Inspection Reports for The Birches at Harleysville
691 MAIN STREET,, HARLEYSVILLE, PA, 19438
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
16.4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
249% worse than Pennsylvania average
Pennsylvania average: 4.7 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
100% occupied
Based on a July 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Plan of Correction
Census: 85
Capacity: 85
Deficiencies: 1
Jul 29, 2025
Visit Reason
The inspection was conducted as a follow-up review of the submitted plan of correction related to a violation concerning resident consent documentation for admission to the secured dementia care unit.
Findings
The plan of correction was determined to be fully implemented. The violation involved a resident who initially objected in writing to admission to the secured dementia care unit, but corrective actions were taken including obtaining consent and reviewing all resident contracts in the secured dementia unit.
Deficiencies (1)
| Description |
|---|
| Resident record lacked documentation that the resident and designated person had not objected to admission to the secured dementia care unit. |
Report Facts
License Capacity: 85
Residents Served: 85
Secured Dementia Care Unit Capacity: 34
Secured Dementia Care Unit Residents Served: 31
Hospice Residents: 7
Residents 60 Years or Older: 74
Residents with Mobility Need: 41
Residents with Physical Disability: 4
Inspection Report
Complaint Investigation
Census: 78
Capacity: 85
Deficiencies: 2
Apr 4, 2024
Visit Reason
The inspection was conducted as a complaint and incident investigation at THE BIRCHES AT HARLEYSVILLE on 04/04/2024.
Findings
The inspection found deficiencies related to unsecured poisonous materials accessible to residents and unlabeled over-the-counter medications belonging to a resident. The submitted plan of correction was determined to be fully implemented.
Complaint Details
The inspection was complaint-driven and incident-related, with a follow-up type of Plan of Correction (POC) submission scheduled.
Deficiencies (2)
| Description |
|---|
| Unsecured poisonous materials such as antiperspirants, hand sanitizers, mouthwash, and skin protectant ointment were accessible to residents who were not assessed as capable of safely using or avoiding them. |
| A jar of over-the-counter medication belonging to a resident was found unlabeled in the resident's bathroom cabinet. |
Report Facts
License Capacity: 85
Residents Served: 78
Secured Dementia Care Unit Capacity: 34
Secured Dementia Care Unit Residents Served: 23
Hospice Residents: 11
Resident Support Staff Total Daily Staff: 126
Waking Staff: 95
Inspection Report
Renewal
Census: 80
Capacity: 85
Deficiencies: 8
Feb 28, 2024
Visit Reason
The inspection was conducted as a renewal inspection of THE BIRCHES AT HARLEYSVILLE facility on 02/28/2024 and 02/29/2024 to review compliance with licensing requirements.
Findings
The inspection identified multiple deficiencies including unsecured enabler bars, unlocked poisonous materials, combustible materials accessible to residents, expired medications in the medication cart, unlocked medication cart, improperly calibrated glucometers, failure to follow prescriber's orders, and incomplete preadmission screening forms. Plans of correction were accepted and implemented with ongoing quality assurance actions.
Deficiencies (8)
| Description |
|---|
| Resident 1 and Resident 2 had enabler bars not secured to the bed frame per manufacturer's instructions. |
| Purell Hand Sanitizer was unlocked, unattended, and accessible to residents in memory care. |
| A can of butane was unlocked, unattended, and accessible to residents in the garden house memory care area. |
| Expired medications for Resident 3 and Resident 4 were found in the home's medication cart. |
| Medication cart was left unlocked in the garden house memory care area. |
| Resident 5 and Resident 6's glucometers were not calibrated properly. |
| Resident 7 was administered medication prior to the prescribed time. |
| Resident 10's preadmission screening form was completed after admission. |
Report Facts
License Capacity: 85
Residents Served: 80
Secured Dementia Care Unit Capacity: 34
Secured Dementia Care Unit Residents Served: 34
Hospice Current Residents: 11
Residents Who Have Mobility Need: 48
Residents Who Are 60 Years of Age or Older: 80
Residents Diagnosed with Mental Illness: 1
Residents Diagnosed with Physical Disability: 1
Inspection Report
Complaint Investigation
Census: 80
Capacity: 85
Deficiencies: 0
Dec 21, 2023
Visit Reason
The inspection was conducted as a complaint and incident investigation at THE BIRCHES AT HARLEYSVILLE facility on 12/21/2023.
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 no follow-up was required.
Report Facts
License Capacity: 85
Residents Served: 80
Secured Dementia Care Unit Capacity: 34
Secured Dementia Care Unit Residents Served: 34
Hospice Current Residents: 11
Resident Support Staff: 0
Total Daily Staff: 123
Waking Staff: 92
Residents 60 Years or Older: 77
Residents Diagnosed with Mental Illness: 1
Residents with Mobility Need: 43
Residents with Physical Disability: 1
Inspection Report
Complaint Investigation
Census: 78
Capacity: 85
Deficiencies: 2
Aug 9, 2023
Visit Reason
The inspection was conducted as a complaint investigation with unannounced partial review visits on 08/09/2023, 08/10/2023, and 08/29/2023 to assess compliance with regulatory requirements.
Findings
The submitted plan of correction was found to be fully implemented following the complaint investigation. Deficiencies involved support plan documentation issues, including a resident not signing the support plan and a delay in completing the initial support plan within the required timeframe.
Complaint Details
The inspection was complaint-driven, with the reason explicitly stated as 'Complaint'. The submitted plan of correction was reviewed and accepted, with follow-up dates scheduled for verification.
Deficiencies (2)
| Description |
|---|
| Resident 1 participated in the development of the support plan but did not sign the support plan. |
| Resident 1's initial support plan was not completed within 72 hours of admission to the secured dementia care unit. |
Report Facts
License Capacity: 85
Residents Served: 78
Secured Dementia Care Unit Capacity: 34
Secured Dementia Care Unit Residents Served: 33
Hospice Residents: 10
Residents Age 60 or Older: 77
Residents with Mobility Need: 36
Residents with Physical Disability: 3
Residents Diagnosed with Mental Illness: 1
Inspection Report
Renewal
Census: 73
Capacity: 85
Deficiencies: 5
Mar 22, 2023
Visit Reason
The inspection was conducted as a renewal visit to review compliance with licensing requirements at THE BIRCHES AT HARLEYSVILLE.
Findings
The facility was found to have several deficiencies including missing eye coverings in the first aid kit, improper freezer temperatures, routine scheduling of fire drills on Fridays, and failure to follow prescriber's medication orders for a resident. Plans of correction were accepted and implemented with ongoing monitoring and staff training.
Deficiencies (5)
| Description |
|---|
| The first aid kit in Daybreak did not include eye coverings. |
| The temperature in the Daybreak Freezer was 15 degrees Fahrenheit, above the required 0°F for frozen food. |
| The temperature in the main kitchen ice cream freezer was 6 degrees Fahrenheit, above the required 0°F for frozen food. |
| The home routinely holds fire drills on Fridays, not on different days and times as required. |
| Two medication errors where prescriber's orders were not followed for Resident 1's sliding scale insulin administration. |
Report Facts
License Capacity: 85
Resident Census: 73
Freezer Temperature: 15
Freezer Temperature: 6
Fire Drills Dates: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Resident Care Director | Responsible for ensuring first aid kits compliance, reporting medication errors, conducting staff training, and ongoing audits. | |
| Dining Services Director | Responsible for freezer temperature compliance and staff training on food storage. | |
| Environmental Services Director | Responsible for scheduling and conducting fire drills per state requirements. | |
| Two Medication Technicians | Did not follow prescriber's orders for Resident 1's medication administration. |
Inspection Report
Complaint Investigation
Census: 74
Capacity: 85
Deficiencies: 1
Oct 17, 2022
Visit Reason
The inspection was conducted as a complaint investigation following concerns related to an incident involving a resident who was injured after rolling down the parking lot in a wheelchair and the home's failure to report the incident to the Department.
Findings
The home failed to report a resident incident to the Department within the required 24-hour timeframe. The resident sustained injuries and was hospitalized. The home subsequently implemented corrective actions including staff training and ongoing monitoring to ensure compliance with reporting requirements.
Complaint Details
The complaint investigation was substantiated as the home did not report the incident involving resident #1 to the Department as required. The home followed up with the hospital and determined no serious injury occurred, but initially failed to report the incident.
Deficiencies (1)
| Description |
|---|
| Failure to report a resident incident to the Department within 24 hours as required. |
Report Facts
License Capacity: 85
Residents Served: 74
Secured Dementia Care Unit Capacity: 34
Secured Dementia Care Unit Residents Served: 28
Hospice Current Residents: 5
Residents with Mobility Need: 36
Residents 60 Years or Older: 74
Residents Diagnosed with Mental Illness: 2
Residents with Physical Disability: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Resident Care Director | Made the written report to the Department on 10/17/22 following the inspection and involved in ongoing monitoring and training | |
| Executive Director | Completed training on 10/18/22, responsible for reviewing concerns at QA meetings, and provided training following inspection | |
| Daybreak Director | Involved in ongoing monitoring of residents sent to hospital and training | |
| Representative Eberhart | Made the home's Executive Director aware of the need to report the incident during inspection |
Inspection Report
Census: 63
Capacity: 85
Deficiencies: 0
Jun 23, 2022
Visit Reason
The inspection was conducted as a licensing inspection by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing on 06/23/2022.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Residents Served: 63
License Capacity: 85
Secured Dementia Care Unit Capacity: 25
Secured Dementia Care Unit Residents Served: 17
Hospice Current Residents: 4
Resident Support Staff: 0
Total Daily Staff: 90
Waking Staff: 68
Residents Age 60 or Older: 62
Residents with Mobility Need: 27
Residents with Physical Disability: 27
Residents Diagnosed with Mental Illness: 2
Inspection Report
Monitoring
Census: 66
Capacity: 85
Deficiencies: 1
May 13, 2022
Visit Reason
The inspection was an unannounced partial monitoring visit conducted to review ongoing compliance and follow-up on previous issues.
Findings
The inspection identified a medication administration error involving an incorrect dose of Morphine given to Resident #1. The facility promptly reported the incident, notified the physician and POA, and implemented corrective actions including staff training and ongoing medication cart audits to ensure compliance.
Deficiencies (1)
| Description |
|---|
| Resident #1 was administered an incorrect dose of Morphine, receiving 0.5 ml (10mg) instead of the prescribed 0.25 ml (5mg) prior to care. |
Report Facts
License Capacity: 85
Residents Served: 66
SDCU Capacity: 25
SDCU Residents Served: 20
Current Hospice Residents: 4
Total Daily Staff: 95
Waking Staff: 71
Residents Age 60 or Older: 65
Residents with Mobility Need: 29
Residents with Physical Disability: 29
Residents Diagnosed with Mental Illness: 1
Residents Diagnosed with Intellectual Disability: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jamie Buchenauer | Deputy Secretary | Signed the letter approving revised license capacity |
Inspection Report
Plan of Correction
Census: 63
Capacity: 85
Deficiencies: 1
Apr 22, 2022
Visit Reason
The inspection was a follow-up review of the submitted plan of correction related to a prior incident at the facility.
Findings
The submitted plan of correction was determined to be fully implemented, with continued compliance required. The main deficiency involved a resident's medical evaluation lacking certain required medical diagnosis information, which was addressed through documentation and procedural updates.
Deficiencies (1)
| Description |
|---|
| Resident #1's medical evaluation did not include a medical diagnosis including physical or mental disabilities of the resident, or medical information pertinent to diagnosis and treatment in case of an emergency. |
Report Facts
License Capacity: 85
Residents Served: 63
Secured Dementia Care Unit Capacity: 25
Secured Dementia Care Unit Residents Served: 20
Hospice Residents: 4
Total Daily Staff: 94
Waking Staff: 71
Residents 60 Years or Older: 62
Residents with Mobility Need: 31
Residents with Physical Disability: 31
Residents Diagnosed with Mental Illness: 1
Inspection Report
Follow-Up
Census: 64
Capacity: 85
Deficiencies: 1
Apr 6, 2022
Visit Reason
The inspection was a partial, unannounced visit conducted due to an incident on 04/06/2022, with a follow-up type of Plan of Correction (POC) submission.
Findings
The facility was found to have a medication administration deficiency where Resident #1 was not administered Levothyroxine as prescribed from 3/1/22 through 3/29/22. The plan of correction was accepted and included staff training and system monitoring to prevent recurrence.
Deficiencies (1)
| Description |
|---|
| Resident #1 was prescribed Levothyroxine 137 mcg daily but was not administered the medication from 3/1/22 through 3/29/22. |
Report Facts
License Capacity: 85
Residents Served: 64
Medication Omission Duration (days): 29
Total Daily Staff: 96
Waking Staff: 72
Secured Dementia Care Unit Capacity: 25
Secured Dementia Care Unit Residents Served: 20
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Claire Mendez | Signed the letter regarding plan of correction acceptance | |
| Resident Care Director | Named in medication omission finding and corrective actions |
Inspection Report
Renewal
Census: 65
Capacity: 85
Deficiencies: 5
Mar 23, 2022
Visit Reason
The inspection was conducted as a partial, unannounced visit for relicensing to open a second memory care neighborhood and to review compliance with licensing requirements.
Findings
The inspection identified deficiencies related to life safety and physical plant issues, including obstructed egress due to a manual keypad locking mechanism on the memory care gate, lack of written approval for the locking device, exit doors equipped with manual keypad mechanisms, combustible materials stored near heat sources, and doors not locked with an electronic or magnetic locking system. Plans of correction were accepted and implemented with completion dates by 05/11/2022.
Deficiencies (5)
| Description |
|---|
| Memory care gate had a manual keypad mechanism blocking egress from the home's exit route to the parking lot. |
| Gate at memory care used as egress route was equipped with manual keypad locking mechanism without written approval or variance. |
| Exit door at the memory care gate was equipped with a manual keypad mechanism. |
| A bottle of Kwik paint stripper with flammable caution instruction was stored inside the boiler room. |
| Doors opening into the parking lot were not locked with an electronic or magnetic locking system. |
Report Facts
License Capacity: 85
Residents Served: 65
Secured Dementia Care Unit Capacity: 25
Secured Dementia Care Unit Residents Served: 22
Hospice Residents: 5
Total Daily Staff: 100
Waking Staff: 75
Inspection Report
Follow-Up
Census: 77
Capacity: 85
Deficiencies: 5
Jan 12, 2022
Visit Reason
The inspection was a follow-up review conducted by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing, to verify that the submitted plan of correction was fully implemented following prior deficiencies.
Findings
The facility was found to have implemented the plan of correction fully. Previous deficiencies included failure to report an incident timely, resident-to-resident abuse, incomplete criminal background checks for staff, failure to implement positive interventions for aggressive behavior, and incomplete support plan documentation. Ongoing monitoring and corrective actions were described to maintain compliance.
Deficiencies (5)
| Description |
|---|
| Failure to report a resident fall incident to the Department within 24 hours as required. |
| Resident #1 physically assaulted resident #2 without proper safety precautions in place. |
| Criminal background check for staff person A was not completed until several months after hire. |
| Failure to implement positive interventions to modify or eliminate aggressive behavior of resident #1. |
| Support plan for resident #1 did not address behavioral and psychological concerns impacting safety. |
Report Facts
License Capacity: 85
Residents Served: 77
Secured Dementia Care Unit Capacity: 25
Residents Served in Dementia Unit: 21
Total Daily Staff: 107
Waking Staff: 80
Number of Residents 60 Years or Older: 53
Residents with Mobility Need: 30
Residents with Physical Disability: 30
Number of Incidents of Aggressive Behavior by Resident #1: 4
Inspection Report
Renewal
Census: 52
Capacity: 85
Deficiencies: 9
Dec 28, 2021
Visit Reason
The inspection was conducted as a renewal inspection of the facility license.
Findings
The inspection identified multiple deficiencies including missing resident signatures on contracts and support plans, incomplete staff orientation and training documentation, obstructed egress due to a locked patio gate, medication administration errors, and lack of resident education on the right to refuse medication. Plans of correction were accepted and documented as implemented.
Deficiencies (9)
| Description |
|---|
| Resident-home contract for resident 1 was not signed by the resident. |
| Resident 1's record did not contain a signed statement acknowledging receipt of resident rights and complaint procedures. |
| Staff person A did not receive timely orientation on fire safety and emergency preparedness topics on her date of hire. |
| Staff person A did not complete timely training within 40 scheduled work hours on resident rights, emergency medical plan, mandatory reporting of abuse and neglect, and reporting of reportable incidents. |
| Garden Walk Ground Patio gated fence had a push button lock with no code to exit, blocking egress. |
| Resident 2 was not administered prescribed medication on 12/15/21 at 8:00 am; medication was signed off but remained in blister pack and not signed on narcotic count sheet. |
| Resident 3 was not administered prescribed medication on 12/10/21 at 7:00 am. |
| Resident 1 was not educated on the right to question or refuse medication if a medication error is suspected; no signed documentation was provided. |
| Resident 4 participated in the development of the support plan but did not sign the support plan. |
Report Facts
License Capacity: 85
Residents Served: 52
Secured Dementia Care Unit Capacity: 25
Residents Served in Dementia Unit: 21
Hospice Residents: 6
Total Daily Staff: 81
Waking Staff: 61
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff person A | Named in deficiencies related to incomplete orientation and training documentation. | |
| Staff person B | Named in medication administration errors and removal from medication administration duties. | |
| Marketing Director | Homes Marketing Director | Responsible for contract review and resident education; involved in deficiencies related to resident contract signatures and education. |
| Executive Director | Homes Executive Director | Provided training and oversight related to contract review and resident education. |
| Resident Care Director | Homes Resident Care Director | Involved in medication administration oversight and training. |
| Memory Care Director | Homes Memory Care Director | Involved in medication administration oversight and support plan review. |
| Maintenance Director | Homes Maintenance Director | Installed push button lock on patio gate causing egress obstruction. |
| Business Office Manager | Homes Business Office Manager | Conducted internal audits of employee files and orientation documentation. |
Inspection Report
Complaint Investigation
Census: 48
Capacity: 85
Deficiencies: 10
Nov 8, 2021
Visit Reason
The inspection was conducted as a complaint investigation to review compliance with licensing requirements and address specific allegations related to staff qualifications, resident care, and documentation.
Findings
The inspection identified multiple deficiencies including staff lacking required documentation and training, residents being denied access to bedrooms, inadequate assistance with eating and toileting, incomplete resident support plans, and missing preadmission screenings. Plans of correction were accepted and follow-up training and audits were implemented.
Complaint Details
The inspection was complaint-driven, with substantiation implied by the findings of multiple deficiencies related to staff qualifications, resident care, and documentation.
Deficiencies (10)
| Description |
|---|
| Direct care staff persons A and B did not have a high school diploma, GED, or active registry status on the Pennsylvania nurse aide registry. |
| Staff person A completed an online FA/CPR training by a source not certified by a hospital or recognized health care organization. |
| Staff persons A and B did not receive or document required initial fire safety orientation on their first day. |
| Staff persons A and B did not complete training within 40 hours on emergency medical plan, mandatory reporting of abuse and neglect, and reporting of reportable incidents. |
| Residents in rooms 24, 26, 28, 30, 32, 35, 36, 37, and 39 were denied access to their bedrooms by staff locking the doors. |
| Resident #3 was not properly assisted with eating and drinking as required by their care plan. |
| Medication administration training record for staff person C lacked verification of passing initial training and timely completion of annual practicum. |
| Resident #1's support plan did not document how incontinence care needs would be met. |
| Resident #2's written cognitive preadmission screening was not completed within 72 hours prior to admission to the secured dementia care unit. |
| Resident #1 experienced delays in toileting assistance, with call bell logs showing waits up to 41 minutes. |
Report Facts
License Capacity: 85
Residents Served: 48
Residents Served in Secured Dementia Care Unit: 19
Capacity of Secured Dementia Care Unit: 25
Current Hospice Residents: 5
Staffing Hours - Total Daily Staff: 72
Staffing Hours - Waking Staff: 54
Residents Waiting Time for Assistance: 41
Inspection Report
Complaint Investigation
Census: 51
Capacity: 85
Deficiencies: 3
Apr 23, 2021
Visit Reason
The inspection was conducted as a complaint and incident investigation with an unannounced partial inspection.
Findings
The inspection found deficiencies related to failure to assist a resident with healthcare appointments, inappropriate staff language and behavior towards residents, and violation of resident privacy during care. Plans of correction were submitted and fully implemented.
Complaint Details
The inspection was triggered by complaints and incidents involving resident care and staff conduct. The allegations included failure to assist with healthcare appointments, disrespectful treatment of residents, and privacy violations. Staff Member A was suspended and terminated following the investigation. Resident #3 is deceased and Resident #2 and #4 moved to other communities.
Deficiencies (3)
| Description |
|---|
| Resident #1 did not receive assistance attending podiatrist appointments as required. |
| Staff Member A used inappropriate language and jokes with residents, including threatening language and profanity. |
| Staff Member A was present and facetiming a family member in Resident #4's room while the resident was receiving care, violating privacy. |
Report Facts
License Capacity: 85
Residents Served: 51
Secured Dementia Care Unit Capacity: 25
Secured Dementia Care Unit Residents Served: 18
Hospice Current Residents: 6
Residents Age 60 or Older: 51
Residents Diagnosed with Mental Illness: 1
Residents Diagnosed with Intellectual Disability: 1
Residents with Mobility Need: 29
Residents with Physical Disability: 1
Notice
Capacity: 85
Deficiencies: 0
Mar 19, 2021
Visit Reason
The document serves as a renewal notification and license issuance for the Personal Care Home 'Birches at Arbour Square' following receipt of the renewal application dated December 9, 2020.
Findings
The Department issued a regular license in response to the renewal application and advised that an annual onsite inspection will be conducted within the next twelve months to ensure compliance with applicable regulations.
Report Facts
Maximum capacity: 85
Secure Dementia Care Unit capacity: 25
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary | Signed the renewal notification letter. |
Inspection Report
Renewal
Census: 63
Capacity: 85
Deficiencies: 13
Mar 2, 2021
Visit Reason
The inspection was an unannounced renewal inspection conducted on 03/02/2021 and 03/03/2021 to review compliance with licensing requirements.
Findings
The inspection identified multiple deficiencies including unlocked narcotics sign-out books, improperly labeled poisonous materials, unlocked poisonous materials in the secured dementia care unit, sanitary condition issues, fire extinguisher inspection overdue, medication administration errors, incomplete medical evaluations, missing documentation on medication procedures, and incomplete resident assessments and support plans. All deficiencies had plans of correction accepted and were reported as implemented or in progress.
Deficiencies (13)
| Description |
|---|
| Unlocked narcotics sign-out books were unattended and accessible on med carts. |
| Spray bottles marked as air-freshener were not stored in original labeled containers. |
| Multiple spray bottles including Febreze air-freshener and disinfectants were found unlocked in the SDCU closet, posing a risk to residents. |
| Toilet bowl in resident bathroom was ringed with black mold and strong odor of urine was present in hallways and resident rooms. |
| Fire extinguisher in the home's van had not been inspected since December 2019. |
| Resident #1's medical evaluation was not completed annually as required. |
| Medication administration error where nurse administered wrong dose of Vimpat due to failure to check label. |
| Controlled substance sign-out sheet for resident #3's Oxycodone did not document receipt and destruction properly. |
| Medication administration record for resident #4 lacked initials of staff administering Morphine Sulfate doses. |
| Resident #5's preadmission screening form did not include determination that resident's needs could be met by the home. |
| Resident #5's initial assessment was not completed within 15 days of admission. |
| Resident #6's support plan was blank in the medical/dental needs section despite known medical conditions. |
| Resident #7 was admitted to the secured dementia care unit without a medical evaluation completed within 60 days prior to admission. |
Report Facts
License Capacity: 85
Residents Served: 63
Secured Dementia Care Unit Capacity: 25
Secured Dementia Care Unit Residents Served: 23
Residents with Mobility Need: 34
Residents Age 60 or Older: 63
Residents Diagnosed with Mental Illness: 3
Residents Diagnosed with Intellectual Disability: 1
Residents with Physical Disability: 1
Inspection Report
Complaint Investigation
Census: 70
Capacity: 85
Deficiencies: 15
Feb 4, 2021
Visit Reason
The inspection was a complaint investigation conducted due to allegations of abuse, neglect, and noncompliance with regulatory requirements at the facility.
Findings
The investigation found multiple violations including delayed abuse reporting, resident neglect, improper medication administration, inadequate staff training, unsanitary conditions, and failure to follow prescriber's orders. The facility submitted plans of correction which were accepted and implemented.
Complaint Details
The complaint investigation was substantiated with findings of abuse, neglect, privacy violations, inadequate staff training, and medication errors.
Deficiencies (15)
| Description |
|---|
| Delayed reporting of suspected resident abuse to the local area agency on aging. |
| Failure to report an incident to the Department within 24 hours as required. |
| Staff person was not given proper respirator mask while providing care to a quarantined resident exposed to COVID-19. |
| Resident abuse including intimidation, physical abuse, neglect, and failure to respond timely to call bells. |
| Violation of resident privacy by electronic dissemination of photos without consent. |
| Administrator failed to adequately manage the home, resulting in neglect and unmet resident needs. |
| Direct care staff received insufficient annual training hours and lacked training in required topics including dementia care. |
| Unsanitary conditions including feces odor, dirty walls, and improper medication administration. |
| Uncovered trash receptacles in dining area of memory care unit. |
| Outdated or unlabeled food items stored in memory care unit refrigerator. |
| Residents in memory care unit lacked access to meals after meal times. |
| Expired medication found in medication cart. |
| Medication cart left unlocked and unattended during narcotics audit. |
| Resident administered medication prescribed for another resident. |
| Failure to follow prescriber's orders for vital sign checks before medication administration. |
Report Facts
Inspection dates: 4
License capacity: 85
Residents served: 70
Secured Dementia Care Unit capacity: 25
Residents served in dementia unit: 24
Hospice residents: 7
Staff total daily: 103
Waking staff: 77
Training hours received: 1.5
Medication cart unattended duration: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff Person B | Agency Personnel Member | Named in resident abuse and delayed reporting findings; banned from building. |
| Staff Person D | Med Tech | Observed asleep during shift; terminated for privacy violation. |
| Staff Person E | Administrator / Executive Director | Failed to manage facility properly; resigned following investigation. |
| Staff Person F | Direct Care Staff | Received insufficient training in 2019; works in Secure Dementia Care Unit. |
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