Inspection Report
Renewal
Census: 66
Capacity: 104
Deficiencies: 12
Jun 17, 2025
Visit Reason
The inspection was conducted as a renewal visit for the facility license, including a full unannounced inspection on 06/17/2025 and 06/18/2025.
Findings
The inspection found multiple deficiencies including missing signed resident statements, incomplete staff fire safety training, maintenance issues such as unattached bathtub drain covers and food storage violations, medication storage and labeling errors, incomplete resident education on medication refusal rights, and insufficient dementia care training for staff. All deficiencies had plans of correction accepted and were implemented by 08/25/2025.
Deficiencies (12)
| Description |
|---|
| Resident #1's record did not contain a signed statement acknowledging receipt of resident rights and complaint procedures. |
| Staff persons A and B did not receive in-person fire safety training during training year 2024. |
| The drain cover to the bathtub in room 321 was not attached to the bathtub. |
| The home's emergency water supply was stored on the floor in room 309. |
| There was no thermometer in the freezer in the Reminiscence kitchenette. |
| The home did not maintain a 3-day supply of emergency drinking water; only 72 gallons were on site instead of the required 198 gallons. |
| The home's written emergency procedures were last submitted on 5/19/25, with the previous submission on 1/23/24. |
| The fire drill record for the drill conducted on 7/24/24 did not include the time the drill was completed (am/pm). |
| Medication cards had punctured blister foil with medication still present and tape covering the opening; expired medication was not discarded timely. |
| A sample of Synthroid 25mcg medication lacked written instructions from the prescriber. |
| Resident #1 was not educated on the right to refuse medication if a medication error is suspected. |
| Direct care staff person C had only 1 hour of dementia care training during the 2024 training year instead of the required 6 hours. |
Report Facts
Residents served: 66
License capacity: 104
Residents served in secured dementia care unit: 19
Hospice residents: 7
Emergency drinking water required: 198
Emergency drinking water on site: 72
Staff total daily: 89
Staff waking: 67
Residents with mobility need: 23
Residents aged 60 or older: 66
Residents diagnosed with mental illness: 2
Inspection Report
Renewal
Census: 64
Capacity: 104
Deficiencies: 7
Jun 17, 2024
Visit Reason
The inspection was an unannounced full renewal inspection conducted on 06/17/2024 and 06/18/2024 to review the facility's compliance with licensing requirements.
Findings
The inspection identified multiple deficiencies related to sanitary conditions, surfaces, furniture and equipment, outdated food, medical evaluation changes, medication record accuracy, and support plan signatures. All deficiencies had plans of correction accepted and were implemented by 08/13/2024.
Deficiencies (7)
| Description |
|---|
| Sugar spilled and dried liquid substance found in the Memory Care Unit Kitchen cabinets. |
| Sticky counters beside and behind the water dispenser in the Memory Care Unit lower kitchen. |
| Broken shelf and drawer piece with sharp corner in the Memory Care Unit lower kitchen cabinet. |
| Undated strawberries with mold found in the main kitchen walk-in refrigerator. |
| Resident 1 did not have an updated medical evaluation after a change in medical condition for a mechanical soft diet. |
| Resident 2's medication administration record did not indicate the strength of prescribed Trazadone 50 mg. |
| Resident 3 participated in support plan development but the facility could not provide the signature page. |
Report Facts
License Capacity: 104
Residents Served: 64
Secured Dementia Care Unit Capacity: 26
Secured Dementia Care Unit Residents Served: 21
Hospice Residents: 11
Residents with Mobility Need: 29
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Resident Care Director | Resident Care Director (RCD) | Named in findings related to medical evaluation changes, medication record, and support plan signatures. |
| Dining Services Coordinator | Dining Services Coordinator (DSC) | Named in findings related to outdated food and food storage training. |
| Maintenance Coordinator | Maintenance Coordinator (MC) | Named in findings related to kitchen sanitation and furniture repair. |
| Executive Director | Executive Director (ED) | Involved in education and monitoring of corrective actions. |
| Wellness Nurses | Wellness Nurses (WN) | Involved in education related to medical evaluation and support plan findings. |
| Medication Care Managers | Medication Care Managers (MCM) | Trained on proper medication record documentation. |
| Lead Care Managers | Lead Care Managers (LCM) | Involved in monitoring kitchen sanitation. |
| Reminiscence Coordinator | Reminiscence Coordinator (RC) | Involved in monitoring kitchen sanitation and support plan meetings. |
| PCC | PCC | Involved in support plan meetings and documentation. |
Inspection Report
Complaint Investigation
Census: 72
Capacity: 104
Deficiencies: 5
Sep 28, 2023
Visit Reason
The inspection was conducted as a complaint investigation with an unannounced partial inspection on 09/28/2023 and a follow-up review on 10/30/2023 to verify the submitted plan of correction.
Findings
The inspection found multiple medication-related deficiencies including unlocked and unattended medication blister packs, improper storage of self-administered medications, residents self-administering medications incorrectly, incomplete medication records, and improperly labeled medications. The facility implemented training sessions and audits to address these issues, with ongoing monitoring planned.
Complaint Details
The inspection was triggered by a complaint, with an unannounced partial inspection conducted on 09/28/2023 and follow-up on 10/30/2023. The submitted plan of correction was reviewed and accepted.
Deficiencies (5)
| Description |
|---|
| Medication blister packs were unlocked, unattended, and accessible on top of the medication cart for several residents. |
| Resident #4 stored several unlocked, unattended medications in his/her room on top of the dresser. |
| Resident #4 self-administered medications incorrectly, including liquid gel capsules in place of cream and loose pills in the room, plus use of non-prescribed over-the-counter medications. |
| Resident #4's medication record did not include a current list of all prescription, CAM, and OTC medications. |
| The pharmacy label for resident #4's tablet was faded, illegible, contained extraneous writing, and the medication inside did not match the manufacturer's description. |
Report Facts
License Capacity: 104
Residents Served: 72
Secured Dementia Care Unit Capacity: 26
Secured Dementia Care Unit Residents Served: 21
Hospice Current Residents: 13
Residents with Mobility Need: 30
Residents Age 60 or Older: 72
Inspection Report
Complaint Investigation
Census: 57
Capacity: 104
Deficiencies: 1
Apr 18, 2023
Visit Reason
The inspection was conducted as a complaint investigation to review compliance at the facility.
Findings
The inspection found that the facility's menus were not properly posted in all required areas, with some menus outdated or missing. The Executive Director promptly corrected the issue and implemented a plan of correction including staff training and ongoing monitoring.
Complaint Details
The visit was complaint-related as indicated by the inspection information section stating the reason as 'Complaint'.
Deficiencies (1)
| Description |
|---|
| Menus for the week of 04/16/23 to 04/22/23 were posted only in the elevators with no additional menus posted in required dining areas. The menu in the Reminiscence Unit dining room did not have the current week's menu visible. The daily menu board in the main dining room showed menus for the previous day. |
Report Facts
License Capacity: 104
Residents Served: 57
Secured Dementia Care Unit Capacity: 26
Secured Dementia Care Unit Residents Served: 18
Hospice Current Residents: 15
Residents Age 60 or Older: 57
Residents with Mobility Need: 27
Total Daily Staff: 84
Waking Staff: 63
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director | Named in relation to posting menus and conducting staff training on menu posting | |
| Dining Service Coordinator | Received training on posting menus | |
| Reminiscence Coordinator | Received training on posting menus |
Inspection Report
Follow-Up
Census: 67
Capacity: 104
Deficiencies: 2
Dec 1, 2022
Visit Reason
The inspection was conducted as a complaint and incident investigation with an unannounced partial review on 12/01/2022, followed by plan of correction submissions and document reviews.
Findings
The facility was found to have staffing shortages impacting timely assistance to residents needing two-person transfers, and medication administration records lacked proper documentation of staff initials. Plans of correction were submitted and accepted, with ongoing monitoring and training implemented to ensure compliance.
Complaint Details
The inspection was complaint-related and incident-driven, with follow-up on plan of correction submissions. Substantiation status is not explicitly stated.
Deficiencies (2)
| Description |
|---|
| Staffing was insufficient to meet the needs of residents requiring two-person assistance for transfers, resulting in long call bell response times. |
| Medication administration records did not include the initials of staff who administered medications for certain residents. |
Report Facts
Residents served: 67
License capacity: 104
Staffing: 106
Waking staff: 80
Residents needing two-person assistance: 6
Call bell response time: 300
Inspection Report
Follow-Up
Census: 65
Capacity: 104
Deficiencies: 9
Oct 31, 2022
Visit Reason
The inspection visit was a full, unannounced renewal inspection with an incident review, conducted to verify compliance and the implementation of a submitted plan of correction.
Findings
The inspection identified multiple deficiencies including delays in resident refund processing after death, incomplete fire safety orientation for new staff, missing emergency telephone numbers by resident telephones, obstructed egress due to a magnetic lock, incomplete evacuation during fire drills, and issues with medical evaluations and assessments for residents. Plans of correction were accepted and implemented by 12/01/2022.
Deficiencies (9)
| Description |
|---|
| Delays in processing refunds to residents' estates after death beyond the required 30 days. |
| New direct care staff did not receive orientation on fire safety and emergency preparedness on their first day. |
| Emergency telephone numbers for nearest hospital and fire department were not posted by telephones in resident rooms. |
| A magnetic lock was in place blocking egress on 'Exit Stair A' on the 3rd floor personal care side. |
| Fire drills conducted on multiple dates did not evacuate all residents to a public thoroughfare or designated fire-safe area. |
| Resident medical evaluations were not completed annually or were misfiled. |
| Preadmission screening form was completed after resident admission date. |
| Resident assessments did not include physician's assessment of mobility or were inconsistent with medical evaluations. |
| Medical evaluation for a resident admitted to the secured dementia care unit did not indicate the need for secured dementia care. |
Report Facts
Residents Served: 65
License Capacity: 104
Staffing Hours - Total Daily Staff: 105
Staffing Hours - Waking Staff: 79
Secured Dementia Care Unit Capacity: 26
Secured Dementia Care Unit Residents Served: 22
Hospice Current Residents: 13
Residents Age 60 or Older: 65
Residents with Mobility Need: 40
Notice
Capacity: 104
Deficiencies: 0
Sep 24, 2021
Visit Reason
The document serves as a renewal notification and license issuance for the Personal Care Home 'Sunrise of Newtown Square' following receipt of a renewal application dated September 21, 2021.
Findings
The Department issued a regular license in response to the renewal application and advised that an onsite annual inspection will be conducted within the next twelve months to ensure compliance with applicable regulations.
Report Facts
Maximum licensed capacity: 104
Secure Dementia Care Unit capacity: 26
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary, Office of Long-term Living | Signed the renewal notification letter |
Inspection Report
Renewal
Census: 57
Capacity: 104
Deficiencies: 13
Jun 29, 2021
Visit Reason
The inspection was a full, unannounced renewal inspection conducted on 06/29/2021 and 06/30/2021 to assess compliance with regulatory requirements for the facility license renewal.
Findings
The inspection identified multiple deficiencies including failure to report an incident timely, HIPAA violations related to medication disposal, incomplete criminal background checks for vendors, sanitary condition issues, improper medication labeling and storage, lack of resident education on medication refusal rights, and deficiencies in activity programming and calendar posting. Plans of correction were submitted and accepted for all deficiencies with ongoing monitoring.
Deficiencies (13)
| Description |
|---|
| Failure to report an unwitnessed resident fall to the Department within 24 hours. |
| Medication labels for residents #2 and #3 were not in compliance with HIPAA due to improper disposal. |
| Three vendors were found unattended on the 2nd floor without completed criminal background checks. |
| Unclean refrigerator with spilled food debris and resident shoes on memory care kitchenette counter. |
| Dumpster lid outside the home was open, not preventing insect and rodent penetration. |
| Unlabeled and undated food and drink items found in refrigerator and freezer in activity room. |
| Pharmacy label for resident #4's medication was altered with handwritten dose. |
| Resident #5's prescribed suppository was not stored on medication cart as indicated; glucometer readings for resident #6 were documented incorrectly. |
| Resident #7 was not educated on the right to refuse medication if a medication error is suspected. |
| Lack of a program of activities promoting resident involvement with others, family, and community. |
| No current weekly activity calendar posted in a public and conspicuous place in the memory care unit. |
| Activities were not offered in the memory care unit as reported by staff. |
| Correction fluid was used on resident #4's rights page in the contract. |
Report Facts
License Capacity: 104
Residents Served: 57
Secured Dementia Care Unit Capacity: 26
Residents Served in Secured Dementia Care Unit: 15
Total Daily Staff: 86
Waking Staff: 65
Residents with Mobility Need: 29
Residents with Physical Disability: 29
Residents 60 Years or Older: 57
Residents Diagnosed with Mental Illness: 1
Hospice Residents: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mia Johnson | Department Representative | Signed the letter confirming plan of correction implementation. |
| Menerva Philson | Facility contact person mentioned in the letterhead. | |
| Executive Director | ED | Named in multiple findings related to incident reporting, staff education, and plan of correction implementation. |
| Resident Care Director | RCD | Responsible for medication label corrections, audits, and staff education. |
| Business Office Coordinator | BOC | Involved in criminal background check audits and vendor clearance. |
| Activities Coordinator | AVC | Responsible for cleaning, activity programming, and calendar posting. |
| Reminiscence Coordinator | RC | Involved in maintaining sanitary conditions and activity programming. |
| Life Enrichment Manager | LEM | Hired to assist with programming in the reminiscence neighborhood. |
| Director of Sales | DOS | Educated on proper record entry corrections. |
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