Inspection Report
Renewal
Census: 33
Capacity: 47
Deficiencies: 6
Apr 16, 2025
Visit Reason
The inspection was conducted as a renewal and complaint investigation visit to assess compliance with licensing regulations and verify correction of previous deficiencies.
Findings
The facility was found to have multiple deficiencies related to staff training, trash receptacle maintenance, and food supply. All cited deficiencies had accepted plans of correction that were fully implemented by the follow-up date.
Complaint Details
The inspection included a complaint investigation component; however, the submitted plan of correction was fully implemented and compliance was maintained.
Deficiencies (6)
| Description |
|---|
| Direct care staff member did not receive the required 12 hours of annual training relating to job duties. |
| Direct care staff member did not receive training about residents with intellectual disabilities during the training year. |
| Direct care staff member did not receive training on The Older Adult Protective Services Act in the training year. |
| The lid of the kitchen garbage can was cracked and broken, allowing potential penetration of insects and rodents. |
| The lids of the outside dumpster were open with approximately 2 feet of garbage inside, not preventing penetration of insects and rodents. |
| The home did not have a three-day supply of nonperishable food and drinking water for residents. |
Report Facts
License Capacity: 47
Residents Served: 33
Current Hospice Residents: 3
Residents with Mental Illness: 4
Residents with Intellectual Disability: 3
Residents with Mobility Need: 15
Residents with Physical Disability: 1
Total Daily Staff: 48
Waking Staff: 36
Inspection Report
Complaint Investigation
Census: 31
Capacity: 47
Deficiencies: 4
Feb 3, 2025
Visit Reason
The inspection was conducted as a complaint investigation following a complaint regarding the care, treatment, and potential abuse of a resident.
Findings
The facility was found to have multiple deficiencies including failure to report an incident to the Department, failure to provide required assistance with activities of daily living, delayed medication administration, and incomplete initial support plans. The submitted plan of correction was accepted and fully implemented by March 14, 2025.
Complaint Details
The complaint involved an investigation by Adult Protective Services into the care, treatment, and potential abuse of a resident. The facility failed to notify the department as required.
Deficiencies (4)
| Description |
|---|
| Failure to report an incident or condition to the Department’s personal care home regional office or complaint hotline within 24 hours as required. |
| Failure to provide assistance with activities of daily living as indicated in the resident’s assessment and support plan, specifically reminding/queuing to maintain adequate intake. |
| Failure to follow the directions of the prescriber regarding timely medication administration; medication was administered late. |
| Initial support plan did not include a plan to meet the assessed personal care need of eating requiring some physical assistance and reminding/queuing. |
Report Facts
License Capacity: 47
Residents Served: 31
Current Hospice Residents: 2
Residents Age 60 or Older: 31
Residents Diagnosed with Mental Illness: 4
Residents Diagnosed with Intellectual Disability: 2
Residents with Mobility Need: 14
Resident Medication Delay: 7
Inspection Report
Complaint Investigation
Census: 32
Capacity: 47
Deficiencies: 4
Jan 24, 2025
Visit Reason
The inspection was conducted as a complaint investigation to review compliance issues at THE ADDISON OF GARDEN WAY PLACE.
Findings
The inspection identified multiple deficiencies including unauthorized video monitoring signage, incomplete medication administration records, failure to follow prescriber's orders, and failure to provide required 30-day discharge notices.
Complaint Details
The visit was complaint-related as indicated by the inspection reason. The complaint involved issues with privacy, medication administration, and discharge procedures.
Deficiencies (4)
| Description |
|---|
| Family of resident installed cameras in the resident's private room without proper signage. |
| Medication administration records did not indicate prescribed medications for certain residents. |
| The home failed to follow prescriber's orders for medication administration for multiple residents. |
| The home did not provide a 30-day advance written notice for discharge or transfer to a resident and their designated person. |
Report Facts
Residents Served: 32
License Capacity: 47
Current Hospice Residents: 2
Total Daily Staff: 46
Waking Staff: 35
Inspection Report
Complaint Investigation
Census: 32
Capacity: 47
Deficiencies: 0
Jan 7, 2025
Visit Reason
The inspection was conducted as a complaint investigation with an unannounced partial inspection on 01/07/2025.
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: 32
License Capacity: 47
Current Hospice Residents: 2
Resident Support Staff: 0
Total Daily Staff: 47
Waking Staff: 35
Residents Age 60 or Older: 32
Residents Diagnosed with Mental Illness: 2
Residents Diagnosed with Intellectual Disability: 2
Residents with Mobility Need: 15
Residents with Physical Disability: 0
Inspection Report
Plan of Correction
Census: 30
Capacity: 47
Deficiencies: 1
Nov 12, 2024
Visit Reason
The inspection was a partial, unannounced monitoring visit conducted on 11/12/2024 to review the facility's compliance and plan of correction implementation.
Findings
The submitted plan of correction was determined to be fully implemented. One specific deficiency involved the presence of an unsealed bag of frozen hamburger patties that appeared freezer burned, which was addressed by discarding the food and providing staff training on food storage and labeling.
Deficiencies (1)
| Description |
|---|
| Unsealed bag of frozen hamburger patties in freezer with approximately 25 patties that appeared freezer burned. |
Report Facts
License Capacity: 47
Residents Served: 30
Current Residents in Hospice: 4
Residents Age 60 or Older: 30
Residents with Mental Illness: 2
Residents with Intellectual Disability: 2
Residents with Mobility Need: 12
Residents with Physical Disability: 1
Inspection Report
Follow-Up
Census: 31
Capacity: 47
Deficiencies: 7
Aug 16, 2024
Visit Reason
The inspection visit on 08/16/2024 was conducted as a follow-up to verify that the submitted plan of correction was fully implemented.
Findings
The facility was found to have implemented the plan of correction fully, addressing previous deficiencies related to resident personal equipment, sanitary conditions, surfaces, outdated food, first aid kit contents, resident assessments, and support plan content.
Deficiencies (7)
| Description |
|---|
| The enabler bar attached to resident bed was uncovered, posing a potential entrapment hazard. |
| Residents shared glucometers, risking sanitary conditions. |
| Multiple sections of concrete are missing from the expansion joint at the building entrance, posing a trip/fall hazard. |
| An open but undated bag of frozen hamburger patties was found in the home's meat freezer. |
| The first aid kit in the home's van used to transport residents did not include adhesive tape. |
| Resident assessment was undated and not on the Department's Assessment Form for Personal Care Homes. |
| The home's support plan for a resident did not include information about the need for an enabler bar. |
Report Facts
Residents Served: 31
License Capacity: 47
Current Residents in Hospice: 4
Residents Age 60 or Older: 31
Residents with Mental Illness: 2
Residents with Intellectual Disability: 2
Residents with Mobility Need: 15
Inspection Report
Re-Inspection
Census: 29
Capacity: 47
Deficiencies: 0
Apr 19, 2024
Visit Reason
The inspection was conducted due to a change in legal entity operating the facility, which is a newly licensed personal care home requiring a re-inspection within 3 months of license effective date.
Findings
The facility was found to be in substantial compliance with applicable regulations during the partial inspection. The licensing inspector was unable to complete a full inspection because this is a new legal entity operating the home. No deficiencies were found.
Report Facts
Total Daily Staff: 42
Waking Staff: 32
Residents Served: 29
License Capacity: 47
Current Hospice Residents: 4
Residents 60 Years or Older: 29
Residents Diagnosed with Intellectual Disability: 2
Residents with Mobility Need: 13
Residents with Physical Disability: 1
Inspection Report
Re-Inspection
Census: 29
Capacity: 47
Deficiencies: 0
Apr 19, 2024
Visit Reason
The inspection was conducted due to a change in legal entity and as a re-inspection of the newly licensed facility within 3 months of the license effective date.
Findings
The facility was found to be in substantial compliance with applicable regulations, with no deficiencies found during this partial inspection.
Report Facts
Residents Served: 29
License Capacity: 47
Current Residents in Hospice: 4
Total Daily Staff: 42
Waking Staff: 32
Residents 60 Years or Older: 29
Residents Diagnosed with Intellectual Disability: 2
Residents with Mobility Need: 13
Residents with Physical Disability: 1
Inspection Report
Complaint Investigation
Census: 26
Capacity: 47
Deficiencies: 4
Jul 13, 2023
Visit Reason
The inspection was conducted as a complaint and incident investigation following allegations of resident abuse and related concerns.
Findings
The investigation found that staff failed to immediately report suspected resident abuse, did not implement a plan of supervision or suspend involved staff promptly, and did not consistently follow the resident's assistance plan for transfers. Additionally, staff were observed shouting at a resident during transfer, violating dignity and respect requirements.
Complaint Details
The visit was complaint-related, investigating allegations of resident abuse involving staff shouting at a resident during transfer and failure to report and supervise staff appropriately. The complaint was substantiated based on observations and interviews.
Deficiencies (4)
| Description |
|---|
| Failure to immediately report suspected abuse of a resident to the local Area Agency on Aging. |
| Failure to immediately develop and implement a plan of supervision or suspend staff involved in alleged abuse. |
| Failure to provide assistance with transfers as indicated in the resident’s assessment and support plan, including use of two staff and a gait belt. |
| Failure to treat a resident with dignity and respect, evidenced by staff shouting directives at the resident during transfer. |
Report Facts
License Capacity: 47
Residents Served: 26
Current Residents in Hospice: 1
Residents 60 Years or Older: 26
Residents Diagnosed with Mental Illness: 2
Residents with Mobility Need: 16
Total Daily Staff: 42
Waking Staff: 32
Inspection Report
Census: 23
Capacity: 47
Deficiencies: 0
Nov 3, 2022
Visit Reason
The inspection was a partial, unannounced licensing inspection conducted due to an incident at the facility.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Resident census: 23
Total licensed capacity: 47
Total daily staff: 36
Waking staff: 27
Residents age 60 or older: 23
Residents diagnosed with mental illness: 2
Residents diagnosed with intellectual disability: 1
Residents with mobility need: 13
Inspection Report
Renewal
Census: 26
Capacity: 47
Deficiencies: 6
Oct 5, 2022
Visit Reason
The inspection was conducted as a renewal review of the facility's license by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing on 10/05/2022 and 10/06/2022.
Findings
The facility was found to have multiple deficiencies including issues with telephone access privacy, window screens, furnace inspection, presence of portable space heaters, fire extinguisher inspections, and medication management. Plans of correction were accepted and implemented to address all deficiencies.
Deficiencies (6)
| Description |
|---|
| The resident telephone at the front desk is not cordless and does not permit residents to make calls in privacy. |
| There is no screen in the living room window in a resident room. |
| The last inspection of the furnace was conducted on 10/23/20, not within the required annual timeframe. |
| A portable space heater was found plugged in and sitting on the floor of the maintenance room, which is prohibited. |
| All 16 fire extinguishers had not been inspected by a fire safety expert since September 2021. |
| A discontinued medication was found in the medication cart for resident #1. |
Report Facts
License Capacity: 47
Residents Served: 26
Total Fire Extinguishers: 16
Inspection Report
Complaint Investigation
Census: 24
Capacity: 47
Deficiencies: 0
Jun 22, 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, but no deficiencies were found and the complaint was not substantiated.
Report Facts
License Capacity: 47
Residents Served: 24
Total Daily Staff: 37
Waking Staff: 28
Current Hospice Residents: 1
Residents 60 Years or Older: 24
Residents Diagnosed with Mental Illness: 1
Residents with Mobility Need: 13
Inspection Report
Complaint Investigation
Census: 24
Capacity: 47
Deficiencies: 1
Apr 13, 2022
Visit Reason
The inspection was conducted as a partial, unannounced visit due to an incident reported at the facility.
Findings
The facility was found to have failed to provide a resident with assistance with personal care and hygiene as indicated in the resident's assessment and support plan, specifically missing showers from 3/20/22 through 4/1/22. A plan of correction was submitted and determined to be fully implemented.
Complaint Details
The visit was complaint-related, focusing on a failure to provide assistance with activities of daily living as per the resident's support plan. The plan of correction was accepted and fully implemented.
Deficiencies (1)
| Description |
|---|
| Resident #1 did not receive assistance with personal care and hygiene, including showers, as indicated in the support plan from 3/20/22 through 4/1/22. |
Report Facts
License Capacity: 47
Residents Served: 24
Staffing Hours: 35
Waking Staff: 26
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jason Williams | Signed the letter confirming plan of correction implementation | |
| Executive Director | Executive Director (ED) | Named in plan of correction training and education |
| Care Services Manager | Care Services Manager (CSM) | Named in plan of correction training, review, and auditing activities |
| Regional Director of Care Services | Regional Director of Care Services (RDCS) | Provided education on regulatory requirements |
Inspection Report
Renewal
Census: 27
Capacity: 47
Deficiencies: 7
Oct 5, 2021
Visit Reason
The inspection was conducted as a renewal inspection of the facility license for Garden Way Place.
Findings
The inspection identified multiple deficiencies related to posting of licensing inspection summary, emergency telephone numbers, food storage and labeling, outdated food, pet vaccination records, and smoking area location. All deficiencies had plans of correction accepted and were implemented.
Deficiencies (7)
| Description |
|---|
| No licensing inspection summary posted in a conspicuous and public place in the home. |
| No emergency telephone numbers including nearest hospital and fire department posted on or by the telephone in the private dining room. |
| Unlabeled and undated opened food items found in freezers #3, #5, and #6. |
| Food stored in opened and unsealed containers including pasta, sorbet, egg rolls, cinnamon rolls, and waffles. |
| Dented #10 can of vanilla pudding found on pantry shelf. |
| Resident cat present without current rabies vaccination certificate; vaccination expired 6/15/21. |
| Designated smoking area located directly on sidewalk in center of enclosed courtyard, not away from common walkways and exits. |
Report Facts
License Capacity: 47
Residents Served: 27
Current Hospice Residents: 3
Residents with Mobility Need: 8
Residents Diagnosed with Mental Illness: 1
Waking Staff: 26
Total Daily Staff: 35
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director | Named in multiple deficiency findings and plans of correction including posting violations, food storage, pet vaccination, and smoking area. |
Inspection Report
Complaint Investigation
Census: 30
Capacity: 47
Deficiencies: 1
Apr 28, 2021
Visit Reason
The inspection was conducted as a complaint investigation to review sanitary conditions at the facility.
Findings
A violation was found involving a pile of dog feces and leaves on the concrete patio near the rear entrance to the courtyard. Immediate corrective actions were taken, and a plan of correction was accepted and fully implemented.
Complaint Details
The inspection was triggered by a complaint. The plan of correction was accepted and fully implemented as of 07/21/2021.
Deficiencies (1)
| Description |
|---|
| There was a pile of dog feces and leaves measuring approximately 30 inches x 24 inches on the concrete patio, approximately 5-feet from the rear entrance to the courtyard. |
Report Facts
License Capacity: 47
Residents Served: 30
Size of feces and leaves pile: 30
Size of feces and leaves pile: 24
Distance from rear entrance: 5
Inspection Report
Complaint Investigation
Census: 26
Capacity: 47
Deficiencies: 2
Feb 12, 2021
Visit Reason
The inspection was conducted as a partial, unannounced incident investigation related to an allegation of resident abuse.
Findings
The facility was found to have failed to immediately report an allegation of resident abuse that occurred on 2/2/21, with the report delayed until 2/9/21. The submitted plan of correction was accepted and fully implemented.
Complaint Details
The complaint involved an allegation that on 2/2/21 a staff person grabbed resident #1 by the arm and dragged the resident down the hall. The allegation was not reported to the local Area Agency on Aging or the Department until 2/9/21. The allegation was substantiated by the facility's failure to report timely.
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 report the incident or condition to the Department’s personal care home regional office or complaint hotline within 24 hours. |
Report Facts
License Capacity: 47
Residents Served: 26
Staffing Hours - Total Daily Staff: 32
Staffing Hours - Waking Staff: 24
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Janine Wenzig | Author of letters regarding inspection and plan of correction | |
| Executive Director | ED | Named in relation to failure to report abuse and responsible for audits and education |
| Care Service Manager | CSM | Conducted immediate assessment of resident #1 and involved in education and audits |
| Regional Director of Care Services | RDCS | Provided education to ED and CSM regarding abuse reporting requirements |
Inspection Report
Complaint Investigation
Census: 27
Capacity: 47
Deficiencies: 3
Jan 21, 2021
Visit Reason
The inspection was a complaint investigation conducted on 01/21/2021 and 01/28/2021 to review allegations of abuse and compliance with reporting requirements.
Findings
The facility was found to have delayed reporting an allegation of abuse against a staff member and failed to immediately suspend or supervise the staff involved. The submitted plan of correction was accepted and fully implemented, including audits and staff education to ensure compliance with abuse reporting laws.
Complaint Details
The complaint involved an allegation of abuse against direct care staff person B regarding resident #1, which was not reported timely to the local Area Agency on Aging or the Department. The staff member continued to provide unsupervised care after the allegation. The complaint was substantiated with findings of delayed reporting and failure to suspend the staff member immediately.
Deficiencies (3)
| Description |
|---|
| Failure to immediately report suspected abuse of a resident to the local Area Agency on Aging. |
| Failure to immediately develop and implement a plan of supervision or suspend the staff person involved in the alleged abuse incident. |
| Failure to report the incident or condition to the Department’s personal care home regional office or complaint hotline within 24 hours. |
Report Facts
License Capacity: 47
Residents Served: 27
Staffing Hours - Total Daily Staff: 34
Staffing Hours - Waking Staff: 26
Residents Diagnosed with Mental Illness: 4
Residents Aged 60 or Older: 27
Residents with Mobility Need: 7
Current Residents Receiving Hospice: 3
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