Inspection Reports for T.l.c. Adult Care Center
9 RIO VISTA DRIVE,, WEST NEWTON, PA, 15089
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
24.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
417% worse than Pennsylvania average
Pennsylvania average: 4.7 deficiencies/yearDeficiencies per year
20
15
10
5
0
Census
Latest occupancy rate
87% occupied
Based on a September 2024 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 26
Capacity: 30
Deficiencies: 10
Date: Sep 19, 2024
Visit Reason
The inspection was conducted as a complaint investigation following an unannounced partial inspection on 09/19/2024.
Complaint Details
The inspection was triggered by a complaint, as stated under Inspection Information on page 2.
Findings
The inspection found multiple deficiencies including missing resident-home contracts, lack of initial and annual resident assessments and support plans, incomplete medical evaluations, medication record discrepancies, and missing preadmission screening assessments. The facility submitted a plan of correction which was accepted and later determined to be fully implemented.
Deficiencies (10)
Resident did not have a resident-home contract completed prior to or within 24 hours of admission.
Resident did not have an initial or annual resident assessment and support plan completed; resident was found in soiled clothing and brief.
Resident did not have an initial documented medical evaluation completed within required timeframe.
Resident did not have an annual documented medical evaluation completed.
Medication Administration Record showed discrepancies between prescribed dose and recorded dose.
Resident did not have a preadmission screening assessment completed within 30 days prior to admission.
Resident did not have an initial assessment completed within 15 days of admission.
Resident did not have an annual assessment completed.
Resident did not have an initial support plan completed within 30 days of admission.
Resident did not have an annual support plan completed or revised within 30 days of annual assessment.
Report Facts
License Capacity: 30
Residents Served: 26
Current Residents in Hospice: 5
Total Daily Staff: 30
Waking Staff: 23
Inspection Report
Renewal
Census: 28
Capacity: 30
Deficiencies: 10
Date: Sep 22, 2023
Visit Reason
The inspection was conducted as a renewal licensing inspection with provisional exit conference on 09/22/2023, including follow-up on previous corrections.
Findings
The facility was found to be in compliance with 55 Pa. Code Chapter 2600 after corrections were made. Several deficiencies were cited related to criminal background checks, staff training, poisonous material storage, refrigerator/freezer temperatures, fire drills, annual medical evaluations, smoking area guidelines, medication administration, and resident record content, all of which had plans of correction accepted and implemented.
Deficiencies (10)
Direct care staff person A had an outdated Pennsylvania Criminal background check completed in 2018.
Direct care staff person B did not receive annual training in Medication Self-Administration and Care for Residents with Dementia and Cognitive Impairments during the 2022 training year.
Direct care staff person B did not receive annual training in Falls and Accident Prevention during the 2022 training year.
Multiple poisonous chemicals were stored on the same shelf with spices and soups in the dry food storage area.
Freezer temperature in the main kitchen refrigerator/freezer was 14°F, above the required 0°F or below.
Fire drill during sleeping hours was not conducted every 6 months; nearly a year elapsed between drills.
Resident #1 did not have an annual medical evaluation completed as required.
Ash can in the front porch smoking area was filled with flammable debris including cigarette butts and empty bottles.
Resident #2 was administered 4 units of insulin instead of the prescribed 3 units according to sliding scale documentation.
Resident #2's record did not include a photograph that is no more than 2 years old.
Report Facts
License Capacity: 30
Residents Served: 28
Total Daily Staff: 33
Waking Staff: 25
Current Residents Hospice: 6
Follow-Up Date: Oct 20, 2023
Freezer Temperature: 14
Fire Drill Date: May 27, 2023
Inspection Report
Renewal
Census: 28
Capacity: 30
Deficiencies: 10
Date: Sep 22, 2023
Visit Reason
The inspection was conducted as a renewal licensing inspection with provisional exit conference on 09/22/2023, including follow-up on previous corrections.
Findings
The facility was found to be in compliance with 55 Pa. Code Chapter 2600 after corrections were made following inspections on 09/22/2023 and 12/21/2023. Several deficiencies were identified related to criminal background checks, staff training, poisonous material storage, refrigerator/freezer temperatures, fire drills, annual medical evaluations, smoking area guidelines, medication administration, and resident record content, all of which had plans of correction accepted and implemented.
Deficiencies (10)
Direct care staff person A had an outdated Pennsylvania Criminal background check completed on 3/9/2018.
Direct care staff person B did not receive annual training in Medication Self-Administration and Care for Residents with Dementia and Cognitive Impairments during the 2022 training year.
Direct care staff person B did not receive annual training in Falls and Accident Prevention during the 2022 training year.
Multiple poisonous chemicals were stored on the same shelf with spices and soups in the dry food storage area in the main kitchen.
The temperature in the freezer compartment of the main kitchen refrigerator/freezer was 14°F, above the required 0°F or below.
The home did not conduct a fire drill during sleeping hours every 6 months; nearly a year elapsed between drills.
Resident #1 did not have an annual medical evaluation completed as required.
The ash can on the front porch smoking area was filled with flammable debris including cigarette butts and empty bottles.
Resident #2 was administered 4 units of insulin instead of the prescribed 3 units based on blood sugar reading; documentation error noted.
Resident #2's record did not include a photograph that is no more than 2 years old.
Report Facts
License Capacity: 30
Residents Served: 28
Total Daily Staff: 33
Waking Staff: 25
Current Residents Hospice: 6
Residents with Mobility Need: 5
Total Daily Staff: 32
Waking Staff: 24
Current Residents Hospice: 2
Residents with Mobility Need: 4
Inspection Report
Plan of Correction
Census: 28
Capacity: 30
Deficiencies: 2
Date: Jun 23, 2023
Visit Reason
The inspection was a partial, unannounced visit conducted due to an incident reported at the facility.
Findings
The report found a repeat violation of resident abuse where a staff member verbally mistreated a resident. Additionally, a direct care staff member was found not to meet qualification requirements. Both staff members were terminated and corrective actions including staff training and resident interviews were implemented.
Deficiencies (2)
A female staff person yelled at resident #1 to 'Get in the fucking shower!' while providing care, constituting verbal abuse.
Direct care staff person A did not have a high school diploma, GED, or active registry status on the Pennsylvania nurse aide registry.
Report Facts
License Capacity: 30
Residents Served: 28
Current Residents in Hospice: 3
Total Daily Staff: 31
Waking Staff: 23
Inspection Report
Complaint Investigation
Census: 28
Capacity: 30
Deficiencies: 11
Date: Jan 26, 2023
Visit Reason
The inspection was conducted as a complaint investigation and incident review following allegations of mistreatment, abuse, and failure to comply with regulations at T.L.C. Adult Care Center.
Complaint Details
The visit was complaint-related due to allegations of mistreatment and abuse of residents, failure to report incidents timely, and other regulatory violations. Several violations were substantiated and repeat in nature.
Findings
Multiple violations were found including resident abuse, failure to report incidents timely, incomplete medical evaluations, medication administration errors, and inadequate staff training. Several violations were repeat offenses and many corrective actions were not implemented by the follow-up date.
Deficiencies (11)
Failure to immediately report suspected abuse of a resident and mistreatment by staff person B.
Failure to report an incident or condition to the Department within 24 hours.
Resident abuse by staff person B including physical and verbal mistreatment.
Staff person C administered CPR despite resident having a do not resuscitate order.
Lack of orientation for direct care staff person C on fire safety and emergency preparedness topics.
Lack of orientation for direct care staff person C on resident rights, emergency medical plan, and abuse reporting.
Direct care staff person C provided unsupervised ADL services without completing required training and competency test.
Resident #2 did not have a completed initial assessment within 15 days of admission.
Resident #2 did not have a written support plan developed and implemented within 30 days of admission.
Medication administration records did not include initials of staff person A who administered medications to multiple residents.
Staff person D administered medications without completing Department-approved medication administration course.
Report Facts
Census at Inspection: 28
Total Capacity: 30
Fine per day: 5
Calculated Fine per day: 140
Mandated Correction Date: 5
Staffing Hours: 32
Waking Staff: 24
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Short | Administrator | Named as home's administrator involved in abuse and incident reporting violations |
| Staff person A | Home's administrator involved in abuse reporting and medication administration violations | |
| Staff person B | Staff terminated for resident abuse | |
| Staff person C | Staff involved in multiple violations including CPR administration, orientation, training, and unsupervised ADL services; no longer employed | |
| Staff person D | Staff who administered medications without completing required training; completed course on 1/20/23 |
Inspection Report
Complaint Investigation
Census: 28
Capacity: 30
Deficiencies: 1
Date: Jan 18, 2023
Visit Reason
The inspection was conducted as a complaint investigation following allegations of mistreatment or abuse of residents and failure to comply with regulations at T.L.C. Adult Care Center.
Complaint Details
The complaint investigation was substantiated by the incident where staff person A obstructed the Department agent's investigation by yelling and refusing to cooperate, resulting in inability to obtain demographic information or complete the investigation.
Findings
Violations of 55 Pa. Code Ch. 2600 were found, including mistreatment or abuse of residents and failure to submit or comply with an acceptable plan of correction. A provisional license was issued and fines were proposed unless violations were corrected within 5 calendar days.
Deficiencies (1)
Staff person A verbally berated and screamed at the Department agent during a complaint investigation, preventing the investigation and access to resident information.
Report Facts
Census at Inspection: 28
Total Capacity: 30
Fines Proposed: 140
Mandated Correction Timeframe: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Short | Owner/Administrator | Named as facility administrator in relation to licensing and inspection |
| Robert Short | Submitted multiple plans of correction and document submissions | |
| Lauren Spagna | Lead Inspector | Conducted the on-site complaint investigation on 01/18/2023 |
| Larry Mazza | Reviewer of plans of correction and document submissions | |
| Staff person A | Involved in violation for verbally abusing Department agent and obstructing investigation |
Inspection Report
Renewal
Deficiencies: 0
Date: Sep 23, 2021
Visit Reason
The inspection was conducted as a licensing inspection by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing.
Findings
No regulatory citations were identified as a result of this inspection.
Notice
Capacity: 30
Deficiencies: 0
Date: Jun 22, 2021
Visit Reason
The document serves as a notification of receipt and approval of the March 18, 2021 renewal application to operate the Personal Care Home and informs that an onsite inspection will be conducted within the next twelve months as required by regulation.
Findings
No inspection findings are reported in this document; it is a license issuance letter confirming the renewal of the facility's license.
Report Facts
Maximum capacity: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary | Signed the license renewal notification letter. |
| Stephanie R. Short | Owner/Administrator/ RN/CEO | Recipient of the license renewal notification. |
Inspection Report
Complaint Investigation
Census: 26
Capacity: 30
Deficiencies: 11
Date: Apr 23, 2021
Visit Reason
The inspection was a complaint investigation conducted due to concerns about staffing, resident care, and compliance with regulations.
Complaint Details
The visit was triggered by a complaint regarding inadequate staffing and resident care concerns, including residents being left unattended after falls and medication administration issues.
Findings
The inspection found multiple deficiencies including inadequate staffing leading to residents being left unattended after falls, failure to complete required medical evaluations, medication administration issues, lack of accessible resident support plans, and failure to follow prescriber's orders for comfort care medication.
Deficiencies (11)
Staffing was inadequate to safely meet supervision needs; residents were left unattended on the floor after falls.
Resident #1 had no medical evaluation completed within required timeframe.
Resident #5 was not assessed for ability to self-administer medications.
Medications were removed from original containers more than 2 hours in advance and stored improperly.
Medication administration records (MAR) were not available or complete for April 2021.
The home did not follow prescriber's orders to administer comfort care medications to resident #1.
Direct care staff persons A and C administered medications without completing required Department-approved medication administration course.
Resident #12's support plan did not adequately address supervision needs; resident was found wandering and opening exit doors.
Resident support plans were not accessible to direct care staff at all times.
Bedroom #8 had only one chair for two residents.
No operable lamp or source of lighting at bedside for residents #2 and #4.
Report Facts
Residents served: 26
Licensed capacity: 30
Residents with mobility needs: 6
Residents needing 2-person assist: 2
Residents on hospice: 3
Medication deficiencies: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jon Kimberland | Lead Reviewer | Signed the letter confirming plan of correction implementation |
| Staff person A | Direct care staff who was alone during incidents and administered medications without required training | |
| Staff person B | Administrator involved in communication about resident care and medication administration | |
| Staff person C | Direct care staff who assisted with resident care and administered medications without required training | |
| Staff person E | Direct care staff who improperly handled resident transfer and medication administration | |
| Staff person F | Direct care staff who refused to administer prescribed morphine until hospice nurse approval |
Inspection Report
Follow-Up
Census: 23
Capacity: 30
Deficiencies: 18
Date: Feb 17, 2021
Visit Reason
The inspection was a follow-up review conducted on 02/17/2021 and 02/18/2021 to verify that the submitted plan of correction was fully implemented following prior citations.
Findings
The facility was found to have implemented the plan of correction fully, addressing deficiencies related to privacy locks, criminal background checks, staff qualifications, first aid/CPR training, fire safety orientation, hot water temperature, mirrors in bedrooms, emergency water supply, unobstructed egress, medical evaluations, medication administration, resident assessments, and support plans. Continued compliance is required.
Deficiencies (18)
No carbon monoxide detector was present in the home in accordance with The Care Facility Carbon Monoxide Alarms Standards Act.
Shared resident bathrooms did not have locks on the doors to provide privacy during bathing, dressing, changing and toilet.
Staff person A did not have a criminal history check completed and provided unsupervised direct care.
Direct care staff person A did not have a high school diploma, GED diploma, or active registry status on the Pennsylvania nurse aide registry.
No staff certified in first aid and obstructive airway techniques and CPR were present during certain shifts.
Staff person A and staff person D did not receive training in fire safety and emergency preparedness orientation topics.
Staff person A and staff person D did not receive orientation training within 40 scheduled working hours.
Direct care staff person A did not complete the Department-approved direct care training course and competency test before providing unsupervised ADL services.
Hot water temperature at the sink in a resident's bathroom measured 130.8 degrees Fahrenheit, exceeding the 120°F limit.
No mirror in multiple bedrooms including bay window bedroom, bedroom [redacted], and bedroom next to main entrance.
The home stores no emergency drinking water on-site and relies on a contract that delivers water within 24 to 48 hours.
The only pathway to the fire exit door was blocked by furniture, allowing an opening of only 3 feet, insufficient for wheelchairs and walkers.
Resident #1's most recent medical evaluation was completed on 7/16/19 with no documentation of primary care physician's determination for subsequent review; Resident #2's medical evaluation was incomplete.
Resident #2 was not administered prescribed medication but staff signed the medication administration record as administered.
Resident #2 did not have a written initial assessment completed within 15 days of admission.
Resident #1 and #3 had outdated assessments and support plans.
Resident #2 did not have a support plan completed within 30 days of admission.
Resident #1 and #3 had outdated support plans for medical, dental, vision, hearing, mental health or other behavioral care services.
Report Facts
License Capacity: 30
Residents Served: 23
Total Daily Staff: 27
Waking Staff: 20
Hot Water Temperature: 130.8
Emergency Drinking Water Required: 69
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