Inspection Report
Census: 72
Capacity: 210
Deficiencies: 0
Apr 14, 2025
Visit Reason
The inspection was conducted as a licensing inspection triggered by an incident.
Findings
No regulatory citations or deficiencies were identified during this inspection.
Report Facts
Total Daily Staff: 123
Waking Staff: 92
License Capacity: 210
Residents Served: 72
Special Care Unit Capacity: 29
Special Care Unit Residents Served: 29
Hospice Current Residents: 11
Residents Diagnosed with Mental Illness: 2
Residents Diagnosed with Intellectual Disability: 0
Residents Receiving Supplemental Security Income: 0
Residents Aged 60 or Older: 72
Residents with Mobility Need: 51
Residents with Physical Disability: 1
Inspection Report
Follow-Up
Census: 83
Capacity: 210
Deficiencies: 4
Mar 24, 2025
Visit Reason
The inspection was conducted as a follow-up to verify the implementation of a previously submitted plan of correction related to a complaint and incident at the facility.
Findings
The facility was found to have deficiencies including improperly labeled poisonous materials, unsanitary bathroom conditions, incomplete or outdated resident assessments, and missing preadmission cognitive screenings for the special care unit. Corrective actions were accepted and implemented with ongoing monitoring planned.
Complaint Details
The visit was complaint-related as indicated by the inspection information section stating the reason as 'Complaint, Incident'.
Deficiencies (4)
| Description |
|---|
| Poisonous materials were not stored in their original, labeled containers; spray bottles with handwritten labels were found unlabeled. |
| Sanitary conditions were not maintained; feces and stains were found on toilets in resident and public bathrooms. |
| Resident assessments were outdated or inaccurate, missing documentation of agitation, aggression, falls, and physical assistance needs. |
| A preadmission cognitive screening was not completed for a resident admitted to the special care unit for Alzheimer's disease or dementia. |
Report Facts
License Capacity: 210
Residents Served: 83
Special Care Unit Capacity: 71
Special Care Unit Residents Served: 34
Current Hospice Residents: 11
Resident Diagnosed with Mental Illness: 2
Residents with Mobility Need: 49
Residents Age 60 or Older: 83
Residents with Physical Disability: 2
Inspection Report
Complaint Investigation
Census: 35
Capacity: 36
Deficiencies: 1
Feb 19, 2025
Visit Reason
The inspection was conducted as a complaint investigation following an allegation of neglect of care needs involving a resident.
Findings
The facility failed to submit an incident report to the Department after protective services investigated the allegation. The plan of correction was accepted and implemented to ensure timely reporting of such incidents in the future.
Complaint Details
The visit was complaint-related due to an allegation of neglect of care needs involving a resident. The complaint was substantiated by the finding that the facility failed to report the incident as required.
Deficiencies (1)
| Description |
|---|
| The home did not submit an incident report to the Department following an investigation by protective services regarding neglect of care needs involving a resident. |
Report Facts
License Capacity: 36
Residents Served: 35
Current Residents in Hospice: 8
Resident Support Staff: 35
Total Daily Staff: 105
Waking Staff: 79
Inspection Report
Complaint Investigation
Census: 120
Capacity: 210
Deficiencies: 0
Feb 3, 2025
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, but no deficiencies or citations were found, indicating no substantiated issues.
Report Facts
Residents Served: 120
License Capacity: 210
Memory Care Unit Capacity: 71
Memory Care Residents Served: 42
Current Hospice Residents: 20
Residents Age 60 or Older: 120
Residents Diagnosed with Mental Illness: 2
Residents with Mobility Need: 52
Residents with Physical Disability: 1
Total Daily Staff: 172
Waking Staff: 129
Inspection Report
Renewal
Census: 96
Capacity: 210
Deficiencies: 7
Jun 17, 2024
Visit Reason
The inspection was conducted as a renewal and complaint investigation with unannounced full notice visits on 06/17/2024, 06/18/2024, and 06/27/2024 to assess compliance and follow-up on submitted plans of correction.
Findings
The facility was found to have multiple deficiencies including expired boiler certificates, sanitary condition issues in the memory care kitchenette and common areas, furniture and equipment in disrepair, lack of soap dispensers in resident bathrooms, and medication record discrepancies. Plans of correction were accepted and fully implemented by 08/20/2024.
Complaint Details
The inspection included a complaint investigation component. Specific complaint details are not explicitly stated, but deficiencies related to medication administration and sanitary conditions were addressed. Substantiation status is not provided.
Deficiencies (7)
| Description |
|---|
| Six boiler certificates expired on 6/1/2023 and were not reinspected until 6/24/2024. |
| Microwave in memory care kitchenette had food crumbs, splatter, and dried spills; no paper towels in common powder room next to nurses station. |
| Toilet in first stall of first floor common women's restroom had mold around caulking and was leaking; broken toilet seat hinge in second stall. |
| No soap within reach of bathroom sink in living unit #303. |
| Resident #2's Dexcom G6 continuous glucose monitor was not set up to store readings; staff and healthcare providers lacked access to historical data. |
| Medication record discrepancies for Resident #4 and Resident #1 with incorrect medication labels and administration details. |
| Resident #2 prescribed Humalog insulin with sliding scale; on 6/11/2024, 9 units required but only 5 units administered. |
Report Facts
License Capacity: 210
Residents Served: 96
Memory Care Capacity: 74
Memory Care Residents Served: 37
Hospice Residents: 16
Residents with Mobility Need: 50
Residents Diagnosed with Mental Illness: 2
Residents Diagnosed with Intellectual Disability: 3
Residents with Physical Disability: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Business Office Director | Involved in scheduling boiler inspection and plan of correction. | |
| Environmental Services Director | Responsible for boiler inspection scheduling, sanitary condition corrections, maintenance oversight, and audits. | |
| Executive Director | In-serviced staff on various corrective actions and compliance. | |
| Resident Services Director | In-serviced staff, monitored medication administration, and coordinated corrections related to resident care and medication. | |
| Food Services Director | Cleaned and sanitized kitchen equipment and monitored sanitary conditions. | |
| LPN Supervisor | Scheduled to retrain medication staff on medication administration. |
Inspection Report
Follow-Up
Census: 96
Capacity: 210
Deficiencies: 1
Apr 2, 2024
Visit Reason
The inspection visit on 04/02/2024 was a complaint-related partial inspection to review the submitted plan of correction and verify compliance.
Findings
The submitted plan of correction was determined to be fully implemented. The deficiency involved failure to provide total physical assistance with transfers as required by the resident's support plan, which required two-person assistance. Staff were in-serviced and procedures updated to ensure compliance.
Complaint Details
The visit was complaint-related and involved a substantiated deficiency regarding inadequate assistance with transfers for a resident requiring two-person physical assistance.
Deficiencies (1)
| Description |
|---|
| Resident was regularly transferred without the required two-person assistance as indicated in the resident's support plan. |
Report Facts
License Capacity: 210
Residents Served: 96
Memory Care Capacity: 71
Memory Care Residents Served: 40
Hospice Residents: 15
Residents with Mental Illness: 3
Residents with Mobility Need: 50
Residents with Physical Disability: 3
Inspection Report
Complaint Investigation
Census: 93
Capacity: 210
Deficiencies: 1
Jul 10, 2023
Visit Reason
The inspection was conducted as a complaint investigation and incident review related to abuse/neglect involving two residents at the facility.
Findings
The investigation found that resident #1 physically abused resident #2 by pulling and dragging them across the bedroom floor, resulting in multiple injuries to resident #2. The facility implemented a plan of correction including immediate notification of families and authorities, one-on-one supervision, medical and psychological assessments, staff education, and ongoing monitoring.
Complaint Details
The complaint investigation was substantiated with findings of abuse/neglect. Resident #2 was injured and hospitalized. Mandatory abuse reports were filed with OAPS, AAA, and the department. The facility took corrective actions including supervision and psychological consultation.
Deficiencies (1)
| Description |
|---|
| Resident #1 physically abused resident #2 causing multiple injuries including skin tears and contusions. |
Report Facts
License Capacity: 210
Residents Served: 93
Special Care Unit Capacity: 71
Special Care Unit Residents Served: 37
Hospice Current Residents: 15
Residents Diagnosed with Mental Illness: 2
Residents with Mobility Need: 49
Residents 60 Years or Older: 93
Residents with Physical Disability: 1
Inspection Report
Complaint Investigation
Census: 99
Capacity: 210
Deficiencies: 7
Apr 4, 2023
Visit Reason
The inspection was conducted as a complaint investigation with an unannounced partial inspection type.
Findings
Multiple deficiencies were identified including unsecured poisonous materials, tripping hazards, lack of hot and cold water in a resident's unit, absence of refrigerator thermometers, outdated food, and medication record errors. Plans of correction were accepted and implemented by early June 2023.
Complaint Details
The inspection was triggered by a complaint as noted in the inspection information section.
Deficiencies (7)
| Description |
|---|
| Poisonous materials were not kept locked and inaccessible to residents, specifically acetone nail polish remover found unsecured near room #101. |
| A long, red and black extension cord was coiled on the floor near nurse's station posing a tripping hazard. |
| Water to the kitchenette sink and bathroom sink in room #315 was turned off, preventing resident #1 from accessing water. |
| No thermometer was present in the small refrigerator in the nurse’s station near room #239. |
| Two undated chocolate Wendy’s Frosty treats were found in the freezer section of the refrigerator/freezer in the third-floor Special Care Unit dining area. |
| Medication record for resident #3 incorrectly indicated 'Give 2 capsules by mouth as needed for diarrhea' instead of the correct dosing instructions. |
| Medications for resident #2 were administered outside the parameters of one hour before and one hour after the scheduled administration time. |
Report Facts
License Capacity: 210
Residents Served: 99
Special Care Unit Capacity: 71
Special Care Unit Residents Served: 38
Hospice Current Residents: 18
Residents Diagnosed with Mental Illness: 2
Residents with Mobility Need: 38
Residents 60 Years or Older: 99
Residents Diagnosed with Intellectual Disability: 0
Residents with Physical Disability: 2
Total Daily Staff: 137
Waking Staff: 103
Inspection Report
Renewal
Census: 87
Capacity: 210
Deficiencies: 6
Nov 7, 2022
Visit Reason
The inspection was conducted as a renewal and complaint investigation of the facility to review compliance with licensing regulations and verify the implementation of a submitted plan of correction.
Findings
Multiple deficiencies were identified including unsecured poisonous materials, uncovered trash cans, lack of operable bedside lamps, expired fire extinguisher inspection tags, unlabeled over-the-counter medications, and incomplete medication administration records. Plans of correction were accepted and implemented by mid-December 2022.
Complaint Details
The inspection included a complaint investigation as indicated by the reason for visit. The submitted plan of correction was fully implemented and compliance was maintained.
Deficiencies (6)
| Description |
|---|
| Upper cabinet in kitchenette was unlocked and accessible containing poisonous materials such as dish liquid, wood polish, and fabric care kit. |
| Small uncovered waste can in private bathroom was full and contained soiled brief and paper products. |
| No operable lamp or lighting source at bedside of residents #1 and #5. |
| Multiple fire extinguishers throughout the home had expired inspection tags dated August 2021. |
| Unlabeled and unsecured over-the-counter medications accessible to residents in kitchenette and private bathrooms. |
| Resident #7's medication administration record lacked an area to record sliding scale insulin units administered. |
Report Facts
License Capacity: 210
Residents Served: 87
Special Care Unit Capacity: 71
Special Care Unit Residents Served: 37
Hospice Current Residents: 13
Residents Age 60 or Older: 87
Residents Diagnosed with Mental Illness: 2
Residents with Mobility Need: 46
Residents with Physical Disability: 2
Total Daily Staff: 133
Waking Staff: 100
Inspection Report
Follow-Up
Census: 85
Capacity: 210
Deficiencies: 5
Oct 7, 2022
Visit Reason
The inspection visit was conducted as a complaint investigation with follow-up to verify the implementation of the submitted plan of correction.
Findings
The submitted plan of correction was determined to be fully implemented, with continued compliance required. Specific deficiencies related to assistance with ADLs, follow prescriber’s orders, and assessment updates were addressed with documented corrective actions.
Complaint Details
The visit was complaint-related, with substantiation implied by the deficiencies cited and follow-up actions required. The plan of correction was submitted and accepted, with implementation dates noted.
Deficiencies (5)
| Description |
|---|
| Resident #1 requires prompting/cueing assistance with personal hygiene and assistance with showering; support plan and shower schedule were not fully followed. |
| Resident #1 was not administered prescribed lantus solostar medication due to unavailability in the residence. |
| Resident #2 was prescribed multiple medications that were not administered due to unavailability in the residence. |
| Resident #3 requires physical assistance with showering; initial assessment and ASP updates were incomplete. |
| Resident #1’s most recent assessment due to significant change indicates need for prompting/cueing assistance with personal hygiene and physical assistance with showering; quarterly assessments and audits were incomplete. |
Report Facts
License Capacity: 210
Residents Served: 85
Staffing Hours - Total Daily Staff: 133
Staffing Hours - Waking Staff: 100
Special Care Unit Capacity: 71
Special Care Unit Residents Served: 38
Hospice Current Residents: 14
Residents Age 60 or Older: 85
Residents with Mental Illness: 2
Residents with Physical Disability: 2
Residents with Mobility Need: 48
Inspection Report
Complaint Investigation
Census: 80
Capacity: 210
Deficiencies: 3
Sep 28, 2022
Visit Reason
The inspection was conducted as a complaint investigation with an unannounced partial inspection on 09/28/2022 and 09/29/2022 to review compliance and follow-up on submitted plans of correction.
Findings
The report found significant deficiencies related to resident care, including failure to update resident assessments and support plans to address changes in health, cognitive decline, and safety risks such as falls and agitation. Multiple unwitnessed falls and behavioral issues were documented, with plans of correction submitted and accepted.
Complaint Details
The visit was complaint-related with substantiation implied by findings of unmet resident care needs, multiple unwitnessed falls, combative and aggressive behaviors, and failure to update assessments and support plans accordingly.
Deficiencies (3)
| Description |
|---|
| Resident #1's assessment was not updated to identify needs for verbal cueing/prompting for meals and use of a sippy cup. |
| Resident #1's support plan was not updated to address decline in health, cognitive functioning, and increased supervision needs. |
| Resident #2's support plan was not updated to address decline in health and cognitive functioning, extensive supervision needs, and multiple documented falls. |
Report Facts
License Capacity: 210
Residents Served: 80
Special Care Unit Capacity: 71
Special Care Unit Residents Served: 36
Hospice Current Residents: 15
Residents Age 60 or Older: 80
Residents Diagnosed with Mental Illness: 2
Residents with Mobility Need: 46
Residents with Physical Disability: 2
Inspection Report
Complaint Investigation
Census: 79
Capacity: 104
Deficiencies: 2
Jul 18, 2022
Visit Reason
The inspection was conducted as a complaint investigation following a complaint received by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing.
Findings
Two deficiencies were identified: improper medication storage where a loose Tylenol caplet was found on the floor in the secured dementia unit, and failure to follow prescriber’s orders resulting in administration of discontinued medications to a resident. Plans of correction were accepted and fully implemented.
Complaint Details
The visit was complaint-related. The complaint involved medication storage and administration issues. The submitted plan of correction was fully implemented and compliance was maintained.
Deficiencies (2)
| Description |
|---|
| Improper storage of medication with a loose Tylenol caplet found on the floor in the secured care dementia unit. |
| Failure to follow prescriber’s orders resulting in administration of discontinued medications to Resident #1. |
Report Facts
License Capacity: 104
Residents Served: 79
Special Care Unit Capacity: 71
Special Care Unit Residents Served: 35
Hospice Residents: 15
Resident with Mobility Need: 45
Resident 60 Years or Older: 79
Resident Diagnosed with Mental Illness: 1
Resident with Physical Disability: 1
Total Daily Staff: 124
Waking Staff: 93
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jon Kimberland | Signed the letter confirming plan of correction implementation. |
Inspection Report
Complaint Investigation
Census: 75
Capacity: 104
Deficiencies: 1
Apr 14, 2022
Visit Reason
The inspection was an unannounced interim inspection triggered by a complaint, provisional, and interim reasons, conducted on April 14 and 15, 2022.
Findings
A violation was found regarding confidentiality of resident records when a 24-hour report binder containing sensitive resident information was left unlocked and unattended at the nurses station. The facility was directed to remove the binder and implement ongoing HIPAA compliance training and audits.
Complaint Details
The inspection was complaint-related, with the reason stated as Complaint, Provisional, Interim. The violation was a repeat violation from previous dates 5/28/2021 and 11/9/2020.
Deficiencies (1)
| Description |
|---|
| A 24-hour report binder containing confidential resident information was unlocked and unattended at the 1st floor nurses station, violating record confidentiality requirements. |
Report Facts
License Capacity: 104
Residents Served: 75
Special Care Unit Capacity: 71
Special Care Unit Residents Served: 31
Hospice Residents: 15
Residents with Mobility Need: 40
Residents 60 Years or Older: 75
Residents Diagnosed with Mental Illness: 1
Residents with Physical Disability: 1
Inspection Report
Follow-Up
Census: 74
Capacity: 104
Deficiencies: 2
Dec 29, 2021
Visit Reason
The inspection was a partial, unannounced follow-up visit conducted on 12/29/2021 to review the submitted plan of correction related to allegations of resident abuse.
Findings
The facility failed to immediately suspend or place on a plan of supervision two staff members involved in alleged physical abuse incidents reported by a resident. Additionally, the facility did not submit required notices of suspension or plans of supervision to the Department for these staff members. The submitted plan of correction was determined to be fully implemented.
Deficiencies (2)
| Description |
|---|
| Failure to immediately suspend or place on a plan of supervision staff members involved in alleged resident abuse incidents. |
| Failure to submit notice of suspension or plan of supervision for staff members involved in alleged resident abuse to the Department. |
Report Facts
License Capacity: 104
Residents Served: 74
Special Care Unit Capacity: 71
Special Care Unit Residents Served: 30
Hospice Residents: 13
Residents with Mobility Need: 44
Residents with Physical Disability: 1
Staff Total Daily: 118
Staff Waking: 89
Inspection Report
Renewal
Census: 73
Capacity: 104
Deficiencies: 16
Dec 21, 2021
Visit Reason
The inspection was conducted as a renewal inspection with complaint and provisional reasons, including unannounced full inspections on December 21 and 22, 2021.
Findings
The facility was found to be in compliance with the Assisted Living Residence regulations overall, but multiple deficiencies were cited including failure to post current license conspicuously, confidentiality breaches, incomplete criminal background checks for staff, incomplete direct care training, unlocked poisonous materials accessible to residents, missing emergency telephone numbers, missing window screens, incomplete first aid kit, improper refrigerator/freezer temperatures, insufficient emergency water supply, incomplete medical evaluations, medication storage issues, inconsistent documentation of self-administered medications, missing resident consent for special care unit admission, missing directions for key-locking devices, and use of outdated standardized forms.
Deficiencies (16)
| Description |
|---|
| Current license was not posted in a conspicuous and public place in the residence. |
| Resident privacy coding document containing names was attached to licensing inspection summary and posted publicly. |
| Pennsylvania criminal background checks not completed for several staff persons. |
| Direct care staff person had not completed required Department-approved direct care training and competency test. |
| Box of Polident denture tablets was unlocked and accessible to residents not assessed capable of safely using poisons. |
| Emergency telephone numbers were not posted by telephones in several resident rooms. |
| No screens present on numerous operable windows in resident bedrooms. |
| First aid kit did not include a breathing shield. |
| Walk-in kitchen freezer temperature was above required level (4-5°F instead of ≤0°F). |
| Emergency drinking water supply was insufficient for a 3-day supply based on resident census. |
| Resident medical evaluation did not include assessment of ability to self-administer medications. |
| Medication prescribed to resident was not available in the residence. |
| Resident's assessment and support plan incorrectly documented ability to self-administer medication. |
| No documentation that resident and designated person agreed to admission to special care unit. |
| Directions for operation of key-locking devices were not posted at emergency exit doors in special care units. |
| Resident's assessment and support plan was not completed on the Department’s current standardized form. |
Report Facts
License Capacity: 104
Residents Served: 73
Resident Support Staff: 14
Total Daily Staff: 130
Waking Staff: 98
Residents in Special Care Unit: 30
Hospice Residents: 13
Residents 60 Years or Older: 73
Residents with Mobility Need: 43
Residents with Mental Illness: 1
Residents with Physical Disability: 1
Emergency Drinking Water Required: 219
Emergency Drinking Water Available: 176
Inspection Report
Complaint Investigation
Census: 40
Capacity: 104
Deficiencies: 3
Aug 30, 2021
Visit Reason
The inspection was a partial, unannounced visit conducted due to a complaint and fine.
Findings
The inspection found multiple deficiencies including an unsigned resident contract, unlabeled and undated leftover food items in refrigerators, and improperly stored food in unsealed containers. Plans of correction were accepted and implemented.
Complaint Details
Inspection was complaint-related and included a fine. The plan of correction was submitted and fully implemented.
Deficiencies (3)
| Description |
|---|
| Resident #1’s contract was not signed by the resident. |
| Unlabeled and undated leftover food items found in refrigerators in memory care units. |
| Food stored in unsealed containers in the walk-in freezer, repeat violation. |
Report Facts
License Capacity: 104
Residents Served: 40
Memory Care Capacity: 71
Memory Care Residents Served: 33
Current Hospice Residents: 3
Residents 60 Years or Older: 72
Residents with Mobility Need: 37
Total Daily Staff: 77
Waking Staff: 58
Inspection Report
Complaint Investigation
Census: 66
Capacity: 104
Deficiencies: 0
Mar 30, 2021
Visit Reason
The inspection was conducted as a complaint investigation during an unannounced visit on 03/30/2021.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Complaint Details
The inspection was complaint-driven; however, no deficiencies or citations were found, indicating no substantiated issues.
Report Facts
Residents Served: 66
License Capacity: 104
Special Care Unit Capacity: 47
Special Care Unit Residents Served: 40
Hospice Current Residents: 3
Residents Age 60 or Older: 66
Residents with Mobility Need: 40
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