Inspection Reports for The Addison of Woodbourne Place
2619 Trenton Rd Levittown, PA 19056, PA, 19056
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Inspection Report
Follow-Up
Census: 24
Capacity: 48
Deficiencies: 7
Nov 4, 2024
Visit Reason
The inspection was conducted as a follow-up review to verify that the submitted plan of correction was fully implemented following previous deficiencies.
Findings
The facility was found to have implemented all required corrections including contract signatures, annual fire safety training, sanitary conditions, first aid kit completeness, medication record accuracy, labeling of OTC medications, and support plan updates related to medical/dental care. Continued compliance must be maintained.
Deficiencies (7)
| Description |
|---|
| Resident-home contracts were not signed by residents as required. |
| Staff persons did not receive required annual fire safety training conducted by a fire safety expert during the 2023 training year. |
| A jar belonging to a resident was found covered and stained with white cream in their room. |
| The first aid kit in the wellness office did not include eye coverings. |
| An OTC medication jar belonging to a resident was not labeled with the resident’s name. |
| A discontinued medication was still listed as current on a resident’s medication administration record. |
| Resident’s support plan did not document risks, safe use, or device identification for a bedside mobility device present on the resident’s bed. |
Report Facts
License Capacity: 48
Residents Served: 24
Current Residents in Hospice: 2
Residents Age 60 or Older: 24
Residents with Mobility Need: 10
Residents with Physical Disability: 10
Total Daily Staff: 34
Waking Staff: 26
Inspection Report
Monitoring
Census: 22
Capacity: 48
Deficiencies: 6
Sep 26, 2024
Visit Reason
The visit was an unannounced partial inspection conducted for monitoring purposes to review compliance and the implementation of a previously submitted plan of correction.
Findings
The inspection found multiple deficiencies including failure to report an incident within 24 hours, lack of staff trained in first aid/CPR on duty during certain shifts, unsecured combustible materials accessible to residents, failure to post weekly menus in a conspicuous place, and medication record inaccuracies including discontinued medications still listed and missing staff initials on medication administration records. The submitted plan of correction was determined to be fully implemented.
Deficiencies (6)
| Description |
|---|
| Incident involving resident fall was not reported to the department within 24 hours as required. |
| No staff member trained in first aid and CPR was on duty during certain shifts despite having 22 residents present. |
| A 20 lb. steel propane tank was unsecured and accessible to residents on the patio area adjacent to the dining area. |
| Weekly menu for the upcoming week was not posted in a conspicuous and public place in the home. |
| Medication record included a discontinued medication as current. |
| Medication administration records lacked initials of staff administering medications on multiple dates. |
Report Facts
Residents present during inspection: 22
Licensed capacity: 48
Staff trained in first aid/CPR: 7
Propane tank weight: 20
Dates missing staff initials on medication records: 15
Inspection Report
Re-Inspection
Census: 20
Capacity: 48
Deficiencies: 1
Apr 18, 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, to ensure compliance with 55 Pa.Code Ch. 2600 for Personal Care Homes.
Findings
The facility was found to be in substantial compliance with the regulations, but the licensing inspector was unable to complete a full inspection due to the new legal entity. Citations were found and must be corrected by specified dates. A provisional license was issued based on substantial but not complete compliance.
Deficiencies (1)
| Description |
|---|
| The bathroom in resident room #28 and #44 does not have an operable window and the ventilation fan is inoperable. |
Report Facts
Residents served: 20
Total daily staff: 32
Waking staff: 24
Inspection Report
Renewal
Census: 23
Capacity: 48
Deficiencies: 9
Feb 15, 2024
Visit Reason
The inspection was an unannounced full renewal inspection conducted to review compliance with licensing regulations and verify the implementation of the submitted plan of correction.
Findings
The facility was found to have multiple regulatory violations including failure to post required telephone numbers, direct care staff qualification issues, unsecured bedside mobility devices, unsanitary medication handling practices, missing emergency telephone numbers, outdated emergency procedures, incomplete menu postings, improper calibration of medical equipment, and incomplete resident support plans. All deficiencies had plans of correction accepted and were implemented by April 11, 2024.
Deficiencies (9)
| Description |
|---|
| Telephone numbers of the Department's personal care home regional office, Pennsylvania Protection & Advocacy, local law enforcement, Commonwealth Information Center, and complaint hotline were not posted in a conspicuous and public place. |
| Direct care staff person A did not have a high school diploma, GED, or active registry status on the Pennsylvania nurse aide registry. |
| Covered bedside mobility devices on Resident 1's and Resident 2's beds were not securely attached, posing possible hazardous conditions. |
| Staff persons B and C were observed using bare, ungloved fingers to remove medication from blister cards during medication passes. |
| Emergency telephone numbers including nearest hospital and fire department were not posted on or by the telephone at the reception desk. |
| The home’s written emergency procedures had not been reviewed, updated, or submitted to the local emergency management agency in 2023. |
| The weekly menu for the upcoming week was not displayed in a conspicuous and public place in the home. |
| Resident 5’s glucometer was not calibrated to the correct time. |
| Resident 2's assessment and support plan did not indicate the need for a bedside mobility device present on the bed. |
Report Facts
License Capacity: 48
Residents Served: 23
Current Hospice Residents: 5
Residents Age 60 or Older: 23
Residents with Mobility Need: 16
Residents with Physical Disability: 1
Total Daily Staff: 39
Waking Staff: 29
Inspection Report
Renewal
Census: 40
Capacity: 48
Deficiencies: 10
Feb 8, 2023
Visit Reason
The inspection was conducted as a renewal visit to assess compliance with licensing requirements at Woodbourne Place.
Findings
The inspection identified multiple deficiencies including unsigned resident contracts, lack of operable bedside lamps, food safety violations related to uncovered and unlabeled food, incomplete medical evaluations, discontinued medications kept in the medication cart, inaccurate controlled substance logs, unavailable prescribed medications, and incomplete resident support plans. All deficiencies had plans of correction submitted and were determined to be fully implemented by the time of the report.
Deficiencies (10)
| Description |
|---|
| Resident 1's home contract was not signed by the resident. |
| Resident 2 did not have access to a source of light that can be turned on/off at bedside. |
| Uncovered tub of butter pecan ice cream stored in the freezer. |
| Unlabeled, undated leftover pie in refrigerator #2. |
| Opened and unsealed tub of butter pecan ice cream in the freezer. |
| Resident 1's medical evaluation did not include immunization history. |
| Discontinued medication for resident 3 was kept in the home's medication cart. |
| Controlled substance log was not updated to reflect the correct number of pills for medications administered to resident 4. |
| Prescribed medications for resident 4 were not available in the home. |
| Resident 1's support plan did not document how identified medical and behavioral needs would be met. |
Report Facts
License Capacity: 48
Residents Served: 40
Current Hospice Residents: 4
Residents Age 60 or Older: 39
Residents with Mobility Need: 9
Residents with Physical Disability: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Care Services Manager | Care Services Manager (CSM) | Validated medical evaluations, removed discontinued medications, updated controlled substance logs, updated resident support plans, and audited compliance. |
| Executive Director | Executive Director (ED) | Presented residency contract, in-serviced staff on regulations, audited compliance, and conducted medication log audits. |
| Regional Executive Director | Regional Executive Director (RED) | Educated Executive Director on contract signature requirements. |
| Maintenance Director | Maintenance Director | Ensured operable bedside lamps and audited resident rooms for compliance. |
| Chef | Chef | Discarded contaminated food, audited kitchen refrigerators and freezers, and ensured food safety compliance. |
Inspection Report
Complaint Investigation
Census: 44
Capacity: 48
Deficiencies: 8
Jan 28, 2022
Visit Reason
The inspection was conducted as a complaint investigation with an unannounced partial inspection visit on 01/31/2022 and an off-site review on 01/28/2022.
Findings
Multiple deficiencies were identified including issues with criminal background checks, direct care staff qualifications, medication storage and administration, medication documentation, and resident assessments. Plans of correction were accepted and implemented with ongoing monitoring and audits scheduled.
Complaint Details
The inspection was complaint-driven, with a partial unannounced inspection conducted on 01/31/2022 and follow-up documentation submissions on 02/22/2022 and 03/07/2022. The plan of correction was accepted and fully implemented.
Deficiencies (8)
| Description |
|---|
| Staff member A's criminal background check was completed late. |
| Direct care staff person B lacked a high school diploma, GED, or active registry status on the Pennsylvania nurse aide registry. |
| Medications were found unsecured in resident #1's room despite the resident not being able to self-administer medications. |
| Loose pills were found in medication carts. |
| Resident #1's prescribed medication Adult Tussin DM SF LIQ was unavailable in the home. |
| Resident #2’s medication administration record lacked initials of the staff who administered medications on 1/1/22. |
| Multiple instances of medications not administered as prescribed for residents #1 and #2. |
| Resident #2's initial assessment was not completed within 15 days of admission. |
Report Facts
License Capacity: 48
Residents Served: 44
Current Residents in Hospice: 4
Residents 60 Years or Older: 40
Residents Diagnosed with Mental Illness: 7
Residents with Mobility Need: 17
Residents with Physical Disability: 1
Total Daily Staff: 61
Waking Staff: 46
Inspection Report
Renewal
Census: 42
Capacity: 48
Deficiencies: 18
Nov 4, 2021
Visit Reason
The inspection was conducted as a renewal visit to review compliance with licensing regulations at Woodbourne Place.
Findings
The inspection identified multiple deficiencies related to staffing, physical site conditions, medication management, and resident records. Corrective actions and education were implemented with follow-up audits scheduled to ensure ongoing compliance.
Deficiencies (18)
| Description |
|---|
| Staff Member A's criminal background check was not completed until 6/2/21. |
| Direct care staff person A provided unsupervised ADL services before completing required training and competency test. |
| Bathrooms in resident bedrooms lacked operable windows or ventilation fans. |
| No emergency telephone numbers posted near the telephone in the kitchen. |
| First aid kit in wellness office did not include tweezers. |
| Food stored in freezer was opened and unsealed. |
| Outdated or unlabeled food found in kitchen freezer. |
| Weekly menu for 11/7/21-11/13/21 was not posted. |
| Resident #5 had taped pills on blister pack. |
| Medication cart was unlocked, unattended, and accessible. |
| Loose pill found in medication cart B. |
| Resident #1 had expired medication (Lantus Solo inj 100/ml) in med cart B. |
| Resident #1's Metformin medication label did not match prescribed dosage. |
| Resident #1's glucometer was not calibrated to correct date and time; Acetaminophen medication was unavailable. |
| Resident #1's Santyl and Desitin ointments were documented as administered but were not given. |
| Resident #1 and #2 blood glucose and blood pressure readings were not taken as prescribed. |
| Resident records for Residents #1, #2, #3, and #4 lacked hair color, eye color, and identifying marks. |
| Medication book and narcotics logs for medication cart A were left unattended and accessible. |
Report Facts
Licensed Capacity: 48
Residents Served: 42
Staffing: 47
Waking Staff: 35
Deficiency Completion Dates: 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Shawn Parker | Regional Executive Director | Educated Executive Director on regulatory requirements. |
| Executive Director | Executive Director | Named in multiple findings related to education, audits, and corrective actions. |
| Regional Director of Care Services | Regional Director of Care Services | Educated Executive Director on direct care training and medication requirements. |
| Maintenance Supervisor | Maintenance Supervisor | Validated operability of bathroom ventilation fans. |
| Administrative Specialist | Administrative Specialist | Updated resident face sheets to include hair color, eye color, and identifying marks. |
Notice
Capacity: 48
Deficiencies: 0
Jun 30, 2021
Visit Reason
The document serves as a renewal notification and license issuance for the Personal Care Home 'Woodbourne Place' following receipt of the renewal application dated March 18, 2021.
Findings
The Department issued a regular license in response to the renewal application and advised that an onsite annual inspection will be conducted within the next twelve months to ensure compliance with applicable regulations.
Report Facts
Maximum capacity: 48
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: 35
Capacity: 48
Deficiencies: 2
May 5, 2021
Visit Reason
The inspection was conducted as a complaint investigation with unannounced notice to assess compliance with licensing regulations at Woodbourne Place.
Findings
Two deficiencies were cited: one involving a direct care staff person lacking required educational qualifications or registry status, and another involving a resident's support plan not being revised timely to reflect changes in mobility needs.
Complaint Details
The inspection was triggered by a complaint. The report does not state substantiation status explicitly.
Deficiencies (2)
| Description |
|---|
| Direct care staff person A does not have a high school diploma, GED, or active registry status on the Pennsylvania nurse aide registry. |
| Resident #1's support plan was not revised within 30 days to reflect changes in mobility assistance needs as indicated on the current assessment. |
Report Facts
License Capacity: 48
Residents Served: 35
Total Daily Staff: 39
Waking Staff: 29
Inspection Report
Complaint Investigation
Census: 35
Capacity: 48
Deficiencies: 2
May 5, 2021
Visit Reason
The inspection was conducted as a complaint investigation with unannounced partial inspections on May 5 and May 19, 2021, to review compliance and follow up on a plan of correction submission.
Findings
Two deficiencies were identified: one involving a direct care staff member lacking required educational qualifications or registry status, and another involving a resident's support plan not being revised to reflect changes in mobility needs. Both deficiencies had plans of correction implemented and fully accepted.
Complaint Details
The inspection was complaint-driven and included a follow-up on the plan of correction submission. The plan of correction was determined to be fully implemented as of June 6, 2022.
Deficiencies (2)
| Description |
|---|
| Direct care staff person A does not have a high school diploma, GED, or active registry status on the Pennsylvania nurse aide registry. |
| Resident #1's support plan was not revised within 30 days to reflect changes in mobility assistance needs as indicated by the resident's current condition. |
Report Facts
License Capacity: 48
Residents Served: 35
Total Daily Staff: 39
Waking Staff: 29
Current Residents in Hospice: 2
Residents Age 60 or Older: 35
Residents Diagnosed with Mental Illness: 1
Residents Diagnosed with Intellectual Disability: 1
Residents with Mobility Need: 4
Residents with Physical Disability: 31
Inspection Report
Complaint Investigation
Census: 35
Capacity: 48
Deficiencies: 11
Feb 12, 2021
Visit Reason
The inspection was a partial, unannounced complaint investigation conducted on 02/12/2021 to review allegations related to resident abuse and other regulatory compliance issues.
Findings
The inspection found multiple deficiencies including failure to immediately report suspected resident abuse, failure to develop a supervision plan or suspend staff involved in abuse allegations, failure to submit incident reports timely, inadequate resident relocation assistance, incomplete staff orientation training, hazardous resident equipment, hot water temperature exceeding limits, unsafe furniture, and lack of placement planning for residents needing higher levels of care. Plans of correction were accepted for all deficiencies.
Complaint Details
The inspection was complaint-driven, triggered by allegations of resident abuse involving staff. The complaint was substantiated with multiple violations found related to abuse reporting, supervision, incident reporting, and resident rights.
Deficiencies (11)
| Description |
|---|
| Failure to immediately report suspected abuse of a resident to the local Area Agency on Aging. |
| Failure to develop and implement a plan of supervision or suspend staff involved in alleged resident abuse. |
| Failure to submit an incident report to the Department within 24 hours regarding suspected abuse. |
| Failure to provide at least 30 days advance written notice to resident of change in level of services and fees. |
| Resident-home contract failed to include a list of personal care services to be provided based on resident's support plan. |
| Failure to provide adequate assistance to resident requesting relocation to another facility. |
| Direct care staff person did not complete required orientation training within 40 scheduled working hours. |
| Resident's shower chair legs were bent to the point of breaking, posing a hazard. |
| Hot water temperature in resident-accessible bathroom exceeded 120°F, measuring 122°F. |
| Wooden chair provided to resident was unsteady and wobbly, posing a hazard. |
| Failure to develop a placement plan for resident determined to need a higher level of care. |
Report Facts
License Capacity: 48
Residents Served: 35
Staffing Hours: 38
Waking Staff: 29
Hot Water Temperature: 122
Inspection Report
Renewal
Census: 34
Capacity: 48
Deficiencies: 4
Jan 11, 2021
Visit Reason
The inspection was a full, unannounced renewal inspection conducted to review compliance with licensing regulations.
Findings
The inspection identified deficiencies related to failure to report suspected resident abuse timely, missing resident contract signatures, inadequate safeguarding of resident money, and presence of discontinued medication in the medication cart. Plans of correction were submitted and partially implemented.
Deficiencies (4)
| Description |
|---|
| Failure to immediately report suspected abuse of a resident involving missing money from resident's wallet. |
| Resident-home contract was not signed by the resident. |
| Failure to provide a system to safeguard a resident's money and property. |
| Discontinued medication was found in the medication cart. |
Report Facts
License Capacity: 48
Residents Served: 34
Current Hospice Residents: 2
Residents Age 60 or Older: 34
Residents with Mobility Need: 3
Residents with Physical Disability: 32
Staff Total Daily: 37
Staff Waking: 28
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Claire Mendez | Licensing Representative | Signed the letter confirming plan of correction implementation. |
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