for resident #4 was not revised timely; previous plan completion date missing. |
Report Facts
License Capacity: 95
Residents Served: 64
Secured Dementia Care Unit Capacity: 29
Residents Served in Dementia Unit: 21
Hospice Residents: 10
Residents Age 60 or Older: 63
Residents with Mobility Need: 32
Residents with Physical Disability: 32
Total Daily Staff: 96
Waking Staff: 72
Inspection Report
Monitoring
Census: 60
Capacity: 95
Deficiencies: 0
Jul 8, 2024
Visit Reason
The inspection was a monitoring visit conducted on 07/08/2024 as a partial, unannounced inspection to assess ongoing compliance of the facility.
Findings
No regulatory citations or deficiencies were identified during this inspection.
Report Facts
License Capacity: 95
Residents Served: 60
Secured Dementia Care Unit Capacity: 29
Secured Dementia Care Unit Residents Served: 16
Hospice Residents: 4
Residents Age 60 or Older: 60
Residents Diagnosed with Mental Illness: 2
Residents with Mobility Need: 31
Resident Support Staff Hours: 91
Waking Staff Hours: 68
Inspection Report
Complaint Investigation
Census: 56
Capacity: 95
Deficiencies: 0
May 15, 2024
Visit Reason
The inspection was conducted as a complaint investigation with an unannounced partial inspection on 05/15/2024.
Findings
No regulatory citations or deficiencies were identified during this inspection.
Complaint Details
The inspection was complaint-related; however, no deficiencies were found and no follow-up was required.
Report Facts
License Capacity: 95
Residents Served: 56
Secured Dementia Care Unit Capacity: 29
Residents Served in Dementia Unit: 16
Hospice Current Residents: 12
Resident Support Staff Hours: 0
Total Daily Staff: 90
Waking Staff: 68
Residents Age 60 or Older: 56
Residents Diagnosed with Mental Illness: 2
Residents Diagnosed with Intellectual Disability: 2
Residents with Mobility Need: 34
Residents with Physical Disability: 0
Inspection Report
Complaint Investigation
Census: 55
Capacity: 95
Deficiencies: 4
May 2, 2024
Visit Reason
The inspection was conducted as a complaint investigation with an unannounced partial inspection on 05/02/2024 to review compliance and follow up on submitted plans of correction.
Findings
The inspection identified deficiencies related to delayed response to call bells for bowel and bladder management, insufficient direct care staffing hours for residents with mobility needs, inadequate waking hours coverage, and incomplete resident medical evaluation documentation. Plans of correction were accepted and implemented to address these issues.
Complaint Details
The inspection was complaint-driven and included a follow-up on the submitted plan of correction, which was found to be fully implemented.
Deficiencies (4)
| Description |
|---|
| Resident required total assistance with bowel and bladder management but call bell log showed no response within 27 minutes on multiple occasions. |
| Direct care staff hours were below the required minimum for residents with mobility needs on multiple dates. |
| Less than 75% of personal care service hours were provided during waking hours on multiple dates. |
| Resident medical evaluation documentation did not indicate the resident's cognitive functioning. |
Report Facts
License Capacity: 95
Residents Served: 55
Secured Dementia Care Unit Capacity: 29
Residents Served in Dementia Unit: 14
Hospice Residents: 11
Residents with Mobility Need: 34
Direct Care Hours Required: 59
Direct Care Hours Provided: 46
Direct Care Hours Required: 60
Direct Care Hours Provided: 56.5
Direct Care Hours Provided: 57.8
Percentage of Direct Care Hours Provided During Waking Hours: 52
Percentage of Direct Care Hours Provided During Waking Hours: 69
Percentage of Direct Care Hours Provided During Waking Hours: 72
Inspection Report
Complaint Investigation
Census: 65
Capacity: 95
Deficiencies: 2
Mar 21, 2024
Visit Reason
The inspection was conducted as a complaint and incident investigation following an unannounced partial inspection on 03/21/2024.
Findings
The investigation found an incident of resident-to-resident abuse involving physical assault, and a deficiency in medical evaluations where body positioning and movement stimulation were not documented. The submitted plan of correction was accepted and fully implemented by 05/09/2024.
Complaint Details
The complaint investigation involved an incident where one resident physically assaulted another in their personal care neighborhood. The assaulted resident sustained injuries to the face and jawline. The incident was unprovoked with no prior history of aggression. The facility implemented a plan of correction including staff training on sexual abuse and signs.
Deficiencies (2)
| Description |
|---|
| Resident-to-resident abuse incident where one resident physically assaulted another, resulting in injuries. |
| Resident medical evaluation did not include body positioning and movement stimulation documentation. |
Report Facts
License Capacity: 95
Residents Served: 65
Secured Dementia Care Unit Capacity: 29
Secured Dementia Care Unit Residents Served: 14
Hospice Residents: 6
Resident with Supplemental Security Income: 1
Residents 60 Years or Older: 65
Residents Diagnosed with Intellectual Disability: 2
Residents with Mobility Need: 34
Total Daily Staff: 99
Waking Staff: 74
Inspection Report
Renewal
Census: 71
Capacity: 95
Deficiencies: 15
Jan 17, 2024
Visit Reason
The inspection was conducted as a renewal and incident review of the facility to determine compliance with licensing requirements and to verify the submitted plan of correction was fully implemented.
Findings
The inspection identified multiple deficiencies including failure to submit an approved plan of supervision for a staff member, delayed incident reporting, inadequate staff orientation and training, unsecured poisonous materials, sanitary issues, uncovered trash receptacles, lack of operable bedside lamps, missed fire drills, loose medication pills, and unsigned support plan documents. Plans of correction were accepted and implemented with ongoing monitoring.
Deficiencies (15)
| Description |
|---|
| Failure to submit an approved plan of supervision for a staff member who returned to work after alleged abuse incident. |
| Incident involving alleged resident abuse was not reported to the department within 24 hours. |
| Refund for deceased resident not issued within required timeframe per Elder Care Payment Restitution Act. |
| Direct care staff did not receive required orientation on fire safety and emergency preparedness on first day of work. |
| Direct care staff did not complete required training within 40 scheduled work hours on resident rights, emergency medical plan, mandatory abuse reporting, and reporting of incidents. |
| Direct care staff did not receive required annual training on meeting resident needs and safe management techniques. |
| Direct care staff did not receive annual fire safety training by a fire safety expert or trained staff. |
| Poisonous materials (toothpaste) found unlocked and accessible to residents not assessed as safe to use poisons. |
| Soiled piece of toilet paper found on outside of toilet bowl in public restroom. |
| Outside dumpsters were not covered with attached lids. |
| Resident did not have access to an operable lamp or other source of lighting at bedside. |
| Unannounced fire drills were not held during January, April, June, and December 2023. |
| Fire drill during sleeping hours not conducted within required 6-month interval. |
| Loose pills found in medication cart drawers. |
| Support plan signature pages for residents were signed but not dated by any signing parties. |
Report Facts
License Capacity: 95
Residents Served: 71
Secured Dementia Care Unit Capacity: 29
Secured Dementia Care Unit Residents Served: 15
Current Hospice Residents: 4
Residents Age 60 or Older: 71
Residents with Mobility Need: 31
Residents Diagnosed with Intellectual Disability: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff member B | Named in abuse incident and supervision plan deficiency; terminated 12/15/23. | |
| Staff member A | Noticed resident holding left shoulder and reported abuse incident. | |
| Staff person C | Received immediate report of abuse incident. | |
| Staff person D | Did not receive required fire safety orientation and 40-hour training. | |
| Direct care staff person E | Did not receive required annual training on resident needs and safe management. | |
| Staff person F | Did not receive required annual fire safety training. |
Inspection Report
Follow-Up
Census: 78
Capacity: 95
Deficiencies: 5
May 22, 2023
Visit Reason
The inspection was a partial, unannounced follow-up visit triggered by an incident to verify the implementation of a previously submitted plan of correction.
Findings
The facility was found to have fully implemented the submitted plan of correction related to multiple deficiencies including abuse, safeguarding resident property, direct care staff qualifications, and support plan signatures. Continued compliance is required.
Deficiencies (5)
| Description |
|---|
| Staff person A grabbed and yanked the arm and wrist of resident 1 during transfer, causing bruising and pain. |
| Failure to safeguard valuables of resident 2 after death, including two Apple iPads taken from the resident's room. |
| Direct care staff person A lacked a high school diploma, GED, or active registry status on the Pennsylvania nurse aide registry. |
| Resident 1 and Resident 2 participated in support plan development but did not sign the support plan. |
| No notation was made regarding resident 2's refusal or inability to sign the support plan. |
Report Facts
License Capacity: 95
Residents Served: 78
Secured Dementia Care Unit Capacity: 22
Secured Dementia Care Unit Residents Served: 15
Residents Age 60 or Older: 78
Residents with Intellectual Disability: 2
Residents with Mobility Need: 62
Total Daily Staff: 140
Waking Staff: 105
Inspection Report
Follow-Up
Census: 75
Capacity: 95
Deficiencies: 4
Oct 5, 2022
Visit Reason
The inspection was a partial, unannounced follow-up visit triggered by an incident at the facility to review the submitted plan of correction.
Findings
The facility was found to have fully implemented the submitted plan of correction related to resident supervision, abuse prevention, documentation of no objection statements for dementia care admissions, and support plan needs. No additional concerns were identified during the follow-up.
Deficiencies (4)
| Description |
|---|
| Resident #1 was left unattended in the courtyard leading to an elopement risk due to unsecured gate and lack of supervision. |
| Resident #2 reported missing money; internal investigation initiated and staff member suspended. |
| Lack of documentation that resident and designated person had no objection to admission to secured dementia care unit. |
| Support plan for resident #1 did not address frequent attempts to elope and exit-seeking behavior. |
Report Facts
License Capacity: 95
Residents Served: 75
Secured Dementia Care Unit Capacity: 30
Residents Served in Dementia Unit: 23
Current Hospice Residents: 8
Resident Mobility Need: 54
Residents Diagnosed with Intellectual Disability: 2
Residents Diagnosed with Physical Disability: 1
Total Daily Staff: 129
Waking Staff: 97
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff member A | Involved in resident #1 elopement incident | |
| Staff member B | Notified of resident #1 elopement and found resident | |
| Staff member C | Reported missing money incident involving resident #2 and was suspended | |
| Reminiscence Coordinator | RC | Secured courtyard gate, updated support plans, and conducted staff in-service |
| Maintenance Coordinator | MC | Secured courtyard gate and conducted quarterly elopement drill |
| Executive Director | ED | Conducted townhall meetings, internal investigations, and oversight of plans of correction |
| Business Office Coordinator | BOC | Confirms team members complete resident abuse training |
Inspection Report
Follow-Up
Census: 75
Capacity: 95
Deficiencies: 2
Aug 1, 2022
Visit Reason
The inspection was a partial, unannounced follow-up visit triggered by an incident to verify the implementation of a submitted plan of correction.
Findings
The facility was found to have fully implemented the submitted plan of correction related to a delayed incident report of missing resident funds and lack of a safeguarding policy for resident belongings. The Executive Director took corrective actions including staff training, updating the resident handbook, and scheduled ongoing quality management reviews.
Deficiencies (2)
| Description |
|---|
| Failure to report a resident's missing money incident to the Department within 24 hours. |
| Lack of a policy or procedure regarding a system to safeguard resident belongings or valuables, and failure to communicate available safeguarding options to residents. |
Report Facts
License Capacity: 95
Residents Served: 75
Secured Dementia Care Unit Capacity: 30
Secured Dementia Care Unit Residents Served: 22
Hospice Residents: 7
Residents with Mobility Need: 52
Residents 60 Years or Older: 75
Residents Diagnosed with Intellectual Disability: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Shawn Parker | Signed the letter confirming full implementation of the plan of correction. | |
| Executive Director | Executive Director (ED) | Named in relation to submitting incident reports, conducting staff training, updating policies, and overseeing plan of correction implementation. |
Inspection Report
Follow-Up
Census: 55
Capacity: 95
Deficiencies: 5
Mar 10, 2022
Visit Reason
The inspection was a partial, unannounced follow-up visit conducted on 03/10/2022 to verify the implementation of a previously submitted plan of correction related to an incident.
Findings
The facility was found to have sanitary and safety deficiencies including clutter and unclean laundry room, dryer maintenance issues, lint accumulation, combustible storage near boilers, and evacuation protocol non-compliance. Plans of correction were accepted and implemented with ongoing monitoring and education.
Deficiencies (5)
| Description |
|---|
| Main laundry room cluttered with plastic bins, unfolded linens, and unclean washer machine. |
| Dryer on second-floor laundry room was out of order with unsecured duct work insulation sleeve causing fire alarm activation. |
| Approximately 10 inches of lint accumulation in lint trap of main dryer; duct cleaning done every 6 months instead of every 3 months as per manufacturer. |
| Twelve cardboard boxes stored near the boiler and paper manufacturer's instructions taped onto boilers. |
| Resident #1 did not evacuate to a public thoroughfare or fire safe area during fire alarm, remaining in bistro area. |
Report Facts
License Capacity: 95
Residents Served: 55
Residents Served in Secured Dementia Care Unit: 14
Hospice Residents: 5
Total Daily Staff: 84
Waking Staff: 63
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Coordinator | Maintenance Coordinator (MC) | Named in multiple findings related to laundry room cleanliness, dryer repair, combustible storage removal, and fire drill evacuation. |
| Executive Director | Executive Director (ED) | Named in findings related to staff education, fire safety meetings, and oversight of corrective actions. |
Inspection Report
Follow-Up
Census: 57
Capacity: 95
Deficiencies: 2
Feb 8, 2022
Visit Reason
The inspection was a partial, unannounced follow-up visit triggered by an incident to verify the implementation of a submitted plan of correction.
Findings
The submitted plan of correction was determined to be fully implemented as of the review dates. The facility was found to have corrected prior deficiencies related to trash removal and evacuation procedures.
Deficiencies (2)
| Description |
|---|
| Trash was left in a resident's room for longer than one week, violating the requirement that trash be removed at least once a week. |
| Residents were not evacuated to a public thoroughfare or fire-safe area during a fire alarm on 2/1/22; staff believed it was a false alarm and redirected residents back to their rooms. |
Report Facts
License Capacity: 95
Residents Served: 57
Memory Care Capacity: 28
Memory Care Residents Served: 16
Total Daily Staff: 97
Waking Staff: 73
Residents with Mobility Need: 40
Inspection Report
Complaint Investigation
Census: 56
Capacity: 95
Deficiencies: 6
Jan 31, 2022
Visit Reason
The inspection was conducted as a complaint investigation with an unannounced partial review of the facility on 01/31/2022 and 02/01/2022.
Findings
The inspection identified multiple deficiencies related to quality management, staff orientation, and sanitary conditions in the kitchen including food storage and protection issues. Plans of correction were submitted and accepted, with measures implemented to address the violations.
Complaint Details
The inspection was triggered by a complaint and conducted as an unannounced partial review on 01/31/2022 and 02/01/2022.
Deficiencies (6)
| Description |
|---|
| The home's quality management plan did not include development and implementation of measures to address dining services concerns related to hot food. |
| Ancillary staff person did not have a general orientation to specific job functions regarding use of the kiosk for dietary guidelines and resident preferences. |
| Sanitary conditions were not maintained: a Dunkin Donuts cup with liquid was found on the kitchen preparation table, stove covered with food spills, and a plastic bin for rice had old dried rice and debris. |
| Food was not protected from contamination: uncovered container of bacon and sausage stored on top of the stove. |
| Food was stored on the floor: boxes of food observed stored on the refrigerator floor. |
| Food was stored in unsealed containers: a box of Domino Premium Cane Powdered sugar was opened and unsealed. |
Report Facts
License Capacity: 95
Residents Served: 56
Secured Dementia Care Unit Capacity: 27
Secured Dementia Care Unit Residents Served: 16
Resident with Mobility Need: 37
Resident Age 60 or Older: 56
Inspection Report
Follow-Up
Census: 59
Capacity: 95
Deficiencies: 3
Dec 13, 2021
Visit Reason
The inspection was a partial, unannounced follow-up visit conducted due to an incident, with a Plan of Correction (POC) submission follow-up.
Findings
The facility was found to have implemented the submitted Plan of Correction fully. Deficiencies involved treatment of residents with dignity and respect, direct care staff qualifications, and initial direct care training requirements, all of which were addressed with corrective actions and training.
Deficiencies (3)
| Description |
|---|
| Staff person A refused to give Resident #1 a scheduled shower and used disrespectful language. |
| Direct care staff person A did not have a high school diploma, GED, or active registry status on the Pennsylvania nurse aide registry. |
| Direct care staff person A did not complete and pass the Department-approved direct care training course and competency test and continued to provide unsupervised ADL services. |
Report Facts
License Capacity: 95
Residents Served: 59
Capacity of Secured Dementia Care Unit: 28
Residents Served in Secured Dementia Care Unit: 18
Total Daily Staff: 100
Waking Staff: 75
Residents with Mobility Need: 41
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff person A | Named in deficiencies related to refusal to provide scheduled shower, lack of qualifications, and incomplete direct care training | |
| Executive Director | Conducted training and oversaw implementation of Plan of Correction | |
| Business Office Coordinator | Responsible for reporting on training compliance and monitoring as part of QAPI |
Inspection Report
Follow-Up
Census: 62
Capacity: 95
Deficiencies: 1
Sep 21, 2021
Visit Reason
The inspection was a partial, unannounced follow-up visit triggered by an incident to verify the implementation of a previously submitted plan of correction.
Findings
The submitted plan of correction related to a support plan signature deficiency was found to be fully implemented. The deficiency involved a resident who participated in the development of their support plan but did not sign it. The facility implemented training and monitoring to ensure compliance.
Deficiencies (1)
| Description |
|---|
| Resident #1 participated in the development of the support plan but did not sign the support plan. |
Report Facts
License Capacity: 95
Residents Served: 62
Secured Dementia Care Unit Capacity: 24
Secured Dementia Care Unit Residents Served: 16
Total Daily Staff: 105
Waking Staff: 79
Inspection Report
Renewal
Census: 58
Capacity: 95
Deficiencies: 5
May 18, 2021
Visit Reason
The inspection was conducted as a renewal inspection of the Sunrise Senior Living of Lower Makefield facility on 05/18/2021 and 05/19/2021.
Findings
The inspection identified multiple deficiencies including failure to post required influenza information, direct care staff providing unsupervised ADL services without completing required training, unsecured poisonous materials accessible to residents, lack of operable bedside lighting for a resident, and missing resident signatures on support plans.
Deficiencies (5)
| Description |
|---|
| The home did not have an influenza poster posted anywhere as required by the Influenza Awareness Act. |
| Direct care staff person A provided unsupervised ADL services without completing and passing the Department-approved direct care training and competency test until 05/18/21. |
| A 2.5 ounce tube of Colgate Cavity Protection Toothpaste labeled as poisonous was unlocked, unattended, and accessible to residents in the bathroom of room 130 in the Reminiscence Unit. |
| Resident #1 did not have access to a source of light that can be turned on/off at bedside. |
| Residents 1, 2, 3, 4 and 5 participated in the development of their support plans but did not sign the support plans, with no documentation of attempts or refusals. |
Report Facts
License Capacity: 95
Residents Served: 58
Secured Dementia Care Unit Capacity: 29
Secured Dementia Care Unit Residents Served: 16
Hospice Residents: 10
Residents Age 60 or Older: 59
Residents with Mobility Need: 40
Total Daily Staff: 98
Waking Staff: 74
Inspection Report
Renewal
Census: 58
Capacity: 95
Deficiencies: 5
May 18, 2021
Visit Reason
The inspection was conducted as a renewal inspection of Sunrise Senior Living of Lower Makefield to assess compliance with licensing requirements.
Findings
The facility was found to have several deficiencies including failure to post required influenza information, direct care staff not completing required training before providing unsupervised services, unsecured poisonous materials accessible to residents, lack of operable lighting at bedside for a resident, and residents not signing support plans. Plans of correction were submitted and fully implemented by September 12, 2022.
Deficiencies (5)
| Description |
|---|
| The home did not have an influenza poster posted anywhere as required by the Influenza Awareness Act. |
| Direct care staff person hired did not complete and pass the Department-approved direct care training course and competency test before providing unsupervised ADL services. |
| A 2.5 ounce tube of Colgate Cavity Protection Toothpaste, identified as a poison control item, was unlocked and accessible to residents in the bathroom of room 130 in the Reminiscence Unit. |
| Resident #1 does not have access to a source of light that can be turned on/off at bedside. |
| Residents 1, 2, 3, 4, and 5 participated in the development of their support plans but did not sign the support plans, and there was no documentation of attempts to obtain signatures or refusals. |
Report Facts
License Capacity: 95
Residents Served: 58
Capacity: 29
Residents Served: 16
Current Residents: 10
Residents Age 60 or Older: 59
Residents with Mobility Need: 40
Inspection Report
Renewal
Capacity: 95
Deficiencies: 0
Apr 29, 2021
Visit Reason
The document is a renewal application and license issuance for Sunrise Senior Living of Lower Makefield, a Personal Care Home, pursuant to Title 55, PA Code, Chapter 2600.
Findings
A regular license is being issued in response to the renewal application. The Department will conduct an onsite inspection within the next twelve months to ensure compliance with applicable regulations.
Report Facts
Maximum capacity: 95
Secure Dementia Care Unit capacity: 29
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