Inspection Report
Renewal
Census: 73
Capacity: 110
Deficiencies: 8
Aug 20, 2025
Visit Reason
The inspection was an unannounced full renewal inspection with an incident review conducted on 08/20/2025 and 08/21/2025, including a follow-up on plan of correction submissions.
Findings
The inspection found multiple deficiencies related to abuse, staff orientation, training, and record-keeping. Several staff members failed to complete required training and orientation, including fire safety, abuse reporting, direct care training, and annual training topics. A financial abuse incident involving staff was investigated and addressed with terminations and police involvement. Plans of correction were accepted and implemented by 10/01/2025.
Deficiencies (8)
| Description |
|---|
| Financial abuse of a resident involving unauthorized use of credit card by staff members. |
| Staff person D did not receive required orientation on fire safety and emergency preparedness topics on their first day. |
| Staff person D did not complete required training within 40 scheduled working hours on resident rights, emergency medical plan, abuse reporting, and incident reporting. |
| Staff person C provided unsupervised ADL services without completing and passing the Department-approved direct care training course and competency test. |
| Staff person D did not receive training on safe management techniques, resident needs assessment, and care for residents with intellectual disabilities during training year 2024. |
| Staff person E did not receive training on care for residents with mental illness or intellectual disability during training year 2024. |
| Staff person F did not receive training on the Older Adult Protective Services Act during training year 2024. |
| Medication administration training record for staff person D lacked date and documentation of successful completion. |
Report Facts
License Capacity: 110
Residents Served: 73
Secured Dementia Care Unit Capacity: 25
Secured Dementia Care Unit Residents Served: 19
Hospice Residents: 5
Mobility Need Residents: 43
Residents 60 Years or Older: 73
Residents Diagnosed with Intellectual Disability: 2
Total Daily Staff: 116
Waking Staff: 87
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff Person A | Named in financial abuse violation involving unauthorized use of resident's credit card. | |
| Staff Person B | Named as possible accomplice in financial abuse violation. | |
| Staff Person C | Direct Care Staff | Failed to complete required direct care training before providing unsupervised ADL services; subsequently terminated. |
| Staff Person D | Failed to receive required orientation and multiple trainings including fire safety, abuse reporting, safe management techniques, and medication administration; removed from duties pending training and retesting. | |
| Staff Person E | Did not receive required training on care for residents with mental illness or intellectual disability during training year 2024; retrained by Executive Director. | |
| Staff Person F | Did not receive training on Older Adult Protective Services Act during training year 2024; retrained by Executive Director. |
Inspection Report
Complaint Investigation
Census: 70
Capacity: 110
Deficiencies: 1
Feb 13, 2025
Visit Reason
The inspection was conducted as a complaint and incident investigation at the Sunrise of Westtown facility.
Findings
The investigation found an incident of resident-to-resident abuse where one resident aggressively shoved another, causing injury that required hospital evaluation and psychiatric assessment. A plan of correction was submitted and fully implemented.
Complaint Details
The complaint involved an incident where a resident was shoved aggressively by another resident, resulting in a fall and injury. The incident was witnessed by multiple staff, EMS was called, and the injured resident was hospitalized. The facility issued a 30-day discharge notice to the aggressor resident and implemented staff training and ongoing monitoring.
Deficiencies (1)
| Description |
|---|
| A resident was physically abused by another resident, resulting in injury requiring hospital transport and psychiatric evaluation. |
Report Facts
License Capacity: 110
Residents Served: 70
Memory Care Unit Capacity: 25
Memory Care Unit Residents Served: 21
Hospice Current Residents: 7
Residents Age 60 or Older: 70
Residents with Intellectual Disability: 1
Residents with Mobility Need: 42
Inspection Report
Monitoring
Census: 59
Capacity: 110
Deficiencies: 2
Feb 21, 2024
Visit Reason
The inspection was a partial, unannounced monitoring visit conducted on 02/21/2024 to review the facility's compliance and implementation of a previously submitted plan of correction.
Findings
The submitted plan of correction was determined to be fully implemented. Two deficiencies were noted: failure to follow prescriber's orders regarding medication administration, and failure to revise a resident's support plan within 30 days following an annual assessment or change in needs. Both deficiencies had corrective actions including audits, retraining, and ongoing quality management.
Deficiencies (2)
| Description |
|---|
| Failure to follow the directions of the prescriber regarding medication administration times for a resident. |
| Support plan was not revised within 30 days to accurately reflect a resident's care needs after annual assessment or change in condition. |
Report Facts
License Capacity: 110
Residents Served: 59
Secured Dementia Care Unit Capacity: 25
Secured Dementia Care Unit Residents Served: 17
Total Daily Staff: 94
Waking Staff: 71
Residents Age 60 or Older: 58
Residents with Mobility Need: 35
Inspection Report
Follow-Up
Census: 56
Capacity: 110
Deficiencies: 1
Nov 8, 2023
Visit Reason
The inspection was a partial, unannounced visit conducted due to a complaint and incident, with a focus on follow-up 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 abuse and neglect involving improper catheter and perineal care, which had resulted in resident deterioration and death. Continued compliance must be maintained.
Complaint Details
The visit was complaint-related, triggered by a complaint and incident. The plan of correction was accepted on 01/29/2024 and fully implemented by 05/09/2024.
Deficiencies (1)
| Description |
|---|
| Failure to provide proper catheter cleaning and perineal care to a resident, resulting in deterioration and placement on hospice, followed by the resident's death. |
Report Facts
License Capacity: 110
Residents Served: 56
Secured Dementia Care Unit Capacity: 25
Secured Dementia Care Unit Residents Served: 15
Hospice Residents: 4
Residents with Mobility Need: 29
Residents with Physical Disability: 3
Plan of Correction Completion Date: 2024
Inspection Report
Renewal
Census: 58
Capacity: 110
Deficiencies: 5
May 15, 2023
Visit Reason
The inspection was conducted as a renewal inspection of the facility license.
Findings
The inspection identified multiple deficiencies including failure to process resident refunds timely, direct care staff lacking required educational qualifications, insufficient first aid/CPR certified staff for the resident census, lack of fire safety orientation for some agency staff, and incomplete annual training for direct care staff.
Deficiencies (5)
| Description |
|---|
| Resident refund was not processed within 30 days after resident's death and room clearance. |
| Direct care staff persons did not have a U.S. high school diploma, GED, or active registry status on the Pennsylvania nurse aide registry. |
| Only one staff person certified in first aid, obstructed airway techniques, and CPR was present for 58 residents, not meeting the requirement of one certified staff per 50 residents. |
| Agency staff persons did not receive required fire safety and emergency preparedness orientation on their first day of work. |
| Direct care staff person did not receive required annual training in medication self-administration and safe management techniques during training year 2022. |
Report Facts
License Capacity: 110
Residents Served: 58
Secured Dementia Care Unit Capacity: 25
Secured Dementia Care Unit Residents Served: 14
Current Hospice Residents: 9
Residents Age 60 or Older: 58
Residents with Mobility Need: 31
Total Daily Staff: 89
Waking Staff: 67
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Business Office Coordinator | Named in multiple findings related to refund processing, staff education audits, and training audits. | |
| Executive Director | Named in multiple findings related to training, audits, and corrective actions. | |
| Resident Care Coordinator | Involved in confirming CPR certified staff and providing training. | |
| Resident Care Director | Involved in confirming CPR certified staff and providing training. | |
| Maintenance Coordinator | Provided fire safety and emergency preparedness training. | |
| Direct care staff person A | Direct care staff | Did not have required educational qualifications initially; diploma obtained later. |
| Direct care staff person B | Agency staff | Did not have required educational qualifications and was removed from work. |
| Direct care staff person E | Direct care staff | Did not receive required annual training in medication self-administration and safe management techniques. |
| Agency staff persons B, C, and D | Agency staff | Did not receive required fire safety and emergency preparedness orientation on first day. |
Inspection Report
Complaint Investigation
Census: 61
Capacity: 110
Deficiencies: 0
May 2, 2023
Visit Reason
The inspection was conducted as a complaint investigation by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing.
Findings
No regulatory citations or deficiencies were identified as a result of the inspection conducted on 05/02/2023.
Complaint Details
The visit was complaint-related with a partial, unannounced inspection type. No deficiencies were found, and follow-up was not required.
Report Facts
License Capacity: 110
Residents Served: 61
Secured Dementia Care Unit Capacity: 25
Secured Dementia Care Unit Residents Served: 15
Hospice Current Residents: 9
Residents Age 60 or Older: 61
Residents with Mobility Need: 30
Inspection Report
Complaint Investigation
Census: 61
Capacity: 110
Deficiencies: 6
Mar 1, 2023
Visit Reason
The inspection was an unannounced partial complaint investigation conducted due to a complaint received by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing.
Findings
The inspection identified multiple deficiencies including failure to provide emergency treatment for a resident with a large hematoma, lack of toilet paper in a bathroom, unlabeled and undated leftover food items, failure to document refusal or inability to sign support plans, and incomplete or untimely medical evaluations and preadmission screenings for residents in the Secure Dementia Care Unit.
Complaint Details
The visit was triggered by a complaint regarding neglect and failure to provide emergency treatment to Resident #1 with a large hematoma and bilateral leg edema.
Deficiencies (6)
| Description |
|---|
| Resident #1 was not provided emergency treatment following discovery of a large hematoma and bilateral leg edema; no physician assessment or emergency treatment was obtained. |
| No toilet paper was provided for the toilet in bathroom 122. |
| Leftover food items in the Secure Dementia Care Unit refrigerator/freezer were not labeled or dated. |
| Resident #1 did not sign the support plan and there was no notation indicating refusal or inability to sign. |
| Resident #1's medical evaluation was not completed within 60 days prior to admission to the Secure Dementia Care Unit. |
| Resident #1's written cognitive preadmission screening was not completed within 72 hours prior to admission to the Secure Dementia Care Unit. |
Report Facts
License Capacity: 110
Residents Served: 61
Memory Care Unit Capacity: 25
Memory Care Unit Residents Served: 18
Staffing Hours - Total Daily Staff: 79
Staffing Hours - Waking Staff: 59
Unlabeled sandwiches: 5
Unlabeled assorted juices: 6
Inspection Report
Follow-Up
Census: 60
Capacity: 110
Deficiencies: 3
Jan 24, 2023
Visit Reason
The inspection visit was conducted as a follow-up to review the submitted plan of correction related to an incident and medical evaluation deficiencies at the facility.
Findings
The facility was found to have failed to report an incident involving a resident and had deficiencies in medical evaluation documentation and support plans addressing behavioral concerns. The submitted plan of correction was determined to be fully implemented as of the follow-up inspection.
Deficiencies (3)
| Description |
|---|
| Failure to report an incident involving a resident knocking over items in his room to the Department within 24 hours. |
| Resident's medical evaluation did not include required elements such as a general physical examination, medication regimen, contraindicated medications, medication side effects, and ability to self-administer medications. |
| Support plan did not address how the home will manage behavioral concerns when certain thoughts are present. |
Report Facts
License Capacity: 110
Residents Served: 60
Secured Dementia Care Unit Capacity: 25
Secured Dementia Care Unit Residents Served: 19
Residents Age 60 or Older: 59
Residents with Mobility Need: 31
Residents with Physical Disability: 5
Inspection Report
Complaint Investigation
Census: 63
Capacity: 110
Deficiencies: 5
Nov 3, 2022
Visit Reason
The inspection was conducted as a complaint investigation to review compliance with regulatory requirements at the facility.
Findings
The inspection identified multiple deficiencies including failure to assist a resident with personal hygiene as required, unlocked poisonous materials accessible to residents, unsanitary conditions in a resident bathroom, lack of operable bedside lighting for a resident, and incomplete medical evaluation documentation missing immunization history.
Complaint Details
The visit was triggered by a complaint as stated under Inspection Information on page 2.
Deficiencies (5)
| Description |
|---|
| Resident #1 requires assistance with bathing but does not receive it as required. |
| Toothpaste and deodorant labeled as poisonous were unlocked and accessible to residents in bathrooms in rooms 114 and 125, with residents not assessed as capable of safely using poisons. |
| Toilet seat in bathroom in room 114 had brown stains appearing to be fecal matter. |
| Resident #1 does not have access to a source of light that can be turned on/off at bedside. |
| Resident #1's medical evaluation did not include immunization history. |
Report Facts
License Capacity: 110
Residents Served: 63
Secured Dementia Care Unit Capacity: 25
Secured Dementia Care Unit Residents Served: 18
Current Hospice Residents: 6
Residents Age 60 or Older: 63
Residents with Mobility Need: 29
Total Daily Staff: 92
Waking Staff: 69
Inspection Report
Complaint Investigation
Census: 60
Capacity: 110
Deficiencies: 5
Oct 20, 2022
Visit Reason
The inspection was conducted as a complaint investigation to review compliance with regulatory requirements and the submitted plan of correction.
Findings
The facility was found to have multiple deficiencies related to incident reporting, staffing for medication administration, medication storage and destruction procedures, availability of prescribed medications, and documentation/reporting of medication refusals. The submitted plan of correction was accepted and fully implemented by the follow-up date.
Complaint Details
The inspection was complaint-driven, with the complaint reason explicitly stated. The plan of correction was reviewed and accepted, with follow-up dates and monitoring described.
Deficiencies (5)
| Description |
|---|
| Failure to report an unwitnessed fall and injury to the resident's head to the Department as required. |
| Lack of staff able to administer PRN medications during the overnight shift as required by the resident's assessment and support plan. |
| Improper destruction of narcotic medication by a single staff member not following the home's written procedures. |
| Prescribed medications were not available in the home as required. |
| Failure to document and report a resident's refusal to take a prescribed medication to the physician as required. |
Report Facts
License Capacity: 110
Residents Served: 60
Secured Dementia Care Unit Capacity: 21
Secured Dementia Care Unit Residents Served: 17
Hospice Current Residents: 6
Residents Age 60 or Older: 59
Residents with Mobility Need: 29
Residents with Physical Disability: 1
Total Daily Staff: 89
Waking Staff: 67
Inspection Report
Plan of Correction
Census: 58
Capacity: 110
Deficiencies: 1
Jun 13, 2022
Visit Reason
The inspection was a partial, unannounced visit conducted due to an incident at the facility on 06/13/2022, with a follow-up type of Plan of Correction (POC) submission.
Findings
The facility was found deficient in documenting the medical and behavioral care services in the resident support plan, specifically regarding resident #1's aggression towards resident #2. The submitted plan of correction was accepted and fully implemented by 02/14/2023.
Deficiencies (1)
| Description |
|---|
| The assessment for resident #1 did not indicate the resident's need for intervention with aggression towards resident #2, and the support plan did not document how this need would be met. |
Report Facts
Licensed Capacity: 110
Residents Served: 58
Secured Dementia Care Unit Capacity: 25
Residents Served in Dementia Care Unit: 17
Residents Age 60 or Older: 56
Residents with Mobility Need: 33
Residents with Physical Disability: 1
Inspection Report
Complaint Investigation
Census: 61
Capacity: 110
Deficiencies: 0
Mar 9, 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 no deficiencies were found; follow-up was not required.
Report Facts
Residents Served: 61
License Capacity: 110
Memory Care Unit Capacity: 25
Memory Care Unit Residents Served: 17
Hospice Residents: 4
Residents Age 60 or Older: 60
Residents with Mobility Need: 33
Residents with Physical Disability: 26
Inspection Report
Renewal
Census: 64
Capacity: 110
Deficiencies: 14
Feb 10, 2022
Visit Reason
The inspection was conducted as a renewal inspection of the facility's license to ensure continued compliance with regulatory requirements.
Findings
The inspection identified multiple deficiencies including issues with criminal background checks, locking poisonous materials, sanitary conditions, hot water temperature, emergency telephone numbers, first aid kit contents, medical evaluations, medication management, key-locking device signage, and record entries. Plans of correction were accepted and implemented with ongoing monitoring.
Deficiencies (14)
| Description |
|---|
| Criminal background check for direct care staff was not requested timely. |
| Poisonous materials (toothpaste) were unlocked and accessible to residents not assessed capable of safe use. |
| Unlabeled personal care items (pink shower puff and grey washcloth) found in shared resident bathroom. |
| Hot water temperature in resident bathroom sink exceeded 120°F. |
| Emergency telephone numbers did not include all required contacts. |
| First aid kit in bistro missing breathing shield. |
| Resident medical evaluation missing key components including ability to self-administer medications, body positioning, health status, and mobility assessment. |
| Discontinued medications found in medication cart. |
| Medication labeling did not reflect updated dosage instructions. |
| Medication administration records missing staff initials and documentation errors. |
| Medication given not following prescriber's orders regarding timing and container separation. |
| Directions for operating key-locking devices not conspicuously posted near exit door. |
| Resident narcotic control records contained multiple entry errors including illegible, crossed out, and overwritten entries without proper notation. |
| Annual medical evaluations for residents were not completed timely. |
Report Facts
License Capacity: 110
Residents Served: 64
Secured Dementia Care Unit Capacity: 25
Residents Served in Dementia Unit: 14
Hospice Residents: 5
Staffing Hours: 94
Waking Staff: 71
Residents Age 60 or Older: 63
Residents Diagnosed with Mental Illness: 15
Residents with Mobility Need: 30
Residents with Physical Disability: 2
Notice
Capacity: 110
Deficiencies: 0
Sep 14, 2021
Visit Reason
The document serves as a renewal notification and issuance of a regular license for the Personal Care Home 'Sunrise of Westtown' 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, and enforcement actions will be taken if noncompliance is found during that inspection.
Report Facts
Maximum licensed capacity: 110
Secure Dementia Care Unit capacity: 25
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary, Office of Long-term Living | Signed the renewal notification letter |
Inspection Report
Complaint Investigation
Census: 62
Capacity: 110
Deficiencies: 10
Jul 19, 2021
Visit Reason
The inspection was conducted as a complaint investigation with an unannounced partial inspection on 07/19/2021 and 07/20/2021.
Findings
Multiple deficiencies were found including failure to report a medication incident timely, insufficient direct care staffing hours, lack of trained staff to administer medications during overnight shifts, missing operable bedside lighting, incomplete annual medical evaluations, failure to follow prescriber's orders, incomplete medication administration training records, and missing discharge destination documentation in resident records.
Complaint Details
The inspection was complaint-driven as indicated by the inspection reason and was unannounced. The exit conference was held on 07/20/2021.
Deficiencies (10)
| Description |
|---|
| Failure to report incident of missing Oxycodone medication to the department within 24 hours. |
| Insufficient direct care staffing hours provided for residents with mobility needs on 7/2/21. |
| Insufficient direct care staffing hours during waking hours on 7/2/21. |
| No qualified staff available or trained to administer medications during the 11pm-7am shift on 7/2/21 and 7/3/21. |
| Only one staff person trained in First Aid/CPR was present during the 11pm-7am shift for 62 residents on 7/2/21 and 7/10/21. |
| Resident beds 117b and 121a and b lacked access to an operable lamp or source of lighting at bedside. |
| Resident #4 and #5 did not have completed annual medical evaluations as required. |
| Resident #1 did not receive prescribed Oxycodone on 7/3/21 due to medication unavailability. |
| Medication administration training record for staff person A was incomplete, lacking required documentation. |
| Resident #6's record did not include the actual discharge destination. |
Report Facts
Residents present: 62
Licensed capacity: 110
Residents with mobility needs: 40
Direct care hours required: 102
Direct care hours provided: 91.5
Direct care hours during waking hours required: 76.5
Direct care hours during waking hours provided: 69
Oxycodone pills stolen: 46
Residents served in secured dementia care unit: 15
Hospice residents: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sandi Wooters | Department Representative | Signed the cover letter for the inspection report. |
Inspection Report
Complaint Investigation
Census: 62
Capacity: 110
Deficiencies: 10
Jul 19, 2021
Visit Reason
The inspection was conducted as a complaint investigation with an unannounced partial inspection on 07/19/2021 and 07/20/2021 to review compliance with regulatory requirements.
Findings
The inspection identified multiple deficiencies including failure to timely report incidents, insufficient direct care staffing hours especially during waking hours, lack of qualified staff to administer medications during overnight shifts, incomplete medication administration training records, missing discharge destination in resident records, and failure to administer prescribed medications due to unavailability. Plans of correction were submitted and found to be implemented.
Complaint Details
The inspection was complaint-driven as indicated by the reason 'Complaint' and was an unannounced partial inspection conducted on 07/19/2021 and 07/20/2021.
Deficiencies (10)
| Description |
|---|
| Failure to report incident of missing Oxycodone medication to the department within required 24 hours. |
| Insufficient direct care staffing hours provided to residents with mobility needs on 7/2/21. |
| Insufficient direct care staffing hours during waking hours on 7/2/21. |
| No qualified staff available or fully trained to administer medications during 11pm-7am shift on 7/2/21 and 7/3/21. |
| Only one staff person trained in First Aid/CPR present during 11pm-7am shift on 7/2/21 and 7/10/21 for 62 residents. |
| Resident beds 117b and 121a and b lacked operable bedside lighting. |
| Resident #5's medical evaluation was not completed or available in the record as required annually. |
| Resident #1 did not receive prescribed Oxycodone medication due to unavailability in the home. |
| Medication administration training record for staff person A was incomplete, unable to verify training completion. |
| Resident #6's record did not include actual discharge destination. |
Report Facts
Residents present: 62
Licensed capacity: 110
Residents with mobility needs: 40
Required direct care hours: 102
Direct care hours provided: 91.5
Required waking hours: 76.5
Waking hours provided: 69
Oxycodone pills stolen: 46
Residents served in secured dementia care unit: 15
Hospice residents: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff Member A | Named in medication administration training record deficiency. | |
| Director of Operations | Provided education and training on incident reporting and staffing requirements. | |
| Executive Director | ED | Provided education and training, reviewed staffing schedules, and monitored compliance. |
| Resident Care Director | RCD | Reviewed schedules, notified physician of missed medication dose, and coordinated training. |
| Wellness Nurse | Involved in medication audits and training. | |
| Personal Care Coordinator | PCC | Involved in scheduling and training related to staffing and medication administration. |
| Reminiscence Coordinator | RC | Involved in scheduling and training related to staffing. |
| Maintenance Coordinator | MC | Assisted with correction of bedside lighting deficiency. |
Inspection Report
Complaint Investigation
Census: 68
Capacity: 110
Deficiencies: 2
May 12, 2021
Visit Reason
The inspection was conducted as a complaint investigation regarding the facility's failure to return a prescribed Hoyer Lift in a timely manner.
Findings
The facility failed to return a Hoyer Lift belonging to a former resident despite multiple attempts by the family to communicate. The complaint was not responded to within the required timeframe, but the plan of correction was fully implemented and the equipment was returned on 05/12/2021.
Complaint Details
A written complaint was filed on March 24, 2021, regarding the failure of the home to return a prescribed Hoyer Lift. The home did not respond to the complaint or return the Hoyer Lift until May 12, 2021.
Deficiencies (2)
| Description |
|---|
| Failure to return a prescribed Hoyer Lift to the medical supplier in a timely manner after resident discharge. |
| Failure to provide a status report to the complainant within 2 business days after submission of a written complaint. |
Report Facts
License Capacity: 110
Residents Served: 68
Staffing Hours - Total Daily Staff: 103
Staffing Hours - Waking Staff: 77
Secured Dementia Care Unit Capacity: 25
Secured Dementia Care Unit Residents Served: 20
Residents Age 60 or Older: 68
Residents Diagnosed with Mental Illness: 2
Residents with Mobility Need: 35
Residents with Physical Disability: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Patricia Adams | Executive Director | Named in relation to the plan of correction and response to the complaint |
Inspection Report
Complaint Investigation
Census: 56
Capacity: 110
Deficiencies: 4
Mar 30, 2021
Visit Reason
The inspection was conducted as a complaint investigation to address concerns at the facility.
Findings
The inspection found multiple deficiencies including inappropriate staff behavior towards a resident, missing criminal background check documentation for a staff member, use of non-standardized forms for resident assessments, and incomplete resident records lacking incident reports.
Complaint Details
The visit was complaint-related, triggered by a complaint as stated in the inspection summary. The complaint involved inappropriate treatment of a resident by a staff member and documentation deficiencies.
Deficiencies (4)
| Description |
|---|
| Staff member A used inappropriate language towards a resident and was terminated for inappropriate behavior. |
| Criminal background check for staff member A was not available at the time of hire. |
| Resident 1's initial assessment was not completed on the Department’s current standardized form and was missing signatures and dates. |
| Resident 1's record did not include a record of incident reports for the individual resident. |
Report Facts
License Capacity: 110
Residents Served: 56
Secured Dementia Care Unit Capacity: 25
Residents Served in Dementia Unit: 15
Resident Mobility Need: 34
Total Daily Staff: 90
Waking Staff: 68
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff member A | Named in findings related to inappropriate behavior and missing criminal background check | |
| Patricia Adams | Signed the cover letter for the inspection report |
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