Inspection Reports for Juniper Village at Devon
445 N Valley Forge Rd, Devon, PA 19333, United States, PA, 19333
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Inspection Report
Monitoring
Census: 60
Capacity: 84
Deficiencies: 14
Aug 4, 2025
Visit Reason
The inspection was a partial, unannounced monitoring visit conducted to review compliance with regulations and verify the implementation of a previously submitted plan of correction.
Findings
The facility was found to have multiple deficiencies including failure to post required licenses and influenza information, incomplete criminal background checks, inadequate direct care staffing hours for residents with mobility needs, incomplete staff training, missing medical evaluation information, incomplete preadmission screening forms, and missing posted instructions for key-locking devices. Plans of correction were accepted and implemented with ongoing compliance monitoring scheduled.
Deficiencies (14)
| Description |
|---|
| The home's copy of 55 Pa.Code Chapter 2600 was not posted in a conspicuous and public place. |
| The home did not have an influenza poster posted as required by the Influenza Awareness Act. |
| Criminal background check for a staff member was not completed prior to hire. |
| Direct care staffing hours were below the required minimum for residents with mobility needs on specific dates. |
| Less than 75% of required personal care service hours were provided during waking hours on specific dates. |
| A staff person did not complete required orientation training within 40 scheduled working hours. |
| A direct care staff person received 0 hours of annual training in the previous training year. |
| A staff person did not receive required training in the Older Adult Protective Services Act during the training year. |
| Two fire extinguishers had not been inspected by a fire safety expert since October 2023. |
| Resident medical evaluation did not include an answer regarding the Mobility Needs Assessment. |
| Resident's preadmission screening form was not completed as required prior to admission. |
| Resident's written cognitive preadmission screening was not completed as required prior to admission to the secured dementia care unit. |
| Directions for operating key-locking devices were not conspicuously posted near exits in the secured dementia care unit. |
| Direct care staff person working in the secured dementia care unit had 0 hours of dementia care training during the previous training year. |
Report Facts
Residents served: 60
License capacity: 84
Residents with mobility needs: 17
Required direct care hours: 94
Provided direct care hours: 74
Provided direct care hours: 77.5
Percentage of required hours during waking hours: 60
Percentage of required hours during waking hours: 59
Total daily staff: 77
Waking staff: 58
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff member A | Named in criminal background check and training deficiencies | |
| Staff person B | Named in orientation training deficiency | |
| Staff person C | Named in annual training content deficiency | |
| Healthcare Director | Named in multiple findings related to staffing, medical evaluations, and training | |
| Maintenance Director | Named in fire extinguisher inspection and key-locking device findings | |
| Administrator | Named in multiple corrective actions and training | |
| Business Office Manager | Named in training compliance monitoring | |
| Memory Care Manager | Named in key-locking device compliance monitoring | |
| Regional Operations Director | Named in auditing associate files for compliance | |
| Regional Healthcare Specialist | Named in auditing medical evaluations and preadmission screens |
Inspection Report
Complaint Investigation
Census: 52
Capacity: 84
Deficiencies: 5
Jun 2, 2025
Visit Reason
The inspection was conducted as a complaint investigation, unannounced, to review compliance with regulations following a reported incident involving a resident injury and other related concerns.
Findings
The facility was found to have multiple deficiencies including failure to timely report an incident, improper handling of a resident transfer leading to injury, lack of a criminal background check for a staff member, unqualified direct care staff, and incomplete staff contact lists. Plans of correction were submitted and fully implemented by the report date.
Complaint Details
The visit was complaint-related, triggered by an incident where a resident sustained a laceration during a transfer. The complaint involved allegations of abuse and neglect related to improper care and failure to report the incident.
Deficiencies (5)
| Description |
|---|
| Failure to submit an incident report to the Department within 24 hours after a resident was taken to the hospital for a laceration requiring six sutures. |
| Staff did not follow the home's policy for refusal of care and proper transfer procedures, resulting in a resident's left foot being caught under a wheelchair causing a bloody laceration. |
| The home did not have a Pennsylvania State Police criminal background check for a staff person at the time of inspection. |
| Direct care staff person did not have a high school diploma, GED, or active registry status on the Pennsylvania nurse aide registry and no waiver was applied for. |
| Staff persons were missing from the facility's staff contact list. |
Report Facts
Residents Served: 52
License Capacity: 84
Secured Dementia Care Unit Capacity: 26
Secured Dementia Care Unit Residents Served: 16
Current Hospice Residents: 4
Residents Age 60 or Older: 52
Residents Diagnosed with Mental Illness: 3
Residents with Mobility Need: 25
Residents with Physical Disability: 1
Inspection Report
Follow-Up
Census: 48
Capacity: 84
Deficiencies: 28
Aug 27, 2024
Visit Reason
The inspection was conducted as a full, unannounced review for renewal and complaint reasons at THE DEVON SENIOR LIVING facility.
Findings
The report details multiple deficiencies related to contract signatures, staff qualifications and training, resident rights, medication management, facility maintenance, and resident assessments. The submitted plan of correction was found to be fully implemented as of the follow-up review.
Complaint Details
The inspection included complaint investigation as part of the renewal review. The plan of correction was fully implemented as of the follow-up review.
Deficiencies (28)
| Description |
|---|
| Resident-home contract for resident #1 was not signed by the resident. |
| Resident #1's record lacked a signed statement acknowledging receipt of resident rights and complaint procedures. |
| Direct care staff person A lacked required qualifications initially. |
| Direct care staff persons B and C did not complete required training on reporting of reportable incidents and conditions within 40 hours. |
| Direct care staff person A received only 11.5 hours of annual training in 2023, less than the required 12 hours. |
| Staff persons A and D did not receive fire safety training by a fire safety expert during 2023. |
| Training records for staff persons D and E did not include length of each course. |
| Procedures for bedside mobility devices lacked periodic assessment for installation, maintenance, and appropriateness. |
| Damage to walls and fixtures in resident #1's room was not fully repaired at time of inspection. |
| Damaged furniture in resident #1's room including bathroom vanity, TV, and lamp. |
| Bedroom #13 occupied by 2 residents had only 1 chair. |
| Resident #1 did not have an operable lamp at bedside. |
| Use of a common towel was observed in shared bathroom of room 13. |
| Unlabeled and undated food items found in kitchen storage areas. |
| Fire extinguisher in 13 passenger van lacked inspection tag. |
| Resident #1's initial medical evaluation was incomplete, missing health status information. |
| Resident #2's annual medical evaluation was incomplete; resident #3 and #4 had incomplete or missing evaluations. |
| Menus in secured dementia care unit were outdated and not posted for current weeks. |
| Resident #5's medication record did not reflect correct dosage as verified by physician. |
| Resident #6's insulin pens were not marked with date opened, making expiration determination impossible. |
| Blood glucose readings for resident #6 and #7 were not properly documented; medication for resident #8 was unavailable. |
| Resident #9's controlled substance was not stored under double lock as required. |
| Resident #1's medication record lacked diagnosis or purpose for prescribed medication; resident #9's medication instructions differed between package and MAR. |
| Medication administration records for residents #1, #6, and #10 lacked initials of administering staff. |
| Resident #1 was not educated on right to refuse medication if medication error suspected. |
| Resident #1's assessment did not include recent aggressive behaviors and property destruction. |
| Resident #3 and #11 had incomplete or improperly completed support plans, including missing device use details and signatures. |
| Direct care staff persons A and D lacked required 6 hours of annual dementia care training in 2023. |
Report Facts
License Capacity: 84
Residents Served: 48
Capacity of Secured Dementia Care Unit: 26
Residents Served in Secured Dementia Care Unit: 16
Current Hospice Residents: 3
Total Daily Staff: 72
Waking Staff: 54
Deficiency Count: 30
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director | Executive Director | Named in multiple findings related to contract audits, training oversight, and plan of correction implementation. |
| Business Office Manager | Business Office Manager | Involved in auditing resident contracts and staff training files. |
| Director of Resident Care | Director of Resident Care | Responsible for training, audits of medical evaluations, medication management, and support plans. |
| Maintenance Director | Maintenance Director | Responsible for fire extinguisher inspections and facility maintenance audits. |
| Culinary Director | Culinary Director | Responsible for food safety, menu posting, and kitchen audits. |
| Director of Resident Services | Director of Resident Services | Responsible for support plan completion and signature audits. |
Inspection Report
Complaint Investigation
Census: 50
Capacity: 84
Deficiencies: 2
Jul 18, 2024
Visit Reason
The inspection was conducted as a complaint investigation with a partial, unannounced review of the facility on 07/18/2024, followed by off-site reviews on 08/01/2024 and 08/13/2024.
Findings
The submitted plan of correction was determined to be fully implemented. Two deficiencies were noted: a non-operable battery in a portable smoke detector in the visitor's bathroom and insufficient dementia care training for a direct care staff person in the secured dementia care unit.
Complaint Details
The inspection was complaint-related as indicated by the reason 'Complaint' and the partial unannounced inspection on 07/18/2024.
Deficiencies (2)
| Description |
|---|
| The portable smoke detector in the 1st floor visitor's bathroom did not have an operable battery installed. |
| Direct care staff person A, who works in the Secure Dementia Care Unit, had only 1 hour of training in dementia care during the 2023 training year, less than the required 6 hours. |
Report Facts
License Capacity: 84
Residents Served: 50
Residents in Secured Dementia Care Unit: 15
Staff Training Hours Required: 6
Staff Training Hours Completed: 1
Total Daily Staff: 76
Waking Staff: 57
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Direct care staff person A | Direct Care Staff | Named in the deficiency related to insufficient dementia care training. |
| Director of Resident Services | Completed dementia training for resident services team members as part of plan of correction. | |
| Executive Director | Responsible for auditing team member training for 2024. | |
| Business Office Manager | Responsible for auditing team member training for 2024. | |
| Maintenance Director | Conducted survey of portable smoke detectors and scheduled monthly surveys as part of plan of correction. |
Inspection Report
Follow-Up
Census: 52
Capacity: 84
Deficiencies: 2
Feb 16, 2024
Visit Reason
The inspection visit on 02/16/2024 was a partial, unannounced follow-up to review the submitted plan of correction related to an incident.
Findings
The submitted plan of correction was determined to be fully implemented. Deficiencies included failure to secure medical care after a flooding incident and missing resident signatures on contracts, both of which were addressed with corrective actions and staff re-education.
Deficiencies (2)
| Description |
|---|
| The resident-home contract was not signed by the resident. |
| Failure to secure medical care for residents after a flooding incident that caused injury. |
Report Facts
License Capacity: 84
Residents Served: 52
Secured Dementia Care Unit Capacity: 26
Secured Dementia Care Unit Residents Served: 15
Hospice Current Residents: 5
Residents with Mobility Need: 26
Residents 60 Years or Older: 52
Residents Diagnosed with Mental Illness: 1
Residents Diagnosed with Intellectual Disability: 2
Inspection Report
Follow-Up
Census: 51
Capacity: 84
Deficiencies: 2
Jan 29, 2024
Visit Reason
The inspection visit on 01/29/2024 was a partial, unannounced follow-up inspection triggered by a complaint and incident, to verify the implementation of a previously submitted plan of correction.
Findings
The submitted plan of correction was determined to be fully implemented as of the follow-up date. Deficiencies related to incomplete medical evaluations and resident record content were corrected, including audits and ongoing monitoring plans to ensure compliance.
Complaint Details
The inspection was complaint-related and included incident review. The plan of correction was accepted and fully implemented by 03/08/2024.
Deficiencies (2)
| Description |
|---|
| Resident medical evaluation did not include medical information pertinent to diagnosis and treatment in case of an emergency, medication regimen, contraindicated medications, medication side effects, and body positioning and movement stimulation. |
| Resident record did not include race, height, weight, color of hair, color of eyes, or a record of incident reports for the individual resident. |
Report Facts
License Capacity: 84
Residents Served: 51
Secured Dementia Unit Capacity: 24
Residents in Dementia Unit: 15
Hospice Residents: 4
Residents with Mobility Need: 27
Residents 60 Years or Older: 51
Residents Diagnosed with Intellectual Disability: 2
Total Daily Staff: 78
Waking Staff: 59
Inspection Report
Renewal
Census: 40
Capacity: 84
Deficiencies: 16
Jul 27, 2023
Visit Reason
The inspection was conducted as a renewal, provisional inspection of THE DEVON SENIOR LIVING facility to review compliance with licensing requirements.
Findings
The inspection identified multiple deficiencies including failure to post influenza awareness information, unsecured poisonous materials accessible to residents, unsanitary conditions in kitchen and storage areas, hot water temperature exceeding limits, improper food storage and labeling, smoking outside designated areas, medication storage and administration errors, missing directions for key-locking devices, and incomplete resident support plans. Plans of correction were accepted and implemented by the facility.
Deficiencies (16)
| Description |
|---|
| Influenza awareness poster was not present in the home. |
| Poisonous materials such as hand soap, cleaners, toothpaste, mouthwash, and deodorants were unlocked and accessible to residents not assessed capable of safely using poisons. |
| Accumulation of debris and unclean items under kitchen sink and spilled frozen liquid in freezer. |
| Hot water temperature in room 13 measured 132°F, exceeding the 120°F limit. |
| Uncovered chocolate ice cream stored in freezer. |
| Eight 5-gallon water bottles stored on the floor in storage room. |
| Unlabeled and undated leftover food items in kitchen refrigerators and freezer. |
| Food stored in unsealed containers including Panko breadcrumbs and vanilla cake. |
| Accumulation of lint in lint traps of commercial dryers. |
| Insufficient 3-day supply of emergency food for 40 residents. |
| Written emergency procedures not submitted to local emergency management agency since 2021. |
| Two employees smoking outside designated smoking area. |
| Loose pill found on medication cart drawer. |
| Medications administered to residents were not signed off on narcotics declining inventory log. |
| Directions for operating locking mechanism not conspicuously posted near main door to Secure Dementia Care Unit. |
| Resident support plan did not address diagnoses of cognitive impairment, heroin dependence, and anxiety. |
Report Facts
Residents served: 40
License capacity: 84
Hot water temperature: 132
Unlabeled leftover food items: 6
Emergency food supply: 9
Emergency food supply: 6
Emergency food supply: 40
Inspection Report
Monitoring
Census: 40
Capacity: 84
Deficiencies: 9
May 12, 2023
Visit Reason
The inspection was a provisional, unannounced monitoring visit to review compliance and the implementation of a previously submitted plan of correction.
Findings
The inspection identified multiple deficiencies related to medication storage, discontinued medications, storage procedures, following prescriber's orders, support plan documentation, medical evaluations, and admission procedures for the secured dementia care unit. All deficiencies had plans of correction submitted and were marked as implemented by August 8, 2023.
Deficiencies (9)
| Description |
|---|
| Medications in the cart lacked 'opened on' dates, violating storage requirements. |
| Discontinued narcotic medication was not destroyed according to policy and regulations. |
| Resident's glucometer was not calibrated to the correct date and time. |
| Resident #3 and #4 were administered medications not following prescriber's orders. |
| Resident #5's support plan did not include dietary needs despite doctor's order for mechanical soft diet. |
| Resident #1's medical evaluation did not indicate need for secured dementia care unit placement. |
| No documentation that residents #1 and #6 and their designated persons had not objected to admission to the secured dementia care unit. |
| Resident #6's initial support plan was completed late, beyond 72 hours of admission to secured dementia care unit. |
| Resident #6's support plan was not revised to reflect agitation and aggression exhibited after admission. |
Report Facts
License Capacity: 84
Residents Served: 40
Secured Dementia Care Unit Capacity: 26
Residents Served in Secured Dementia Care Unit: 15
Current Hospice Residents: 3
Residents Age 60 or Older: 39
Residents Diagnosed with Intellectual Disability: 2
Residents with Mobility Need: 17
Inspection Report
Enforcement
Census: 39
Capacity: 84
Deficiencies: 10
Nov 30, 2022
Visit Reason
The inspection was conducted as a result of complaint and monitoring concerns, including multiple visits on June 9, 27, 28, September 8, 9, and November 30 and December 12, 2022, to assess compliance with Pennsylvania Department of Human Services regulations for Personal Care Homes.
Findings
Multiple violations were found related to medication administration, storage, labeling, and documentation, as well as sanitary conditions and prescription adherence. The facility was issued a first provisional license with a requirement to correct all violations by specified dates, or face fines and possible license revocation.
Complaint Details
The inspection was complaint-related and included monitoring. Specific substantiation status is not stated.
Deficiencies (10)
| Description |
|---|
| Instances of shared glucometers between residents with inconsistent or missing glucose log readings. |
| Staff persons who had not completed Department-approved medication administration courses administered medications improperly. |
| Discontinued prescriptions remained on medication carts. |
| Loose pills found in multiple medication carts. |
| Original containers for prescription medications lacked proper pharmacy labels. |
| Improper storage procedures for medications and medical equipment by trained staff. |
| Failure to document medication administration times properly. |
| Failure to follow prescriber's orders for insulin and other medications, including missed doses and incorrect dosages. |
| Staff persons without completed diabetes patient education programs administered insulin injections. |
| Medication administration training records lacked documentation of course completion for certain staff. |
Report Facts
Fine Per Resident Per Day: 5
Calculated Fine Per Day: 195
Mandated Correction Date: 5
License Capacity: 84
Residents Served: 39
Secured Dementia Care Unit Capacity: 20
Secured Dementia Care Unit Residents Served: 12
Hospice Current Residents: 5
Inspection Report
Monitoring
Census: 35
Capacity: 84
Deficiencies: 0
Oct 20, 2022
Visit Reason
The inspection was a monitoring visit conducted by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing, to assess compliance at THE DEVON SENIOR LIVING facility.
Findings
No regulatory citations or deficiencies were identified during the inspection. The facility was found to be in compliance with licensing requirements.
Report Facts
Resident Support Staff: 0
Total Daily Staff: 49
Waking Staff: 37
License Capacity: 84
Residents Served: 35
Secured Dementia Care Unit Capacity: 26
Secured Dementia Care Unit Residents Served: 11
Hospice Current Residents: 3
Residents Age 60 or Older: 35
Residents with Mobility Need: 14
Inspection Report
Renewal
Census: 42
Capacity: 84
Deficiencies: 7
Sep 8, 2022
Visit Reason
The inspection was a renewal inspection conducted to assess compliance with licensing requirements for The Devon Senior Living facility.
Findings
The inspection identified multiple violations including failure to report a medication error, lack of dignity and respect in resident treatment, missing documentation for fire department notification, incomplete annual medical evaluations for residents, improper medication storage procedures, incomplete medication administration records, and failure to follow prescriber's orders. Plans of correction were submitted with some implemented and others not yet implemented as of the report date.
Deficiencies (7)
| Description |
|---|
| Failure to report medication error to the Department within 24 hours. |
| Failure to treat resident with dignity and respect; staff spoke loudly and created an unwanted spectacle. |
| No documentation of written notification to local fire department regarding home address, bedroom locations, and evacuation assistance. |
| Residents #3 and #4 did not have completed annual medical evaluations for 2022. |
| Medication (Polyethylene Glycol 3350) was not available in the home as prescribed. |
| Medication administration records for resident #1 did not include initials of staff administering medications on specified dates. |
| Resident #1 was not administered prescribed medications on 9/8/22 due to medication unavailability. |
Report Facts
Census at Inspection: 42
Total Licensed Capacity: 84
Fine Per Resident Per Day: 5
Calculated Fine Per Day: 195
Mandated Correction Date: 5
Inspection Report
Enforcement
Census: 36
Capacity: 84
Deficiencies: 6
Jun 9, 2022
Visit Reason
The inspection was conducted as a partial, unannounced incident investigation related to violations found during multiple licensing inspections on June 9, 27, and 28, 2022, September 8 and 9, 2022, and November 30 and December 12, 2022.
Findings
The facility was found to have multiple violations related to resident care, including a fatal choking incident involving resident #1 who was served food inconsistent with their prescribed mechanical soft diet. The Department revoked the facility's certificate of compliance and issued a first provisional license. Fines are proposed for violations unless corrected by the mandated dates.
Deficiencies (6)
| Description |
|---|
| Resident #1 was served food inconsistent with prescribed mechanical soft diet, leading to choking and death due to asphyxiation. |
| Failure to update resident #1's medical evaluation after choking incident and death. |
| Failure to meet resident #1's special dietary needs as prescribed by physician. |
| Failure to provide dietary alternative for resident #1 during dinner. |
| Failure to follow prescriber's orders for resident #1's diet, resulting in death. |
| Failure to revise resident #1's support plan within 30 days of assessment and changes in medical needs. |
Report Facts
Census at Inspection: 39
Fine Per Resident Per Day: 5
Calculated Fine Per Day: 195
License Capacity: 84
Residents Served: 36
Secured Dementia Care Unit Capacity: 26
Secured Dementia Care Unit Residents Served: 11
Residents 60 Years or Older: 35
Residents Diagnosed with Intellectual Disability: 1
Residents with Mobility Need: 9
Inspection Report
Complaint Investigation
Census: 35
Capacity: 84
Deficiencies: 0
Mar 14, 2022
Visit Reason
The inspection was conducted as a complaint investigation during an unannounced partial inspection on 03/14/2022.
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 substantiated issues were found.
Report Facts
License Capacity: 84
Residents Served: 35
Secured Dementia Care Unit Capacity: 20
Secured Dementia Care Unit Residents Served: 8
Hospice Residents: 4
Residents 60 Years or Older: 34
Residents Diagnosed with Intellectual Disability: 1
Residents with Mobility Need: 11
Inspection Report
Renewal
Census: 39
Capacity: 84
Deficiencies: 18
Dec 9, 2021
Visit Reason
The inspection was conducted as a renewal and incident investigation at THE DEVON SENIOR LIVING facility.
Findings
The inspection identified multiple deficiencies including failure to post the current license inspection summary, incomplete staff access records during an incident investigation, sanitary and safety violations, improper food storage and labeling, medication labeling and storage issues, incomplete staff orientations and training, and missing documentation for support plan signatures. All deficiencies had plans of correction implemented or directed.
Deficiencies (18)
| Description |
|---|
| The home's most recent License Inspection Summary was not posted in a conspicuous and public place. |
| Incomplete staff schedule provided to Department agent during incident investigation. |
| The home does not have contact information for all substitute staff. |
| Ancillary staff person did not have a general orientation to specific job functions. |
| No sanitary method of hand drying in the bathroom in resident room. |
| Hot water temperature in resident room bathrooms exceeded 120°F. |
| Resident did not have access to a source of light that can be turned on/off at bedside. |
| No soap dispenser in the bathroom in resident room. |
| Food not protected from contamination; uncovered food items found in refrigerators. |
| Leftover food items were unlabeled and undated in multiple refrigerators and storage areas. |
| No thermometer in the Unit 6 freezer in the main kitchen. |
| Pharmacy label for resident's medication did not include correct instructions for administration. |
| Resident's medication administration record did not match prescribed instructions. |
| Residents participated in support plan development but did not sign the support plans. |
| Multiple substitute personnel did not receive orientation on fire safety and emergency preparedness topics. |
| Staff person did not complete required orientation on reporting of reportable incidents and conditions within 40 hours. |
| Direct care staff person provided unsupervised ADL services without completing required training. |
| Medications prescribed to residents were not available in the home. |
Report Facts
License Capacity: 84
Residents Served: 39
Staff Members During Investigation: 15
Staff Members Named in Schedule: 9
Total Daily Staff: 50
Waking Staff: 38
Hot Water Temperature: 123.9
Hot Water Temperature: 122.1
Notice
Capacity: 84
Deficiencies: 0
Sep 7, 2021
Visit Reason
This document serves as a renewal notification and license issuance for The Devon Senior Living 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
Maximum capacity: 84
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary, Office of Long-term Living | Signed the renewal notification letter |
Inspection Report
Renewal
Census: 47
Capacity: 84
Deficiencies: 17
Feb 8, 2021
Visit Reason
The inspection was conducted as a renewal visit to review compliance with licensing regulations at The Devon Senior Living facility.
Findings
The inspection identified multiple deficiencies including improper placement of carbon monoxide detectors, incomplete criminal background checks, staff lacking required qualifications and orientations, unsafe storage of poisonous materials, sanitary issues, snow and ice obstructions blocking emergency exits, medication management errors, and missing or outdated medical evaluations and support plans. All deficiencies were corrected or plans of correction accepted with follow-up monitoring.
Deficiencies (17)
| Description |
|---|
| Carbon monoxide detectors were improperly placed less than 15 feet from fossil fuel burning devices. |
| Criminal history background check for staff person A was requested more than one year prior to date of hire. |
| Direct care staff persons A and B lacked high school diplomas, GEDs, or active registry status on the Pennsylvania nurse aide registry. |
| Staff persons A and B did not receive required fire safety and emergency preparedness orientation on their first day. |
| Staff persons A and B did not complete required orientation on resident rights, emergency medical plan, mandatory abuse reporting, and reportable incidents within 40 scheduled working hours. |
| Staff persons A and B provided unsupervised ADL services without completing Department-approved direct care training and competency test. |
| A bottle of purple liquid hand soap labeled as poisonous was unlocked and accessible to residents. |
| Sticky dried brown substance present on medication cart tray. |
| Snow and ice obstructed emergency exit walkways and doors, blocking egress. |
| Expired medication (Ketoconazole Shampoo) present on medication cart. |
| Sample prescription medication (Alendronate Sodium) not labeled with resident's name or instructions. |
| Resident #3's glucometer reading did not match glucose log; resident #4's medication missing and glucometer not calibrated. |
| Resident #4's Ammonium Lactate Lotion was documented as administered but was not available. |
| Resident #4 missed multiple prescribed medications on specified dates. |
| Resident #1's medical evaluation was outdated at time of admission to secured dementia care unit. |
| Directions for operating key-locking devices at secured unit doors were not conspicuously posted. |
| Resident #1's initial support plan was completed after admission to secured dementia care unit. |
Report Facts
License Capacity: 84
Residents Served: 47
Memory Care Unit Capacity: 26
Memory Care Residents Served: 12
Staff Total Daily: 64
Waking Staff: 48
Snow Accumulation: 3
Inspection Report
Follow-Up
Census: 48
Capacity: 84
Deficiencies: 1
Jan 13, 2021
Visit Reason
The inspection was a partial, unannounced follow-up visit conducted due to an incident, to verify the implementation of a previously submitted plan of correction.
Findings
The submitted plan of correction related to a resident rights violation was fully implemented. The employee involved was suspended pending investigation and subsequently terminated. The facility committed to ongoing education on resident rights.
Deficiencies (1)
| Description |
|---|
| Staff member told a resident to stop saying who they voted for, implying voters for Donald Trump are racist, causing the resident to feel uncomfortable. |
Report Facts
License Capacity: 84
Residents Served: 48
Secured Dementia Care Unit Capacity: 26
Residents Served in Dementia Unit: 13
Hospice Residents: 5
Resident Mobility Need: 17
Residents 60 Years or Older: 48
Residents Diagnosed with Intellectual Disability: 1
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