Inspection Report
Follow-Up
Census: 60
Capacity: 110
Deficiencies: 2
Feb 4, 2025
Visit Reason
The inspection was a complaint-related partial unannounced review conducted to verify the implementation of a submitted plan of correction.
Findings
The submitted plan of correction was determined to be fully implemented. Deficiencies related to resident contract signatures and initial resident assessments were addressed with retraining, audits, and ongoing monitoring.
Complaint Details
The visit was complaint-related as indicated by the inspection reason. The plan of correction was accepted and fully implemented.
Deficiencies (2)
| Description |
|---|
| The resident-home contract was not signed by the resident. |
| Resident assessment did not include the resident's history of a suicide attempt. |
Report Facts
Residents served: 60
License capacity: 110
Secured Dementia Care Unit capacity: 25
Secured Dementia Care Unit residents served: 17
Hospice current residents: 4
Residents age 60 or older: 60
Residents with mobility need: 36
Residents with physical disability: 2
Residents diagnosed with mental illness: 1
Inspection Report
Complaint Investigation
Census: 59
Capacity: 110
Deficiencies: 3
Oct 16, 2024
Visit Reason
The inspection was conducted as a complaint and incident investigation to review allegations related to resident abuse and compliance with regulatory requirements.
Findings
The investigation found that a staff member physically abused a resident by grabbing their arm and yelling, resulting in bruising and ongoing pain. Additional deficiencies included failure to provide required medication self-administration training to direct care staff and incomplete resident records lacking required face sheets. Plans of correction were accepted and implemented, including staff termination, retraining, audits, and ongoing monitoring.
Complaint Details
The complaint investigation substantiated physical abuse by Staff Member A, who was placed on administrative leave and subsequently terminated. The resident reported bruising and pain from the incident and expressed fear of retaliation.
Deficiencies (3)
| Description |
|---|
| Resident was physically abused by a staff member who grabbed the resident's arm and yelled, causing bruising and pain. |
| Direct care staff person did not receive required medication self-administration training during the 2023 training year. |
| Resident record did not include a face sheet with required demographic and medical information. |
Report Facts
License Capacity: 110
Residents Served: 59
Memory Care Unit Capacity: 25
Memory Care Residents Served: 16
Current Hospice Residents: 5
Residents Diagnosed with Mental Illness: 2
Residents with Mobility Need: 36
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff Member A | Named in physical abuse finding and termination |
Inspection Report
Complaint Investigation
Census: 59
Capacity: 110
Deficiencies: 5
Jun 17, 2024
Visit Reason
The inspection was conducted as a complaint investigation to review compliance with care requirements and licensing regulations at the facility.
Findings
The inspection found deficiencies related to failure to provide assistance with activities of daily living, unlicensed hospice services, neglect and abuse concerns, missing criminal background checks for staff, and a safety hazard with a smoke detector. Plans of correction were accepted and implemented.
Complaint Details
The visit was complaint-related, triggered by concerns about resident care including assistance with activities of daily living, hospice licensing, abuse/neglect, and staff background checks. The complaint was substantiated as deficiencies were found.
Deficiencies (5)
| Description |
|---|
| Failure to provide assistance with reminders to eat and personal grooming as required by resident's assessment and support plan. |
| Hospice services provided by an unlicensed hospice provider whose license had expired. |
| Resident neglect and failure to provide required assistance and reminders, including feeding and grooming. |
| Staff member who pronounced a resident deceased had no criminal background or license information in the file. |
| Smoke detector in room 325 was hanging by a wire and not attached to the ceiling, posing a safety hazard. |
Report Facts
License Capacity: 110
Residents Served: 59
Secured Dementia Care Unit Capacity: 25
Secured Dementia Care Unit Residents Served: 14
Hospice Current Residents: 3
Residents Age 60 or Older: 59
Residents with Mobility Need: 33
Total Daily Staff: 92
Waking Staff: 69
Inspection Report
Complaint Investigation
Census: 56
Capacity: 110
Deficiencies: 2
Jul 27, 2023
Visit Reason
The inspection was conducted as a complaint investigation and incident review at the facility on 07/27/2023.
Findings
Two deficiencies were identified: failure to immediately report suspected resident abuse as required by law, and failure to document in the resident's support plan the medical and behavioral care services needed. Both deficiencies had corrective plans of action accepted and implemented by 08/22/2023.
Complaint Details
The visit was complaint-related, triggered by an incident where resident #1 pushed resident #2's head into a table causing a concussion. The abuse allegation was not reported using the required Act 13 document to the local area agency on aging.
Deficiencies (2)
| Description |
|---|
| Failure to immediately report suspected abuse of a resident as required by the Older Adult Protective Services Act and related regulations. |
| Failure to document in the resident’s support plan the medical, dental, vision, hearing, mental health or other behavioral care services needed or referrals as determined necessary. |
Report Facts
Resident census: 56
Total licensed capacity: 110
Secured Dementia Care Unit capacity: 25
Residents served in Secured Dementia Care Unit: 17
Residents diagnosed with mental illness: 2
Residents with mobility need: 34
Residents with current resident status in hospice: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dan Bevan | Interim Regional Director | Provided training on frequent RASP/ISP updates with Wellness team. |
| Katelyn Metzger | Resident Care Director | Named in training and monitoring of plan of correction implementation. |
Inspection Report
Renewal
Census: 50
Capacity: 110
Deficiencies: 13
Feb 27, 2023
Visit Reason
The inspection was conducted as a renewal inspection combined with complaint and incident reasons, including a plan of correction submission review.
Findings
The inspection identified multiple deficiencies related to staff qualifications, training, safety, medication administration, and facility safety measures. All deficiencies had plans of correction accepted and were implemented by April 27, 2023.
Deficiencies (13)
| Description |
|---|
| Direct care staff person A did not have a US high school diploma, GED, or active registry status on the Pennsylvania nurse aide registry. |
| Direct care staff persons A and B did not receive training in Medication self-administration during training year 2022. |
| Poisonous materials (hand soap) were unlocked, unattended, and accessible to residents in the secure dementia care unit bedroom. |
| No emergency telephone numbers including nearest hospital and fire department were posted on or by telephones in resident bedrooms. |
| First aid kit in Reminiscence did not include a thermometer. |
| Outdated or unlabeled food items (tuna sandwiches, crab cakes, pretzel nuggets) were found in the Reminiscence kitchen and walk-in freezer. |
| A chair blocked emergency egress at the emergency exit in the dining area. |
| Fire extinguisher in the bus had not been inspected by a fire safety expert since 11/2021. |
| During a fire drill, the home's total evacuation time exceeded the maximum safe evacuation time specified by a fire safety expert. |
| First aid kit in the bus used to transport residents did not include a thermometer. |
| Prescription medications and syringes were unlocked, unattended, and accessible in resident 1's bedroom; resident 1 is not capable of self-administering medications. |
| Medication administration record did not document the time medication was administered for resident 1. |
| The home did not fully follow prescriber's orders for medication administration for residents 1 and 2, with missed or incomplete doses documented. |
Report Facts
Licensed Capacity: 110
Residents Served: 50
Deficiencies cited: 13
Inspection Report
Follow-Up
Census: 33
Capacity: 110
Deficiencies: 4
Dec 1, 2022
Visit Reason
The inspection was a partial, unannounced follow-up visit conducted due to an incident at the facility 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 resident abuse, activities of daily living assistance, and staff training deficiencies. The report details incidents of verbal and emotional abuse by staff, failure to report abuse, and inadequate assistance with oral care, all of which were addressed through staff termination, retraining, and additional training plans.
Deficiencies (4)
| Description |
|---|
| Failure to immediately report suspected abuse of resident #1 by staff person A and failure of staff person B to report the incident. |
| Resident #1 did not receive required assistance with oral care as indicated in the resident’s assessment and support plan. |
| Emotional abuse and intimidation of resident #1 by staff person A, witnessed by staff person B who failed to report the incident. |
| Staff training plan lacked detailed training on providing oral care and the different types of abuse. |
Report Facts
License Capacity: 110
Residents Served: 33
Secured Dementia Care Unit Capacity: 25
Residents Served in Dementia Unit: 11
Total Daily Staff: 49
Waking Staff: 37
Residents Age 60 or Older: 44
Residents with Mobility Need: 16
Inspection Report
Complaint Investigation
Census: 48
Capacity: 110
Deficiencies: 0
Jun 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 and the follow-up type was noted as not required.
Report Facts
Total Daily Staff: 73
Waking Staff: 55
License Capacity: 110
Residents Served: 48
Secured Dementia Care Unit Capacity: 25
Secured Dementia Care Unit Residents Served: 11
Residents Age 60 or Older: 48
Residents with Mobility Need: 25
Residents Receiving Supplemental Security Income: 0
Residents Diagnosed with Mental Illness: 0
Residents Diagnosed with Intellectual Disability: 0
Residents with Physical Disability: 0
Inspection Report
Complaint Investigation
Census: 46
Capacity: 110
Deficiencies: 0
May 17, 2022
Visit Reason
The inspection was conducted as a complaint and incident investigation with unannounced partial inspections on multiple dates.
Findings
No deficiencies or regulatory citations were identified during the inspection.
Complaint Details
The inspection was complaint and incident related, with an exit conference held on 05/23/2022. No deficiencies were found.
Report Facts
License Capacity: 110
Residents Served: 46
Secured Dementia Care Unit Capacity: 25
Residents Served in Dementia Unit: 11
Hospice Residents: 6
Residents Age 60 or Older: 46
Residents with Mobility Need: 32
Residents with Physical Disability: 2
Total Daily Staff: 78
Waking Staff: 59
Inspection Report
Complaint Investigation
Census: 47
Capacity: 110
Deficiencies: 0
Mar 21, 2022
Visit Reason
The inspection was conducted as a complaint investigation with unannounced partial inspections on 03/21/2022 and 03/29/2022.
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
Resident Census: 47
Total Licensed Capacity: 110
Secured Dementia Care Unit Capacity: 25
Residents in Secured Dementia Care Unit: 12
Resident Support Staff: 75
Waking Staff: 56
Residents with Mobility Need: 28
Residents 60 Years or Older: 47
Inspection Report
Complaint Investigation
Census: 47
Capacity: 110
Deficiencies: 6
Mar 10, 2022
Visit Reason
The inspection was conducted as a complaint and incident investigation with an unannounced partial review of the facility.
Findings
The inspection identified multiple deficiencies including a malfunctioning electromagnetic lock on a secured dementia unit door allowing a resident to exit without triggering an alarm, failure to implement positive interventions for resident behavior, incomplete support plans lacking documentation of aggression needs and signatures, and missing conspicuous posting of directions for key-locking devices. Plans of correction were accepted and implemented with ongoing monitoring.
Complaint Details
The visit was complaint-related and incident-driven, with follow-up on plan of correction submissions. The complaint involved resident safety and behavior management issues.
Deficiencies (6)
| Description |
|---|
| The back door on the home's 3rd floor secured dementia unit opened without entering the keycode or triggering the alarm. |
| Staff failed to implement positive interventions including redirection and de-escalation techniques for resident exhibiting aggressive behavior. |
| Resident #1's support plan did not document how the need for aggression would be met. |
| Resident #1's support plan lacked a signature page. |
| Directions for operating the home's locking mechanism were not conspicuously posted near the back door from the Secure Dementia Care Unit. |
| Support plan for resident #1 was not revised to address changes in aggressive behavior. |
Report Facts
License Capacity: 110
Residents Served: 47
Secured Dementia Care Unit Capacity: 25
Residents Served in Secured Dementia Care Unit: 12
Total Daily Staff: 75
Waking Staff: 56
Residents with Mobility Need: 28
Residents 60 Years or Older: 47
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Claire Mendez | Signed the letter confirming plan of correction implementation. | |
| Reminiscence Coordinator | Conducted retraining, observations, and revisions related to deficiencies and plans of correction. | |
| Personal Care Coordinator | Assisted in reviewing and updating resident support plans. | |
| Maintenance Coordinator | Assisted in posting directions for locking mechanisms. | |
| Staff A | Tested the malfunctioning door lock after the incident. | |
| Staff B | Involved in incident with resident's aggressive behavior and failure to implement positive interventions. |
Inspection Report
Renewal
Census: 54
Capacity: 110
Deficiencies: 8
Nov 3, 2021
Visit Reason
The inspection was a renewal and provisional licensing inspection conducted unannounced on 11/03/2021 at the Sunrise of Paoli facility.
Findings
The inspection identified multiple deficiencies including unsecured poisonous materials accessible to residents, unsanitary conditions such as a dirty ice machine and stained carpets, lint accumulation in the dryer, unlabeled medications, incomplete staff training documentation, and improper refrigerator temperatures. Plans of correction were accepted for all deficiencies with completion dates set for 12/10/2021.
Deficiencies (8)
| Description |
|---|
| Poisonous materials were unlocked and accessible to residents in the Memory Care unit. |
| Ice machine in the main kitchen had a brown substance around the door and on the inside plastic; carpets at Exit Stair C were stained and discolored. |
| Significant amount of lint found in the main dryer's lint trap. |
| No pharmacy label on the bottle of Apetamin vitamin syrup found in the Memory Care unit. |
| OTC medication (Apetamin Vitamin syrup) was not labeled with the resident's name. |
| Staff person A lacked documentation of successful completion of Department-approved diabetes patient education program within the last 12 months. |
| Medication administration training record for staff person A did not include documentation of successful completion of handwashing or gloving. |
| Temperature in the small refrigerator in the main kitchen was 54°F, exceeding the required 40°F or below. |
Report Facts
License Capacity: 110
Residents Served: 54
Secured Dementia Care Unit Capacity: 25
Residents Served in Dementia Care Unit: 14
Hospice Residents: 5
Waking Staff: 69
Total Daily Staff: 92
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff person A | Medication Care Manager | Named in findings related to incomplete diabetes patient education and medication administration training. |
| Maintenance Coordinator | Responsible for removing poisonous materials, cleaning lint traps, and overseeing carpet replacement. | |
| Reminiscence Coordinator | Provided staff training on poisonous materials and medication labeling. | |
| Dining Services Coordinator | Responsible for cleaning the ice machine and monitoring refrigerator temperatures. | |
| Executive Director | Involved in reviewing and monitoring plans of correction. |
Inspection Report
Follow-Up
Census: 52
Capacity: 110
Deficiencies: 0
Aug 25, 2021
Visit Reason
The inspection visit on 08/25/2021 was a partial, unannounced follow-up to verify the implementation of a previously submitted plan of correction as part of provisional monitoring.
Findings
The submitted plan of correction was determined to be fully implemented, and the facility was found to be in compliance at the time of the follow-up inspection.
Report Facts
Total Daily Staff: 85
Waking Staff: 64
Residents Served: 52
License Capacity: 110
Secured Dementia Care Unit Capacity: 25
Residents Served in Dementia Unit: 14
Residents Age 60 or Older: 52
Residents with Mobility Need: 33
Inspection Report
Monitoring
Census: 48
Capacity: 110
Deficiencies: 2
Apr 8, 2021
Visit Reason
The inspection was an unannounced partial monitoring and interim inspection conducted on 04/08/2021 to assess compliance with licensing regulations at the Sunrise of Paoli facility.
Findings
The inspection found deficiencies related to staff orientation in general fire safety and emergency preparedness, as well as training on resident rights, emergency medical plans, and mandatory reporting of abuse and neglect. Plans of correction were accepted with completion dates set for May 18, 2021.
Deficiencies (2)
| Description |
|---|
| Staff persons did not receive orientation on evacuation procedures, staff duties during fire drills and emergency evacuation, designated meeting place, smoking safety procedures, use of fire extinguishers, smoke detectors, fire alarms, telephone use and notification of emergency services. |
| Staff persons did not complete training on resident rights, emergency medical plan, mandatory reporting of abuse and neglect under the Older Adult Protective Services Act, and reporting of reportable incidents and conditions within 40 scheduled working hours. |
Report Facts
License Capacity: 110
Residents Served: 48
Secured Dementia Care Unit Capacity: 25
Secured Dementia Care Unit Residents Served: 16
Residents with Mobility Need: 30
Residents Age 60 or Older: 48
Total Daily Staff: 78
Waking Staff: 59
Inspection Report
Complaint Investigation
Census: 52
Capacity: 110
Deficiencies: 5
Dec 10, 2020
Visit Reason
The inspection was conducted as a complaint investigation following allegations related to resident neglect and failure to provide CPR during a medical emergency.
Findings
The investigation found that staff failed to provide CPR to an unresponsive resident without a DNR order, violating abuse and neglect regulations and emergency medical plan requirements. Additional deficiencies included failure to orient new staff on fire safety and emergency preparedness, and incomplete training on resident rights and mandatory abuse reporting within required hours.
Complaint Details
The complaint investigation was triggered by allegations that staff failed to provide CPR to a resident found unresponsive without a pulse and without a DNR order. The investigation substantiated neglect due to deprivation of services and failure to follow emergency medical policies.
Deficiencies (5)
| Description |
|---|
| Resident was neglected due to deprivation of services when CPR was withheld by certified staff during a medical emergency. |
| Certified CPR staff failed to provide CPR in accordance with training and policy despite instructions from supervisor and 911 operator. |
| The home's written emergency medical plan was not properly followed regarding CPR initiation for an unresponsive resident without a DNR order. |
| Several staff persons did not receive orientation on fire safety and emergency preparedness topics on their first day of work. |
| Several staff persons did not complete training on resident rights, emergency medical plan, mandatory abuse reporting, and incident reporting within 40 scheduled working hours. |
Report Facts
License Capacity: 110
Residents Served: 52
Residents Served in Secure Dementia Care Unit: 16
Staffing Hours: 77
Waking Staff: 58
Residents with Mobility Need: 25
Inspection Dates: 5
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