Inspection Reports for The Addison of McCullough Place
500 Cheney Oak Dr, Johnstown, PA 15905, United States, PA, 15905
Back to Facility ProfileDeficiencies per Year
8
6
4
2
0
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Renewal
Census: 39
Capacity: 55
Deficiencies: 5
Sep 10, 2024
Visit Reason
The inspection was conducted as a renewal review of the facility's compliance with licensing regulations.
Findings
The facility was found to have multiple deficiencies related to record confidentiality, evacuation times, medication storage and management, and resident record content. All deficiencies had plans of correction accepted and were implemented by 11/21/2024.
Deficiencies (5)
| Description |
|---|
| Resident records containing privacy coding documents were unlocked, unattended, and accessible in a conspicuous area. |
| The home's maximum safe evacuation time was exceeded during drills on 4/26/24 and 6/27/24. |
| Prescription medications and syringes were found unlocked, unattended, and accessible in a resident's bathroom cabinet. |
| Expired medications were found in the home's medication cart for residents. |
| Resident #3's record did not include a death certificate despite the resident dying in the home. |
Report Facts
Residents Served: 39
License Capacity: 55
Total Daily Staff: 51
Waking Staff: 38
Current Residents in Hospice: 11
Residents Age 60 or Older: 39
Residents with Mental Illness: 1
Residents with Mobility Need: 12
Inspection Report
Census: 36
Capacity: 36
Deficiencies: 0
Apr 30, 2024
Visit Reason
The inspection was a partial, announced licensing inspection conducted on 04/30/2024 for the purpose of a new inspection at the facility.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Total Daily Staff: 47
Waking Staff: 35
Residents Served: 36
Current Residents in Hospice: 10
Residents Diagnosed with Mental Illness: 2
Residents with Mobility Need: 11
Inspection Report
Follow-Up
Census: 33
Capacity: 55
Deficiencies: 1
May 31, 2023
Visit Reason
The inspection visit occurred as a follow-up to review the submitted plan of correction after an incident at the facility.
Findings
The facility was found to have fully implemented the submitted plan of correction related to a violation where a staff member did not treat a resident with dignity and respect. The staff member was placed on administrative leave and subsequently terminated, and re-education and auditing measures were implemented to ensure compliance.
Deficiencies (1)
| Description |
|---|
| Staff Person A did not treat Resident #1 with dignity and respect by telling the resident not to use their call light because the staff did not have time to respond. |
Report Facts
License Capacity: 55
Residents Served: 33
Current Residents in Hospice: 7
Residents Age 60 or Older: 33
Residents Diagnosed with Mental Illness: 1
Residents with Mobility Need: 16
Inspection Report
Renewal
Census: 38
Capacity: 55
Deficiencies: 3
Mar 1, 2023
Visit Reason
The inspection was conducted as a renewal visit with an incident noted, to assess compliance with licensing regulations and verify the implementation of a submitted plan of correction.
Findings
The inspection identified deficiencies related to unsecured poisonous materials, outdated food items, and improper storage of medications. The facility submitted and implemented a plan of correction addressing these issues, including staff re-education, audits, and disposal of hazardous items.
Deficiencies (3)
| Description |
|---|
| Poisonous materials such as disinfecting wipes, bleach powder, mouthwash, and hand sanitizer were found unsecured and accessible to residents who are unable to safely use or avoid poisonous materials. |
| Multiple dented cans of food were found in the kitchen pantry, which is against regulations prohibiting use of outdated or spoiled food or dented cans. |
| Resident's Eucerin Cream container was cracked and leaking, indicating improper storage of medications. |
Report Facts
License Capacity: 55
Residents Served: 38
Staffing Hours: 41
Waking Staff: 31
Dented Cans: 3
Residents with Mobility Need: 3
Hospice Residents: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director | Executive Director (ED) | Named in plan of correction for locking poisonous materials, discarding dented cans, and re-educating staff |
| Care Service Manager | Care Service Manager (CSM) | Conducted audits and re-educated staff on medication storage requirements |
| Regional Director of Care Services | Regional Director of Care Services (RDCS) | Re-educated Executive Director and staff on regulatory requirements |
Inspection Report
Renewal
Census: 42
Capacity: 55
Deficiencies: 8
May 3, 2022
Visit Reason
The inspection was a full, unannounced renewal inspection conducted on 05/03/2022 and 05/04/2022 to review compliance with licensing regulations.
Findings
The inspection identified multiple deficiencies related to contract signatures, annual medical evaluations, medication storage and labeling, medication administration, and support plan signatures. Plans of correction were accepted and implemented with audits and education scheduled to ensure ongoing compliance.
Deficiencies (8)
| Description |
|---|
| Resident #4's resident-home contract was not signed by the resident. |
| Resident #2’s most recent medical evaluation did not include the Medical Professional License Number. |
| Two tubes of medication were unlocked, unattended, and accessible in Resident #3's bathroom, who cannot self-administer medications. |
| Resident #5's medication label did not match the prescribed dosage and instructions. |
| Medications for Residents #1, #3, #4, #5, and #6 were not available in the home as prescribed. |
| Resident #4 and Resident #5's medication administration records did not include prescribed medications. |
| The home did not follow prescriber's orders for multiple residents due to unavailable medications. |
| Residents #4 and #5 participated in support plan development but did not sign the plan, and the home did not document refusal or inability to sign. |
Report Facts
License Capacity: 55
Residents Served: 42
Current Hospice Residents: 11
Residents with Mobility Need: 21
Residents 60 Years or Older: 42
Total Daily Staff: 63
Waking Staff: 47
Notice
Capacity: 55
Deficiencies: 0
Jun 30, 2021
Visit Reason
The document serves as a renewal notification and issuance of a regular license for McCullough Place Personal Care Home, confirming receipt of the renewal application and advising of the requirement for an annual onsite inspection within the next twelve months.
Findings
No inspection findings are reported in this document; it is an administrative notice confirming license renewal and outlining future inspection requirements.
Report Facts
Total licensed capacity: 55
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary, Office of Long-term Living | Signed the renewal notification letter |
Inspection Report
Renewal
Deficiencies: 0
Jun 9, 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.
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